Background: HIV testing is the critical entry point for all HIV prevention, care and treatment interventions; however, testing levels remain suboptimal. We aimed to determine the incremental cost-effectiveness of four evidence-based HIV testing strategies in six US cities with differing rates of HIV testing.
Methods: Built off a systematic evidence synthesis, we adapted and extended an HIV transmission model to replicate HIV microepidemics in Atlanta, Baltimore, Los Angeles, Miami, New York City and Seattle. We projected outcomes at the population-level and across a range of demographic groups over 25 years, holding HIV care at levels consistent with the latest available evidence and matching official population growth projections. Four HIV testing interventions in healthcare settings were identified in the US CDC''s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention and from recently published literature: opt-out routine testing in primary care, EMR testing offer reminders in hospital emergency departments, nurse-initiated testing in primary care, and opioid treatment program (OTP)-based integrated testing. For each intervention delivered over a 5-year sustainment period at a 50% scale of delivery (defined as the proportion of a target population who are provided with the intervention), we estimated incremental costs (2018 USD; including testing, implementation and other healthcare costs), quality-adjusted life years (QALYs) gained, and HIV infections averted for each intervention compared to the status quo, holding calibrated testing rates at 2015 levels.
Results: Calibrated testing rates ranged from 11,017 per 100,000 population in Baltimore to 32,010/100,000 in New York City. We estimated HIV testing interventions delivered over a 5-year period to 50% of their respective target populations would result in total incremental cost savings ranging from $0.06 million for OTP-based integrated testing in Atlanta, to $1.10 billion saved for nurse-initiated testing in Miami by 2040. Outcomes ranged from 10 QALYs gained and five HIV infections averted for OTP-integrated testing in Seattle, to 16,243 QALYs gained and 6,153 HIV infections averted for nurse-initiated testing in Los Angeles.
Conclusions: Evidence-based HIV testing strategies were cost saving across all six cities, regardless of current testing rates. Efforts to increase HIV testing should remain a key component of HIV prevention strategies.