Abstract
BackgroundIn France, roughly 40,000 HIV-infected persons are unaware of their HIV infection. Although previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France.Methods/Principal FindingsWe estimated the life expectancy (LE), cost and cost-effectiveness of alternative HIV screening strategies in the French general population and high-risk sub-populations using a computer model of HIV detection and treatment, coupled with French national clinical and economic data. We compared risk-factor-based HIV testing (“current practice”) to universal routine, voluntary HIV screening in adults aged 18–69. Screening frequencies ranged from once to annually. Input data included mean age (42 years), undiagnosed HIV prevalence (0.10%), annual HIV incidence (0.01%), test acceptance (79%), linkage to care (75%) and cost/test (€43). We performed sensitivity analyses on HIV prevalence and incidence, cost estimates, and the transmission benefits of ART. “Current practice” produced LEs of 242.82 quality-adjusted life months (QALM) among HIV-infected persons and 268.77 QALM in the general population. Adding a one-time HIV screen increased LE by 0.01 QALM in the general population and increased costs by €50/person, for a cost-effectiveness ratio (CER) of €57,400 per quality-adjusted life year (QALY). More frequent screening in the general population increased survival, costs and CERs. Among injection drug users (prevalence 6.17%; incidence 0.17%/year) and in French Guyana (prevalence 0.41%; incidence 0.35%/year), annual screening compared to every five years produced CERs of €51,200 and €46,500/QALY.Conclusions/SignificanceOne-time routine HIV screening in France improves survival compared to “current practice” and compares favorably to other screening interventions recommended in Western Europe. In higher-risk groups, more frequent screening is economically justifiable.
Highlights
An estimated 6,500 to 7,600 new cases of HIV were diagnosed every year between 2003 and 2008 in France, where the overall population size is 63 million
When we combined the favorable effects of screening on HIV transmission with individual-level life expectancies and costs, the cost-effectiveness ratio improved to J57,400/quality-adjusted life year (QALY)
We found that a one-time routine, voluntary HIV test in the French general population decreases the delay from HIV infection to diagnosis, increases mean CD4 count at diagnosis, improves survival among HIV-infected patients, reduces secondary infections at ten years, and achieves cost-effectiveness ratios that are viewed as acceptable by French standards [48]
Summary
An estimated 6,500 to 7,600 new cases of HIV were diagnosed every year between 2003 and 2008 in France, where the overall population size is 63 million. HIV tests are free of charge in France and current HIV testing rates among non-blood donors rank second in Europe at 5 million tests per year [2,3], roughly 40,000 of an estimated 106,000–134,000 HIV-infected people throughout the country remain unaware of their infection [4]. Several recent studies in the United States, have shown that routine, voluntary HIV screening is clinically effective and cost-effective compared to ad hoc practices of HIV testing [7,8]. Previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France
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