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

Juusola, Jessie L.a; Brandeau, Margaret L.a; Long, Elisa F.b; Owens, Douglas K.c,d; Bendavid, Erand,e

doi: 10.1097/QAD.0b013e328349f067
Epidemiology and Social

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.

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aDepartment of Management Science and Engineering, Stanford University, Stanford, California

bSchool of Management, Yale University, New Haven, Connecticut

cVeterans Affairs Palo Alto Healthcare System, Palo Alto

dCenter for Primary Care and Outcomes Research, Stanford University, Stanford

eDivision of General Internal Medicine, Stanford University Medical Center, Stanford, California, USA.

Correspondence to Jessie L. Juusola, Department of Management Science and Engineering, Huang Engineering Center, Suite 263, 475 Via Ortega, Stanford, CA 94305, USA. Tel: +1 650 279 8855; e-mail:

Received 25 March, 2011

Revised 24 May, 2011

Accepted 15 June, 2011

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

© 2011 Lippincott Williams & Wilkins, Inc.