The cost-effectiveness of symptom-based testing and routine screening for acute HIV infection in men who have sex with men in the USA

Abstract

Objective: Acute HIV infection often causes influenza-like illness (ILI) and is associated with high infectivity. We estimated the effectiveness and cost-effectiveness of strategies to identify and treat acute HIV infection in men who have sex with men (MSM) in the USA.

Design: Dynamic model of HIV transmission and progression.

Interventions: We evaluated three testing approaches: viral load testing for individuals with ILI, expanded screening with antibody testing, and expanded screening with antibody and viral load testing. We included treatment with antiretroviral therapy for individuals identified as acutely infected.

Main outcome measures: New HIV infections, discounted quality-adjusted life years (QALYs) and costs, and incremental cost-effectiveness ratios.

Results: At the present rate of HIV-antibody testing, we estimated that 538,000 new infections will occur among MSM over the next 20 years. Expanding antibody screening coverage to 90% of MSM annually reduces new infections by 2.8% and costs US$ 12,582 per QALY gained. Symptom-based viral load testing with ILI is more expensive than expanded antibody screening, but is more effective and costs US$ 22,786 per QALY gained. Combining expanded antibody screening with symptom-based viral load testing prevents twice as many infections compared to expanded antibody screening alone, and costs US$ 29,923 per QALY gained. Adding viral load testing to all annual HIV tests costs more than US$ 100,000 per QALY gained.

Conclusion: Use of HIV viral load testing in MSM with ILI prevents more infections than does expanded annual antibody screening alone and is inexpensive relative to other screening interventions. Clinicians should consider symptom-based viral load testing in MSM, in addition to encouraging annual antibody screening.

Figure 1. Cost-Effectiveness of Testing for & Treating Acute HIV Infection

Incremental costs and quality-adjusted life years (QALYs) are plotted for each strategy of testing for HIV infection, with the origin corresponding to the status quo. Under each strategy, 50% of individuals identified as acutely infected receive antiretroviral therapy (ART) for the duration of their acute infection. The solid lines show the incremental cost-effectiveness ratio (ICER) relative to the next-best alternative. The dashed lines show the ICER relative to the next-best alternative if increasing annual screening coverage is infeasible. Although these strategies are dominated by similar strategies with expanded annual screening coverage, they are relevant if increasing screening coverage is infeasible. Incremental costs and QALYs are calculated over a 20-year time horizon and are discounted to the present at 3% annually. Note: Ab = antibody, VL = viral load, Symptom-based = 35% of symptomatic acutely infected MSM receive Ab & VL testing.

Figure 2. ICER of Testing for & Treating Acute HIV Infection by HIV Prevalence

The horizontal axis displays the initial HIV prevalence in the total modeled population, and the vertical axis shows the incremental cost-effectiveness ratio (ICER) relative to the status quo. Under each strategy, 50% of individuals identified as acutely infected receive antiretroviral therapy (ART) for the duration of their acute infection. Incremental costs and quality-adjusted life years (QALYs) used to calculate the ICER are calculated over a 20-year time horizon and are discounted to the present at 3% annually. Note: Ab = antibody, VL = viral load, Symptom-based = 35% of symptomatic acutely infected MSM receive Ab & VL testing.