Cost-effectiveness of Targeted Human Immunodeficiency Virus Screening in an Urban Emergency Department

Objectives: Although targeted screening of patients at high risk for human immunodeficiency virus (HIV) infection in the emergency department (ED) improves patient outcomes and may prevent HIV transmission, ED-based screening programs incur additional costs and have thus not been widely scaled up. The objective of this study was to evaluate the cost-effectiveness of ED-based targeted HIV screening as implemented in actual practice. Methods: This was a cost-utility analysis of a rapid HIV screening program in an urban ED. Physicians were encouraged to screen patients undergoing inpatient admission or who had HIV risk factors. The authors measured costs directly and estimated quality-adjusted life expectancy using chart review, literature assumptions, and mathematical modeling. Incremental cost utility was evaluated from a societal perspective using a lifetime time horizon. Results: From June 2008 through September 2009, a total of 3,766 HIV tests were ordered (235 tests per month), of which an estimated 2,406 (64%) represented screening in patients without HIV-related signs or symptoms. Nineteen (0.8%) patients were newly diagnosed through screening during the study period, of whom nine (47%) were eligible for antiretroviral therapy (ART) and maintained consistent outpatient follow-up. Estimated screening costs were $82,300 per year, or $45.53 per screening test, of which $28.01 (62%) was for program management. Targeted screening prevented an estimated 2.1 HIV transmission events over 16 months. Per patient screened, targeted screening saved $112 (95% uncertainty range [UR] = $20 to $225) and resulted in 2.71 quality-adjusted life-days gained (95% UR = 1.71 to 4.01). Cost-utility was most sensitive to the prevalence of undiagnosed HIV in the screened population. Conclusions: Targeted HIV screening, as implemented in an urban ED, is cost saving and increases quality-adjusted life expectancy. ACADEMIC EMERGENCY MEDICINE 2011; 18: 745-753 (C) 2011 by the Society for Academic Emergency Medicine