Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

中文翻译：

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急诊科艾滋病毒筛查的成本效益：在急诊科试验中使用增强筛查技术进行实用随机艾滋病毒检测的结果


HIV 的识别仍然是一项重要的健康优先事项，其中急诊科 (ED) 是重点关注的焦点。急诊室中各种艾滋病毒筛查策略的相对成本效益仍然很大程度上未知。本研究的目的是利用多中心、务实的随机临床试验的结果，比较急诊科中非靶向和两种形式的靶向选择退出 HIV 筛查的计划成本和成本效益。这项经济评估嵌套在急诊科使用增强筛查技术进行 HIV 检测 (TESTED) 试验中，该试验是一项多中心实用临床试验，针对 2014 年 4 月至 2016 年 1 月进行的不同基于急诊室的 HIV 筛查策略进行。 16 岁或以上的患者在美国 4 个城市急诊室中，精神状态正常、病情不危重或未知感染艾滋病毒的患者被随机接受 3 种艾滋病毒选择退出筛查方法中的一种，包括非针对性、增强针对性或传统针对性。每种筛查方法都完全融入日常紧急护理中。使用实际试验结果确定直接计划成本，并使用时间-动作评估来估算人员活动成本。主要结局是新诊断出的艾滋病毒。按筛查方法计算的年度化 ED 计划总成本是使用调整至 2023 年的美元计算的，每位新诊断出艾滋病毒患者的成本也是如此。进行了单向和多向敏感性分析。该试验对 76,561 名患者进行了随机就诊，完成了 14,405 项 HIV 检测，并有 24 例 (0.2%) 新诊断。年化新诊断总数为 12.9，非靶向、增强靶向和传统靶向筛查的年化总成本分别为 111,861 美元、88,629 美元和 70,599 美元。 在筛查方法中，每次新诊断 HIV 的费用分别为 20,809 美元、23,554 美元和 18,762 美元。与传统的针对性筛查相比，强化针对性筛查的成本较高，但每年发现的新病例相似。与传统的靶向筛查相比，非靶向筛查的增量成本效益比为 25,586 美元。结果对艾滋病毒流行率和艾滋病毒检测费用最为敏感。非针对性艾滋病毒筛查比针对性筛查成本更高，主要是因为进行的艾滋病毒检测数量增加。每种艾滋病毒筛查策略的每次新的艾滋病毒诊断的策略内成本相似，而传统的针对性筛查每次新诊断的成本最低。对于预算有限或艾滋病毒感染率极低的环境，传统的有针对性的方法可能是首选；然而，鉴于每次新的艾滋病毒诊断成本略高，希望检测最新病例的急诊室可能更喜欢非针对性筛查。