We evaluated the health outcomes, costs, and cost-effectiveness of voluntary HIV screening and counseling among 15- to 49-year-olds in Russia. The costs and benefits of HIV screening have not been evaluated rigorously in middle income countries, and therefore, the value of screening has been uncertain. The effectiveness and efficiency of HIV screening in Russia is particularly important because it is prototypic of the epidemics in Eastern Europe.
Our analysis has three main findings. First, early diagnosis through screening resulted in a substantial gain in life expectancy and quality-adjusted life expectancy for HIV-infected individuals. The life expectancy increase of approximately 2 years is a large increment and is similar to the gain we estimated for individuals identified through screening in the U.S. (9
). Second, one-time screening is cost-effective, even when prevalence is extremely low, if it is accompanied by modestly effective counseling to reduce risk behavior and at least partial access to ART. Because HIV testing is inexpensive in Russia, counseling of modest efficacy and less-than-universal access to ART are sufficient to justify the costs of screening. Third, as expected, periodic screening is most cost-effective in high-incidence risk groups.
Based on our estimate of 1.2% HIV prevalence, once-per-lifetime screening cost $6,910 per QALY gained, which is just over half of Russia’s per capita GDP. WHO guidelines consider interventions that cost less than the per capita GDP very cost-effective, and interventions that cost less than three times the per capita GDP cost-effective (23
). Screening is very cost-effective because the cost of a negative HIV test and counseling in Russia are low; counseling and treatment reduce HIV transmission; and the survival benefit due to ART is substantial.
Using WHO guidelines, screening was cost-effective even with very low prevalence of undiagnosed HIV cases. Disregarding transmission, screening was cost-effective if prevalence was at least 0.04%. When transmission-related costs and benefits were included, once-per-lifetime HIV screening was cost-effective if prevalence was at least 0.02%. The considerable survival benefit associated with early identification and treatment resulted in favorable cost-effectiveness ratios for HIV screening at low prevalence, even when transmission-related benefits were not taken into account.
The ideal repeat screening interval varied depending on HIV incidence, but our findings were robust across a wide range of incidence. When annual incidence ranged from 0.0375% to 0.15% per year among 15- to 49-year-old individuals, screening as frequently as every two years remained cost-effective. Incidence would need to be at least 0.3% per year for annual screening to be cost-effective, suggesting that annual screening could be appropriate for high-risk groups, but would not be an efficient use of resources for the general population.
Our analysis highlights the critical importance of including risk-reduction counseling in HIV screening programs in Russia. In our base-case analysis, we assumed counseling reduced risky sexual behavior by 20% and had no effect on injection drug use behavior. The degree to which counseling reduces risky behavior has a large impact on the cost-effectiveness of once-per-lifetime and repeat screening because effective counseling can lead to substantial reductions in HIV transmission.
It is important to note that we analyzed voluntary screening. If serious adverse outcomes relating to HIV diagnosis, such as discrimination or stigmatization, were to occur, our results would not be applicable. In addition to ethical considerations, such consequences could substantially reduce quality of life, which would make screening less cost-effective as shown in our sensitivity analysis.
Our analysis has limitations. We included only the benefit from reduced sexual transmission of HIV. Given the limited availability of needle exchange and the lack of substitution therapy in Russia (2
), we assumed no change in transmission via injection drug use, as a conservative approach. Should such programs expand in Russia, HIV screening would likely become even more cost-effective than we estimated due to additional reduction in transmission (43
In addition, in our analysis, HIV-infected individuals who did have access to ART could receive up to three ART regimens aimed at suppressing viral load, followed by lifelong nonsuppressive therapy. Given limited access to ART in Russia, it is possible that some individuals on treatment will have access to fewer drug regimens, which could lead to lower lifetime costs as well as fewer benefits. Nonetheless, our findings were robust to the proportion of patients receiving ART because screening in Russia is relatively inexpensive and counseling alone can offer substantial transmission benefit. Therefore, even in the setting of limited ART access, screening can be an efficient use of resources.
In conclusion, early detection and treatment of HIV in Russia result in substantial improvements in life expectancy among infected individuals. Voluntary HIV screening of 15- to 49-year-olds every two years is cost-effective by WHO guidelines. Such screening identifies HIV-infected individuals earlier, providing health benefits to infected individuals and to the rest of the population due to reduced transmission. Effective counseling is a key component of both the effectiveness and cost-effectiveness of these programs. The health benefit that we projected for screening will be fully realized only if HIV-infected individuals do not suffer adverse outcomes from stigmatization and discrimination.