Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study

BACKGROUND AND IMPORTANCE

The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic.

OBJECTIVE

To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis.

DESIGN

This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios.

SETTINGS AND PARTICIPANTS

Patients attended 34 Spanish EDs.

INTERVENTION OR EXPOSURE

The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results.

OUTCOME MEASURES AND ANALYSIS

The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI).

MAIN RESULTS

HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests.

CONCLUSION

Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis

INTRODUCTION

Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs).

METHODS

We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing.

RESULTS

We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0-80.1, I2 = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9-68.4, I2 = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1-43.9, I2 = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5-34.3, I2 = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world.

DISCUSSION

This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs.

CONCLUSIONS

Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.

Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care

BACKGROUND

Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care.

METHODS

We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed.

RESULTS

Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics.

CONCLUSIONS

Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.

Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review

The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE^®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Finding and treating early-stage HIV infections: A cost-effectiveness analysis of the Sabes study in Lima, Peru

Background

Sabes, a treatment-as-prevention intervention among men who have sex with men and transgender women in Lima, Peru, was developed to identify HIV during early primary infection (<3 months from acquisition) through monthly serologic assays and HIV RNA tests. Newly diagnosed individuals were rapidly linked to care and offered to initiate ART. In this study we sought to study the cost-effectiveness of Sabes compared to the standard of care (SOC) for HIV testing and initiation of treatment.

Methods

We adapted a compartmental model of HIV transmission to evaluate the cost-effectiveness of the Sabes approach compared to the SOC using a government health care perspective, 20-year time horizon, and 3% annual discounting. We estimated the proportion of cases of HIV detected during early primary infection, reduction in HIV incidence and prevalence, incremental cost-effectiveness ratio (ICER), and net monetary benefit. We analyzed costs using data from the Sabes study, the Peruvian Ministry of Health, published literature, and expert consultation.

Findings

The Sabes intervention is projected to identify 9294 early primary HIV infections in Lima, Peru over 20 years. The intervention costs $6,896 per early primary infection diagnosed and by 2038 is expected to decrease the fraction of early infections among prevalent infections by 62%. Sabes is expected to improve health, resulting in greater total discounted QALYs per person than the SOC (16·7 vs 16·4, respectively). Sabes had an ICER of $1431 (22% per capita GDP in Peru) per QALY compared to SOC.

Interpretation

Our analysis suggests that in Lima, Peru the Sabes intervention could be a cost-effective approach to reduce the burden of HIV even under stringent cost-effectiveness criteria. This finding suggests that programs that use frequent HIV testing, rapid linkage to care and initiation of ART should be considered as part of a comprehensive HIV prevention strategy.

Funding

National Institutes of Health.

How to best conduct universal HIV screening in emergency departments is far from settled

HIV screening in the emergency department (ED), including universal screening irrespective of risk assessments, has shown strong promise in past studies, identifying many new cases of HIV infection among those who lack access to traditional HIV testing services. Yet, over the years a consistent set of challenges and limitations have presented themselves in settings throughout the United States. We review considerations for evaluating and improving the success of ED-based HIV screening programs in the United States.

Impact and barriers of an HIV rapid test program implementation at an oncological referral center in Mexico

The aim of this study was to evaluate the implementation of human immunodeficiency virus (HIV) screening with rapid tests in an oncologic center in Mexico City, report the HIV prevalence, and describe contacts screening and linkage to HIV care while identifying barriers to the performance of the program. In 2014, an HIV rapid test program was implemented in four departments of the hospital "Instituto Nacional de Cancerología". From 2014 to 2016, 3032 HIV rapid tests were performed in the hospital. The overall HIV prevalence was 0.8%, with the highest prevalence in the Hematology Department (2.4%). In the Gynecology Department, prevalence was 0.05%. Only 25 and 22 tests were performed in the lung cancer and germ cell tumor clinic, respectively, with one positive test. The health staff not offering the test was the main limitation to the full implementation of the program in those departments. The contacts screening led to three positive cases. The acceptance of the test was 99%. Patients who tested positive were seen by an infectious diseases physician on the same day the test was performed. Rapid HIV tests are a useful tool to expand HIV diagnosis in patients with cancer and to establish a rapid linkage to HIV care. Staff education needs to be improved to raise awareness of the health staff for a successful scale up of the program.

Cost-effectiveness of HIV screening in high-income countries: A systematic review

INTRODUCTION

Over 2 million people in high-income countries live with HIV. Early diagnosis and treatment present benefits for infected subjects and reduce secondary transmissions. Cost-effectiveness analyses are important to effectively inform policy makers and consequently implement the most cost-effective programmes. Therefore, we conducted a systematic review regarding the cost-effectiveness of HIV screening in high-income countries.

METHODS

We followed PRISMA statements and included all papers evaluating the cost-effectiveness of HIV screening in the general population or in specific subgroups.

RESULTS

Thirteen studies considered routine HIV testing in the general population. The most cost-effective option appeared to be associating one-time testing of the general population with annual screening of high-risk groups, such as injecting-drug users. Thirteen studies assessed the cost-effectiveness of HIV screening in specific settings, outlining the attractiveness of similar programmes in emergency departments, primary care, sexually transmitted disease clinics and substance abuse treatment programmes.

DISCUSSION

Evidence regarding the health benefits and cost-effectiveness of HIV screening is growing, even in low-prevalence countries. One-time screenings offered to the adult population appear to be a valuable choice, associated with repeated testing in high-risk populations. The evidence regarding the benefits of using a rapid test, even in terms of cost-effectiveness, is growing. Finally, HIV screening seems useful in specific settings, such as emergency departments and STD clinics.

Lessons Learned From the Development and Parameterization of a Computer Simulation Model to Evaluate Task Modification for Health Care Providers

Computer simulation is a highly advantageous method for understanding and improving health care operations with a wide variety of possible applications. Most computer simulation studies in emergency medicine have sought to improve allocation of resources to meet demand or to assess the impact of hospital and other system policies on emergency department (ED) throughput. These models have enabled essential discoveries that can be used to improve the general structure and functioning of EDs. Theoretically, computer simulation could also be used to examine the impact of adding or modifying specific provider tasks. Doing so involves a number of unique considerations, particularly in the complex environment of acute care settings. In this paper, we describe conceptual advances and lessons learned during the design, parameterization, and validation of a computer simulation model constructed to evaluate changes in ED provider activity. We illustrate these concepts using examples from a study focused on the operational effects of HIV screening implementation in the ED. Presentation of our experience should emphasize the potential for application of computer simulation to study changes in health care provider activity and facilitate the progress of future investigators in this field.

Modelling the cost-effectiveness of HIV care shows a clear benefit when transmission risk is considered in the calculations - A message for Central and Eastern Europe

BACKGROUND

HIV epidemic remains a major global health issue. Data from cost-effectiveness analyses base on CD4+ count and morbidity in patients with symptomatic and asymptomatic HIV infection. The approach adopted in these analyses includes many other factors, previously not investigated. Additionally, we evaluate the impact of sexual HIV transmission due to delayed cART on the cost-effectiveness of care.

METHODS

A lifetime Markov model (1-month cycle) was developed to estimate the cost per quality adjusted life years (QALY) for a 1- and 3-year delay in starting cART (as compared to starting immediately at linkage to care) lifetime costs, clinical outcomes and cost-effectiveness. Patients were categorized into having asymptomatic HIV, AIDS, Hodgkin's Lymphoma, and non-AIDS defining condition. Mortality rates and utility values were obtained from published literature. The number of new infected persons was estimated on the basis of sexual orientation, the number of sexual partners per year, the number of sex acts per month, frequency of condom use and use of cART. For the input Test and Keep in Care (TAK) project cohort data were used. Costs of care, cART and potential life-years lost were based on estimated total costs and the difference in expected QALY gained between an HIV-positive and an average person in Polish population. Costs were based on real expenditures of the Ministry of Health, National Health Fund, available studies and experts' opinion. Costs and effects were discounted at rates of 5% and 3.5%, respectively.

RESULTS

Input data were available for 141 patients form TAK cohort. The estimated number of new HIV infections in low, medium and high risk transmission groups were 0.28, 0.61, 2.07 with 1 and 0.82, 1.80, 6.11 with a 3-year delay, respectively. This reflected QALY loss due to cART delay of 0.52, 1.13, 3.84 and 2.02, 4.43, 15.03 for a 1- and 3-year delay, respectively. If additional costs of treatment and potential life-years lost due to new HIV infections were not taken into account, initiating cART immediately at linkage to care was not cost-saving irrespective of cART delay. Otherwise, when additional costs and QALY lost due to new HIV infections were included, immediate cART initiation was cost-saving regardless of the chosen scenarios.

CONCLUSIONS

If new HIV infections are not taken into account, then starting cART immediately does not dominate comparing to delaying cART. When taking into account HIV transmission in cost-effectiveness analysis, immediate initiation of HIV treatment is a profitable decision from the public payer's perspective.

Progression and Transmission of HIV/AIDS (PATH 2.0)

BACKGROUND

HIV transmission is the result of complex dynamics in the risk behaviors, partnership choices, disease stage and position along the HIV care continuum-individual characteristics that themselves can change over time. Capturing these dynamics and simulating transmissions to understand the chief sources of transmission remain important for prevention.

METHODS

The Progression and Transmission of HIV/AIDS (PATH 2.0) is an agent-based model of a sample of 10,000 people living with HIV (PLWH), who represent all men who have sex with men (MSM) and heterosexuals living with HIV in the U.S.A. Persons uninfected were modeled as populations, stratified by risk and gender. The model included detailed individual-level data from several large national surveillance databases. The outcomes focused on average annual transmission rates from 2008 through 2011 by disease stage, HIV care continuum, and sexual risk group.

RESULTS

The relative risk of transmission of those in the acute phase was nine-times [5^th and 95^th percentile simulation interval (SI): 7, 12] that of those in the non-acute phase, although, on average, those with acute infections comprised 1% of all PLWH. The relative risk of transmission was 24- to 50-times as high for those in the non-acute phase who had not achieved viral load suppression as compared with those who had. The relative risk of transmission among MSM was 3.2-times [SI: 2.7, 4.0] that of heterosexuals. Men who have sex with men and women generated 46% of sexually acquired transmissions among heterosexuals.

CONCLUSIONS

The model results support a continued focus on early diagnosis, treatment and adherence to ART, with an emphasis on prevention efforts for MSM, a subgroup of whom appear to play a role in transmission to heterosexuals.

Fourth generation assays for HIV testing

INTRODUCTION

Laboratory diagnosis of HIV infection is essential for the prevention of infection and the identification of infected individuals who could benefit from highly active antiretroviral therapy. Since the release of the first assays for the detection of anti-HIV antibodies, the technology of immunoassays has improved.

AREAS COVERED

Fourth generation assays - simultaneously detecting HIV p24 antigen and antibodies - have been developed and have been a major improvement in the detection of HIV infection, with a reduction of the diagnostic window. Studies have provided definite evidence for their clinical utility. Combination assays with separate results for anti-HIV antibodies and p24 antigen have been developed. Expert Commentary: In conclusion, fourth generation assays are an effective tool for the laboratory diagnosis of HIV infection. The ADVIA Centaur HIV Ag/Ab Combo assay is in line with most recent fourth generation assays and its clinical utility has been assessed.

All-in-one dry-reagent time-resolved immunofluorometric assay for the rapid detection of HIV-1 and -2 infections

An all-in-one (AIO) dry-reagent time-resolved fluorometric immunoassay that requires minimal liquid handling was developed for the detection of anti-HIV-1 and -2 antibodies. To prepare the AIO wells, in vivo biotinylated capture antigens (r-Bio-HIV-1env and r-Bio-HIV-2env) were immobilized on streptavidin-coated microtitration wells and Eu(III) chelate labelled non-biotinylated tracer antigens [r-HIV-1env-Eu(III) and r-HIV-2env-Eu(III)] were dried in stable form in the same wells. The HIV AIO assay was evaluated with serum/plasma samples (n=148) from in-house and commercial panels at two different incubation times of 15 min and 1h. The overall sensitivity of the AIO assay was 98.6% and specificity was 100% for both the incubation times. The AIO assay can accept whole blood matrix. This assay is envisioned to fill the gap between the rapid point-of-care assays and traditional enzyme immunoassays (EIA) in terms of complexity and turnaround time, without compromising the performance.

A systematic review on cost effectiveness of HIV prevention interventions in the United States

BACKGROUND

The Centers for Disease Control and Prevention (CDC) focus on funding HIV prevention interventions likely to have high impact on the HIV epidemic. In its most recent funding announcement to state and local health department grantees, CDC required that health departments allocate the majority of funds to four HIV prevention interventions: HIV testing, prevention with HIV-positives and their partners, condom distribution and policy initiatives.

OBJECTIVE

We conducted a systematic review of the published literature to determine the extent of the cost-effectiveness evidence for each of those interventions.

METHODOLOGY

We searched for US-based studies published through October 2012. The studies that qualified for inclusion contained original analyses that reported costs per quality-adjusted life-year saved, life-year saved, HIV infection averted, or new HIV diagnosis. For each study, paired reviewers performed a detailed review and data extraction. We reported the number of studies related to each intervention and summarized key cost-effectiveness findings according to intervention type. Costs were converted to 2011 US dollars.

RESULTS

Of the 50 articles that met the inclusion criteria, 33 related to HIV testing, 15 assessed prevention with HIV-positives and partners, three reported on condom distribution, and one reported on policy initiatives. Methodologies and cost-effectiveness metrics varied across studies and interventions, making them difficult to compare.

CONCLUSION

Our review provides an updated summary of the published evidence of cost effectiveness of four key HIV prevention interventions recommended by CDC. With the exception of testing-related interventions, including partner services, where economic evaluations suggest that testing often can be cost effective, more cost-effectiveness research is needed to help guide the most efficient use of HIV prevention funds.

Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the emergency department

BACKGROUND

The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.

METHODS

This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.

RESULTS

During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were $148,997, whereas total annualized costs for diagnostic HIV testing were $31,355. The average costs per HIV diagnosis were $9,932 and $7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.

CONCLUSIONS

Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.

Cost-effectiveness analysis of screening for KRAS and BRAF mutations in metastatic colorectal cancer

BACKGROUND

In 2009, the American Society of Clinical Oncology recommended that patients with metastatic colorectal cancer (mCRC) who are candidates for anti-epidermal growth factor receptor (EGFR) therapy have their tumors tested for KRAS mutations because tumors with such mutations do not respond to anti-EGFR therapy. Limiting anti-EGFR therapy to those without KRAS mutations will reserve treatment for those likely to benefit while avoiding unnecessary costs and harm to those who would not. Similarly, tumors with BRAF genetic mutations may not respond to anti-EGFR therapy, though this is less clear. Economic analyses of mutation testing have not fully explored the roles of alternative therapies and resection of metastases.

METHODS

This paper is based on a decision analytic framework that forms the basis of a cost-effectiveness analysis of screening for KRAS and BRAF mutations in mCRC in the context of treatment with cetuximab. A cohort of 50 000 patients with mCRC is simulated 10 000 times, with attributes randomly assigned on the basis of distributions from randomized controlled trials.

RESULTS

Screening for both KRAS and BRAF mutations compared with the base strategy (of no anti-EGFR therapy) increases expected overall survival by 0.034 years at a cost of $22 033, yielding an incremental cost-effectiveness ratio of approximately $650 000 per additional year of life. Compared with anti-EGFR therapy without screening, adding KRAS testing saves approximately $7500 per patient; adding BRAF testing saves another $1023, with little reduction in expected survival.

CONCLUSIONS

Screening for KRAS and BFAF mutation improves the cost-effectiveness of anti-EGFR therapy, but the incremental cost effectiveness ratio remains above the generally accepted threshold for acceptable cost effectiveness ratio of $100 000/quality adjusted life year.

Cost effectiveness of the National HIV/AIDS Strategy goal of increasing linkage to care for HIV-infected persons

BACKGROUND

One of the goals of the National HIV/AIDS Strategy (NHAS) is to increase the proportion of HIV-infected individuals linked to care within 3 months of diagnosis (early linkage) from 65% to 85%. Earlier access to care, and eventually, to treatment, increases life expectancy and quality of life for HIV-infected persons. However, longer treatment is also associated with higher costs, especially for antiretroviral drugs. We evaluated the cost effectiveness of achieving the NHAS goal and estimated the maximum cost that HIV programs could spend on linkage to care and remain cost effective.

METHODS

We used the Progression and Transmission of HIV/AIDS model to estimate the effects on life measures and costs associated with increasing early linkage to care from 65% to 85%. We estimated an incremental cost-effectiveness ratio as the additional cost required to reach the target divided by the quality-adjusted life years (QALYs) gained and assumed that programs costing $100,000 or less per QALY gained are cost effective.

RESULTS

Achieving the NHAS linkage-to-care goal increased life expectancy by 0.4 years and delayed the onset of AIDS by 1.2 years on average for every HIV-diagnosed person. Increasing early linkage to care cost an extra $62,200 per QALY gained, considering only benefits to index persons. The maximum that could be cost effectively spent on early linkage-to-care interventions was approximately $5100 per HIV-diagnosed person.

CONCLUSIONS

Considerable investment can be cost effectively made to achieve the NHAS goal on early linkage to care.

Return on public health investment: CDC's Expanded HIV Testing Initiative

BACKGROUND

Over a 3-year period, the Centers for Disease Control and Prevention invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing.

METHODS

We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared with when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1-year to 5-year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection.

RESULTS

Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 to $2.01 for alternative testing intervals of 1-5 years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%.

CONCLUSIONS

The expanded testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs.

HIV testing and care systems focused on sexually transmitted HIV in China

BACKGROUND

Over three-quarters of new HIV infections in China during 2009 were estimated to be from sexual transmission. Over half of those living with HIV do not know their serostatus and identifying and treating individuals with sexually transmitted HIV infection has been challenging.

OBJECTIVE

This global assessment explores Chinese systems for detecting and treating those with HIV infection with a particular focus on groups at increased risk of sexually transmitted HIV.

METHODS

Published literature, grey sources and non-governmental reports were reviewed to describe HIV testing and care systems in China.

RESULTS

HIV testing and care in China involve several parallel health systems and have been largely successful in reaching large numbers of vulnerable individuals. Provider-initiated testing and counselling has been more effective than voluntary counselling and testing programmes for expanding HIV testing efforts in China. Individuals with sexually transmitted HIV infection are underrepresented in the antiretroviral care system compared with other high-risk groups.

CONCLUSIONS

Comprehensive HIV testing and care bring together a number of Chinese health systems, but there are still gaps and challenges. Research and programmes focused on HIV testing and care for those with increased sexual risk are needed.

How Much Should We Pay for a New HIV Diagnosis? A Mathematical Model of HIV Screening in US Clinical Settings

Objective. To develop a model to assist clinical setting decision makers in determining how much they can spend on human immunodeficiency virus (HIV) screening and still be cost-effective. Design. The authors developed a simple mathematical model relating the program cost per new HIV diagnosis to the cost per HIV infection averted and the cost per quality-adjusted life year (QALY) saved by screening. They estimated outcomes based on behavioral changes associated with awareness of HIV infection and applied the model to US sexually transmitted disease clinics. Methods. The authors based the cost per new HIV diagnosis (2009 US dollars) on the costs of testing and the proportion of persons who tested positive. Infections averted were calculated from the reduction in annual transmission rates between persons aware and unaware of their infections. The authors defined program costs from the sexually transmitted disease clinic perspective and treatment costs and QALYs saved from the societal perspective. They undertook numerous sensitivity analyses to determine the robustness of the base case results. Results. In the base case, the cost per new HIV diagnosis was $2528, the cost per infection averted was $40,516, and the cost per QALY saved was less than zero, or cost-saving. Given the model inputs, the cost per new diagnosis could increase to $22,909 to reach the cost-saving threshold and to $63,053 for the cost-effectiveness threshold. All sensitivity analyses showed that the cost-effectiveness results were consistent for extensive variation in the values of model inputs. Conclusions. HIV screening in a clinical setting is cost-effective for a wide range of testing costs, variations in positivity rates, reductions in HIV transmissions, and variation in the receipt of test results.

Screening acute HIV infections among Chinese men who have sex with men from voluntary counseling & testing centers

Background

Recent studies have shown the public health importance of identifying acute HIV infection (AHI) in the men who have sex with men (MSM) of China, which has a much higher risk of HIV transmission. However, cost-utility analyses to guide policy around AHI screening are lacking.

Methodology/Principal Findings

An open prospective cohort was recruited among MSM living in Liaoning Province, Northeast China. Blood samples and epidemiological information were collected every 10 weeks. Third-generation ELISA and rapid test were used for HIV antibody screening, western blot assay (WB) served for assay validation. Antibody negative specimens were tested with 24 mini-pool nucleic acid amplification testing (NAAT). Specimens with positive ELISA but negative or indeterminate WB results were tested with NAAT individually without mixing. A cost-utility analysis of NAAT screening was assessed. Among the 5,344 follow-up visits of 1,765 MSM in 22 months, HIV antibody tests detected 114 HIV chronic infections, 24 seroconverters and 21 antibody indeterminate cases. 29 acute HIV infections were detected with NAAT from 21 antibody indeterminate and 1,606 antibody negative cases. The HIV-1 prevalence and incidence density were 6.6% (95% CI: 5.5–7.9) and 7.1 (95% CI: 5.4–9.2)/100 person-years, respectively. With pooled NAAT and individual NAAT strategy, the cost of an HIV transmission averted was $1,480. The addition of NAAT after HIV antibody tests had a cost-utility ratio of $3,366 per gained quality-adjusted life year (QALY). The input-output ratio of NAAT was about 1∶16.9.

Conclusions/Significance

The HIV infections among MSM continue to rise at alarming rates. Despite the rising cost, adding pooled NAAT to the HIV antibody screening significantly increases the identification of acute HIV infections in MSM. Early treatment and target-oriented publicity and education programs can be strengthened to decrease the risk of HIV transmission and to save medical resources in the long run.

HIV testing: the cornerstone of HIV prevention efforts in the USA

An estimated 1.2 million persons in the USA are infected with HIV, of whom approximately 20% are unaware they are infected. HIV testing and knowledge of HIV serostatus have important individual and public health benefits, including reduction of morbidity, mortality and HIV transmission. Although testing is the necessary first step to prevention, more than half of the US adult population has never been tested for HIV. However, this proportion is increasing due to revised national recommendations to make HIV testing a routine part of healthcare, expansion of testing efforts at local, state and national levels, and progress in the development and adoption of new testing technologies. In this article, we describe the essential role of HIV testing as a public health prevention strategy, examine recent advances in HIV testing technologies and testing implementation, and identify future directions for HIV testing in the USA.