Cost-Effectiveness of Geographically Targeted HIV Testing in Emergency Departments

Emergency departments (EDs) are uniquely positioned to identify undiagnosed HIV, yet HIV testing rates in EDs remain among the lowest of any care setting and have declined in recent years. This persists despite renewed federal efforts through the Ending the HIV Epidemic initiative (EHE) calling for expanded HIV testing, with a focus on a subset of high-risk “priority” jurisdictions. Many ED directors cite a perceived lack of cost-effectiveness as a key barrier to more frequent HIV testing.

We developed a microsimulation model with a lifetime horizon of 100,000 individuals, simulating probabilistic transitions between health states among a cohort of persons presenting to EDs for care. Individuals were assigned nationally representative ED patient characteristics to capture geographic variation in age, sex, and social and structural determinants of health associated with poorer outcomes and HIV risk. We also allowed for known differential ED utilization among populations. We compared a base case assumption of 1% HIV testing to five distinct strategies: universal testing, testing in all EHE priority jurisdiction EDs, testing in all EDs with a teaching hospital affiliation, testing in teaching-affiliated ED within priority jurisdictions, and no testing. From a healthcare and societal perspective, we estimated discounted costs, quality-adjusted life years (QALYs), new HIV diagnoses and mortality, and conducted probabilistic sensitivity analyses varying HIV incidence, linkage to care, and ED visit volumes.

At a willingness-to-pay threshold of $100,000 per QALY, targeting HIV screening to teaching-affiliated EDs in EHE priority jurisdictions was the most cost-effective strategy. Broader screening strategies increased testing but were not as cost-effective. In probabilistic sensitivity analysis, conclusions were robust, with uncertainty driven primarily by HIV incidence and linkage to care.

Targeting HIV screening to the highest-risk emergency departments, priority jurisdiction EDs with teaching hospital affiliations, was the most cost-effective strategy identified and may be the most efficient use of limited resources.