Volume 4, Issue 10, Pages e465-e474 (October 2017) Cost-effectiveness of screening for HIV in primary care: a health economics modelling analysis  Dr Rebecca F Baggaley, PhD, Michael A Irvine, PhD, Werner Leber, PhD, Valentina Cambiano, PhD, Jose Figueroa, MFPH, Heather McMullen, PhD, Prof Jane Anderson, FRCP, Andreia C Santos, PhD, Fern Terris-Prestholt, PhD, Alec Miners, PhD, Prof T Déirdre Hollingsworth, PhD, Prof Chris J Griffiths, DPhil  The Lancet HIV  Volume 4, Issue 10, Pages e465-e474 (October 2017) DOI: 10.1016/S2352-3018(17)30123-6 Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

Figure 1 Schematic illustrating HIV screening model structure Background death rate is applied to each compartment but, for clarity, is not shown. Numbers refer to stages of HIV infection: 1=acute infection; 2=CD4 count of more than 500 cells per μL; 3=CD4 count of 350–500 cells per μL; 4=CD4 count of 200–349 cells per μL; and 5=CD4 count of less than 200 cells per μL. Diagnosis rate for compartment 1 is assumed to be zero (ie, no diagnoses occur during acute infection). Model assumed diagnosis upon progression to AIDs (appendix p 3). The Lancet HIV 2017 4, e465-e474DOI: (10.1016/S2352-3018(17)30123-6) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

Figure 2 Outcomes of the RHIVA2 intervention (A) Cumulative QALYs gained as a result of the RHIVA2 trial over time. The intervention is continued for 28 months only (the duration of the RHIVA2 trial). (B) ICER of cost per QALY gained as a result of the RHIVA2 trial, over time, for the three explored scenarios of increased long-term health-care costs for patients diagnosed with late infection. The grey band represents the £20 000–30 000 threshold of cost-effectiveness of interventions used by NICE in the UK. (C) Scenario lines show additional cost of RHIVA2 against QALYs gained, over time, highlighting each 5 year increment since start of the intervention (shown as coloured dots). Shaded grey area represents the NICE threshold of cost-effectiveness. QALY=quality-adjusted life-year. ICER=incremental cost-effectiveness ratio. NICE=National Institute for Health and Care Excellence. The Lancet HIV 2017 4, e465-e474DOI: (10.1016/S2352-3018(17)30123-6) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

Figure 3 Tornado plot of model parameters varied in univariate sensitivity analysis of scenario 1 Parameters are arranged from widest range of model outcome, with range of model input values shown in parentheses. Dashed line represents ICER estimate for 40 years after RHIVA2 intervention using base case values of all parameters (appendix pp 16–18). Model parameters varied in univariate sensitivity analysis with minimal effect on the ICER (ie, even less than the parameter quality of life multiplier for identified asymptomatic infections, first year) are not shown. ART=antiretroviral therapy. ICER=incremental cost-effectiveness ratio. *Quality of life multiplier. The Lancet HIV 2017 4, e465-e474DOI: (10.1016/S2352-3018(17)30123-6) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions

Figure 4 Model sensitivity to assumptions on change in sexual behaviour after diagnosis, quality of life, and QALY and cost discount rates Scenario analyses exploring the sensitivity of model results to different (A) levels of reduction in sexual behaviour among people upon HIV diagnosis; (B) assumptions regarding quality of life after diagnosis; and (C) QALY and cost discount rates. The NICE threshold for cost-effectiveness of £20 000–30 000 is shown in grey. QALY=quality-adjusted life-year. NICE=National Institute for Health and Care Excellence. The Lancet HIV 2017 4, e465-e474DOI: (10.1016/S2352-3018(17)30123-6) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license Terms and Conditions