Routine HIV screening in France: clinical impact and cost-effectiveness

Abstract

Background: In 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 findings: We 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/significance: One-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.

Figure 1. Effect of undiagnosed HIV prevalence on the cost effectiveness a one-time routine, voluntary HIV test vs. “current practice”, with base case incidence.

Incidence rates are as follows: general population, 0.01/100PY; heterosexuals, 0.01/100PY; French Guyana, 0.35/100PY; MSM, 0.99/100PY; and IDU, 0.17/100PY. MSM: men who have sex with men; IDU: injection drug users; PY: person-year.

Figure 2. Sensitivity analyses: One-time routine, voluntary HIV test vs. “current practice” in the general population, with base case prevalence and incidence.

The width of the bar indicates the variation in the incremental cost-effectiveness ratio associated with alternative parameter values for that input. The numbers to the right and left of the bars indicate the lower- and upper-bounds of the ranges used in sensitivity analyses.