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March 16, 1994

The Cost-effectiveness of HIV Testing of Physicians and Dentists in the United States

Author Affiliations

From the Center for AIDS Prevention Studies, Prevention Sciences Group (Drs Phillips, Lowe, Kahn, Lurie, and Avins), the Institute for Health Policy Studies (Drs Phillips, Kahn, and Lurie), and the Department of Epidemiology and Biostatistics (Drs Kahn and Avins), School of Medicine, University of California-San Francisco; the Division of General Internal Medicine, San Francisco General Hospital, University of California— San Francisco (Dr Avins); and the Student Health Center, University of California—Berkeley (Dr Ciccarone). Dr Lowe is now with the Department of Emergency Medicine and Center for Clinical Epidemiology and Biostatistics, School of Medicine, University of Pennsylvania, Philadelphia.

JAMA. 1994;271(11):851-858. doi:10.1001/jama.1994.03510350061038

Objective.  —To evaluate the cost-effectiveness of alternative policies for human immunodeficiency testing (HIV) testing of physicians and dentists.

Methods.  —Decision analysis and cost-effectiveness analysis from a societal perspective were used. Data were derived from extensive literature review and consultation with experts. We conducted sensitivity analyses and also performed a cost-benefit analysis.

Analyses.  —We analyzed policies for mandatory or voluntary testing of all physicians, surgeons, and dentists; for those testing positive, we analyzed mandatory or voluntary exclusion from practice, restriction from performance of invasive procedures, or requirements to inform patients of serostatus.

Main Outcome Measure.  —Cost per patient infection averted.

Results.  —Although one-time mandatory testing of surgeons and dentists with mandatory restriction of those found to be HIV-positive is more cost-effective than other policies, the cost-effectiveness varies tremendously under different scenarios. Results were highly sensitive to several data inputs, especially HIV seroprevalence of surgeons and dentists and transmission risk. For example, under a medium seroprevalence and transmission risk scenario, mandatory testing of all surgeons might avert 25 infections at a total cost of $27.9 million or $1 115 000 per infection averted and an incremental cost of $291 000 compared with current testing; however, the incremental cost-effectiveness per patient infection averted ranges from $29 807 000 under a low-risk scenario to a savings of $81 000 under a high-risk scenario.

Conclusion.  —Our analysis neither justifies nor precludes a mandatory testing policy. Further research on the key data inputs is needed. Given the ethical, social, and public health implications, mandatory testing policies should not be implemented without greater certainty as to their cost-effectiveness.(JAMA. 1994;271:851-858)