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December 21, 1994

The Cost-effectiveness of Voluntary Counseling and Testing of Hospital Inpatients for HIV Infection

Author Affiliations

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

JAMA. 1994;272(23):1832-1838. doi:10.1001/jama.1994.03520230042036

Objective.  —To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV).

Data Sources.  —Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors.

Data Extraction.  —We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force.

Data Synthesis.  —Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence=1%), testing to detect inpatient HIV infection would cost $16 104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive.

Conclusions.  —This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.(JAMA. 1994;272:1832-1838)