Italy faces challenges with late HIV diagnoses, which leads to worse health outcomes and higher healthcare costs. In Italy, the proportion of late diagnoses (i.e., a CD4 count <350 cells/mm3) has increased to 60% in 2020—10% higher than the European average (1). With an estimated 13,000–15,000 undiagnosed HIV cases in Italy, innovative testing strategies are urgently needed to close the gap towards the UNAIDS goal of diagnosing 95% of all people living with HIV (PLWH) (1,2).
Recent real-world studies from England, Ireland, and Portugal have demonstrated that routine opt-out HIV screening in EDs could increase early detection and improve linkage to care in medium/high-prevalence regions, and play a vital role in reducing stigma (3–6).
We aimed to estimate the cost-effectiveness of opt-out HIV testing in hospital emergency departments. We developed a closed-cohort hybrid decision tree–Markov model to compare health economic outcomes of two HIV testing strategies in the ED: universal opt-out vs. indicator-condition-guided testing (IC) (Italian standard of care). Data sources included national reports, published studies on healthcare costs, and HIV public health data. Where Italian-specific data were unavailable, estimates from other European studies were used. A lifetime time horizon and a National Health Service perspective were used.
Our model results indicated that universal opt-out HIV testing in the ED was cost-effective compared to IC when HIV prevalence was ≥ 0.25% (at a willingness-to-pay threshold of €30 000/QALY). This prevalence threshold is similar to the 0.2% threshold above which NICE recommends ED HIV testing in the UK (>0.2%)(2). This threshold may be particularly useful to inform local decision-makers in Italy, where healthcare decisions are made at the regional level. Our model also showed that opt-out testing in the ED can improve linkage to care. For every 10,000 individuals attending ED, opt-out testing yielded 16 additional new HIV diagnoses and 14 more individuals linked to care compared to IC.
The model may underestimate the full benefits of this strategy, as it did not account for disengaged patients or transmissions averted. We hope this study will contribute to the ongoing national dialogue on the potential introduction of universal opt-out HIV testing strategy in EDs in Italy. The complete results, including secondary and scenario analyses, have been published in European Journal of Public Health in April 2025.
Link to the publication: https://doi.org/10.1093/eurpub/ckaf057
Acknowledgements: This work was commissioned and funded by Gilead Sciences. The work was carried out independently by Aquarius Population Health
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Article by Hairuo He May 2025