This document summarizes a systematic review of cost-effectiveness analyses of HIV prevention interventions in the United States. The review identified 45 studies evaluating 14 intervention strategies required by the National HIV/AIDS Strategy. Most interventions were found to be cost-effective, with median costs per infection averted ranging from $3,365 for HIV screening to $90,678 for preventing perinatal transmission. However, some required interventions like linkage and retention to care lacked cost-effectiveness data. Future research is needed to fill these gaps and strengthen the methods used in cost-effectiveness evaluations of HIV prevention.

1. Cost-Effectiveness of HIV Prevention
Interventions in the United States:
A Systematic Review
Ya-lin A. Huang, PhD
Arielle Lasry, PhD
Angela B. Hutchinson, PhD
Stephanie L. Sansom, PhD
Acknowledgement
CDC Prevention Modeling and Economic Team members
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention

2. BACKGROUND
 Goals of National HIV/AIDS Strategy (NHAS)
 To reduce new HIV infections
 To increase access to care and strengthen treatment outcomes
 To reduce HIV-related health disparities
 ECHPP (Enhanced Comprehensive HIV Prevention Plans)
 For 12 selected jurisdictions with the highest AIDS prevalence to
develop and implement the best mix of prevention interventions
 14 intervention/strategies were required to be included and
prioritized based on local epidemic profile, costs, and scalability

3. OBJECTIVES
 To perform a comprehensive systematic review of
published CEA literature that evaluated HIV
intervention implemented in the US
 To highlight gaps in the literature

4. METHODS
 Literature Search
 Electronically
• 6 databases: PubMed/ PsycInfo/ Embase/Cochrance/ CINAHL/EconLit
• Searched from the earliest date available to January 25th, 2011
• Used keywords and MeSH terms that reflect both “Cost-effectiveness”
and “HIV” categories
 Manually
• Reference lists of relevant articles
• Suggestions of experts in the field

5. METHODS
 Study Selection Criteria
 Reported cost-utility or cost-effectiveness ratios
• e.g. , cost per QALY saved
 Original studies
• e.g., empirical or model-based
 US-based studies
 Evaluated ECHPP-defined intervention strategies
 Abstraction
 Using a pre-specified 28-item abstraction form
• e.g., study characteristics, key aspects of analysis, sources of data and
key results
 Two reviewers coded independently
 Discrepancies were resolved through discussion

6. RESULTS — Selection Process
3,977 identified published studies
621 articles presented CE outcomes
506 original studies
249 US-based studies
45 studies related to ECHPP-required HIV
prevention interventions for review

7. RESULTS — Study Distribution
Nb. Of CE
ECHPP Required Intervention Strategy
Studies
Routine, opt-out screening for HIV in clinical settings of patients ages
9
13-64
Ongoing partner services 9
Prevention of perinatal transmission 8
Interventions or strategies promoting adherence to antiretroviral
5
medications
HIV testing in non-clinical settings to identify undiagnosed HIV
3
infection
Provision of Post-Exposure Prophylaxis to populations at greatest risk 3
Policies and procedures that will lead to the provision of antiretroviral
3
treatment in accordance with current guidelines

8. RESULTS — Study Distribution (Cont’d)
Nb. Of CE
ECHPP Required Intervention Types
Studies
Behavioral risk screening followed by risk reduction interventions for
2
HIV-positive persons
Condom distribution prioritized to target HIV-positive and high-risk
1
populations
Efforts to change existing structures, policies, and regulations 1
Linkage to HIV care, treatment, and prevention services for those
1
testing positive and not currently in care
Interventions or strategies promoting retention in or re-engagement
0
in care
STD screening according to current guidelines 0
Linkage to other medical and social services (e.g., mental health
0
treatment, drug treatment, housing assistance)

9. RESULTS — CE Summary
Type of CE Inter-Quartile
Intervention Outcome Median* Range* Comment
Routine opt-out HIV Cost/QALY saved $34,411 -- Testing in primary care setting
screening in clinical settings
Cost/New diagnosis $3,365 ($2,123 - $5,856) Testing in primary care
settings, UCC, ED, STD clinics
Evaluation of expanded HIV Cost/QALY saved $46,000 ($40,500-$56,922) Prevalence-based studies
screening based on (range of undiagnosed
prevalence in general pop. seroprevalence: 0.05 % to 3 %)
Partner services Cost/New diagnosis $7,824 ($6,054 - $14,045)
Prevention of perinatal Cost/HIV infection $90,678 ($90,277 - $91,080) Universal screening on
transmission averted pregnant women
Cost/Life year saved $68,270 -- Second testing on high risk
pregnant women
Adherence to antiretroviral Cost/QALY saved $34,500 ($13,650 - $52,000) Patients with early stage and
medications advanced stage of HIV
infection
HIV testing in non-clinical Cost/New diagnosis $12,211 ($7,845 - $16,657) Testing by CBOs or in
settings prisons/jails
Non-occupational post- Cost/QALY saved $24,367 ($23,482 - $25,251) Overall sexual/IDU exposure (
exposure prophylaxis (PEP) 46% source known HIV+ )
Early initiation of HAART Cost/QALY saved $17,617 ($11,064 - $34,000) General HIV-infected adults
and uninsured HIV-infected
adults
* All the dollar values in this table are inflated to 2009 US dollars.

10. DISCUSSION
 The identified CE results within intervention types were
generally consistent with one another
 Most of the medians of the CE results suggested cost-effective
 Gaps in Current Cost-Effectiveness Knowledge
 Lack of CE data for some interventions:
• Linkage and retention to care
• Structural intervention
• Linkage to other medical and social services
• STD screening
 Limitation
 There is wide variation in methods. This review did not include any
review of the quality of methods

11. FUTURE RESEARCH/ NEXT STEPS
 Fill in the gaps in the cost-effectiveness of HIV
prevention literature
 Incorporate measures to assess the strength of the
evidence that informs costs and effectiveness
underlying each cost-effectiveness evaluation.

12. Thank You!
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention