COST-EFFECTIVENESS OF MANDATORY COMPARED WITH VOLUNTARY SCREENING FORHUMAN-IMMUNODEFICIENCY-VIRUS IN PREGNANCY

Objective: To determine the cost-effectiveness of mandatory screening for human immunodeficiency virus (HIV) in pregnancy compared with that of voluntary screening under varying assumptions about patient behavi or. Methods: Using a health care system perspective, a decision-analys is model was constructed to estimate the outcomes and costs of the two strategies. Average and incremental cost-effectiveness ratios were ca lculated for each strategy. Sensitivity analyses were performed to tes t the effects of different values on the results of the simulation. In particular, we examined the potential effects of changes in patient b ehavior resulting from mandatory screening on our estimates of cost-ef fectiveness. Results: At a prevalence of 170 per 100,000, average cost s per case prevented were $255,158 and $367,998 for mandatory and volu ntary screening, respectively. The incremental cost-effectiveness of m andatory compared with voluntary screening was $29,478. These values d ecreased as prevalence of HIV increased, or as the estimated lifetime cost of pediatric HIV infection increased: above an estimated cost for pediatric HIV of $129,250, mandatory screening was less expensive and more effective than voluntary screening. Assumptions about patient be havior affected these results: a 40% reduction in zidovudine acceptanc e in women identified only through mandatory screening increased the i ncremental cost-effectiveness to $112,434. The impact of behavior incr eased as the prevalence of HIV increased. Conclusion: Mandatory screen ing will prevent more cases of pediatric AIDS, but at a somewhat highe r cost than voluntary screening under baseline assumptions. The cost-e ffectiveness of mandatory screening will be influenced by patient beha vior, especially acceptance of zidovudine treatment among women who wo uld have refused voluntary screening. (C) 1998 by The American College of Obstetricians and Gynecologists.