Abstract
Background: Incarcerated populations experience disproportionately high rates of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and sexually transmitted infections (STIs), particularly in geographic "hotspot" areas. Despite Center of Disease Control (CDC) recommendations for routine opt-out screening, most U.S. jails rely on risk-based approaches that miss a substantial proportion of infections. Missing opportunities to treat for these infectious diseases in jails represents a significant issue; reducing the prevalence of communicable diseases on a national level requires addressing carceral hotspot areas.
Objective: To compare the cost-effectiveness of routine opt-out versus risk-based screening for HIV, HCV, chlamydia, syphilis, and gonorrhea in jails located within infection hotspots.
Methods: We created Markov state transition models using parameters derived from existing literature for five major infections – HIV, HCV, chlamydia, syphilis, and gonorrhea. With these models, we ran simulations that showcase the predicted number of infected incarcerated individuals who receive treatment with opt-out screening versus risk-based screening. Using health utility values and treatment costs, we calculated the Incremental Cost Effectiveness Ratio (ICER) for all infection models that we compared to a Willingness to Pay Threshold (WTP) to assess the relative cost effectiveness of opt-out screening and risk-based screening.
Results: For STI models, opt-out screening shows high cost-effectiveness relative to the WTP, with ICER values being far below the $100,000 WTP (ranging from $727 to $4,941 additional cost for opt-out screening per QALY gained). The HCV model showed moderate cost effectiveness with opt-out screening, with an ICER of $85,760 per QALY gained, whereas the HIV model was not cost-effective. Additionally, a higher proportion of infected individuals are estimated to be able to complete full treatment course while incarcerated with opt-out screening. Considerable gains were seen with the chlamydia and syphilis models with 20.5% and 22.8% more infection positive cases estimated to be fully treatable during incarceration respectively.
Conclusions: Routine opt-out screening for most infectious diseases examined is highly cost-effective in hotspot jails. Our findings support prioritizing opt-out screening implementation in high-burden correctional facilities as a strategy to improve individual health outcomes and reduce community transmission.