Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
J Adolesc Health. 2018 Jan;62(1):22-28. doi: 10.1016/j.jadohealth.2017.08.028.
To assess the optimal age at which a one-time HIV screen should begin for adolescents and young adults (AYA) in the U.S. without identified HIV risk factors, incorporating clinical impact, costs, and cost-effectiveness.
We simulated HIV-uninfected 12-year-olds in the U.S. without identified risk factors who faced age-specific risks of HIV infection (.6-71.3/100,000PY). We modeled a one-time screen ($36) at age 15, 18, 21, 25, or 30, each in addition to current U.S. screening practices (30% screened by age 24). Outcomes included retention in care, virologic suppression, life expectancy, lifetime costs, and incremental cost-effectiveness ratios in $/year-of-life saved (YLS) from the health-care system perspective. In sensitivity analyses, we varied HIV incidence, screening and linkage rates, and costs.
All one-time screens detected a small proportion of lifetime infections (.1%-10.3%). Compared with current U.S. screening practices, a screen at age 25 led to the most favorable care continuum outcomes at age 25: proportion diagnosed (77% vs. 51%), linked to care (71% vs. 51%), retained in care (68% vs. 44%), and virologically suppressed (49% vs. 32%). Compared with the next most effective screen, a screen at age 25 provided the greatest clinical benefit, and was cost-effective ($96,000/YLS) by U.S. standards (<$100,000/YLS).
For U.S. AYA without identified risk factors, a one-time routine HIV screen at age 25, after the peak of incidence, would optimize clinical outcomes and be cost-effective compared with current U.S. screening practices. Focusing screening on AYA ages 18 or younger is a less efficient use of a one-time screen among AYA than screening at a later age.
评估美国无明确 HIV 风险因素的青少年和年轻成年人（AYA）进行一次性 HIV 筛查的最佳年龄，综合考虑临床影响、成本和成本效益。
我们模拟了美国无明确风险因素的 12 岁 HIV 未感染者，他们面临特定年龄的 HIV 感染风险（0.6-71.3/10 万 PY）。我们对 15、18、21、25 或 30 岁时进行一次性筛查（在现行美国筛查实践基础上，24 岁时筛查率为 30%）进行建模。结果包括从卫生保健系统角度保留在医疗中、病毒学抑制、预期寿命、终生成本和增量成本效益比（每节省 1 年生命的成本）。在敏感性分析中，我们改变了 HIV 发病率、筛查和联系率以及成本。
所有一次性筛查均发现了一小部分终身感染（0.1%-10.3%）。与现行美国筛查实践相比，25 岁时的筛查导致 25 岁时最有利的护理连续体结局：诊断比例（77%比 51%）、与护理联系（71%比 51%）、保留在医疗中（68%比 44%）和病毒学抑制（49%比 32%）。与下一个最有效的筛查相比，25 岁时的筛查提供了最大的临床获益，且符合美国标准（<10 万美元/YLS）的成本效益（96,000 美元/YLS）。
对于美国无明确风险因素的 AYA，在发病高峰期后 25 岁进行一次性常规 HIV 筛查，可优化临床结局，并与现行美国筛查实践相比具有成本效益。与在较晚年龄筛查相比，将筛查重点放在 18 岁或更年轻的 AYA 上，对 AYA 进行一次性筛查的效率较低。
