Routine human immunodeficiency virus testing: an economic evaluation of current guidelines

Mapping hematologists' HIV testing behavior among lymphoma patients-A mixed-methods study

BACKGROUND

HIV testing among patients with malignant lymphoma (PWML) is variably implemented. We evaluated HIV testing among PWML, and mapped factors influencing hematologists' testing behavior.

MATERIALS

We conducted a mixed-methods study assessing HIV testing among PWML, factors influencing HIV testing and opportunities for improvement in five hospitals in the region of Amsterdam, the Netherlands. The proportion of PWML tested for HIV within 3 months before or after lymphoma diagnosis and percentage positive were assessed from January 2015 through June 2020. Questionnaires on intention, behavior and psychosocial determinants for HIV testing were conducted among hematologists. Through twelve semi-structured interviews among hematologists and authors of hematology guidelines, we further explored influencing factors and opportunities for improvement.

FINDINGS

Overall, 1,612 PWML were included for analysis, including 976 patients newly diagnosed and 636 patients who were referred or with progressive/relapsed lymphoma. Seventy percent (678/976) of patients newly diagnosed and 54% (343/636) of patients with known lymphoma were tested for HIV. Overall, 7/1,021 (0.7%) PWML tested HIV positive, exceeding the 0.1% cost-effectiveness threshold. Questionnaires were completed by 40/77 invited hematologists, and 85% reported intention to test PWML for HIV. In the interviews, hematologists reported varying HIV testing strategies, including testing all PWML or only when lymphoma treatment is required. Recommendations for improved HIV testing included guideline adaptations, providing electronic reminders and monitoring and increasing awareness.

CONCLUSIONS

Missed opportunities for HIV testing among PWML occurred and HIV test strategies varied among hematologists. Efforts to improve HIV testing among PWML should include a combination of approaches.

Improving indicator-condition guided testing for HIV in the hospital setting (PROTEST 2·0): A multicenter, interrupted time-series analysis

BACKGROUND

Indicator-condition (IC) guided HIV testing is a feasible and cost-effective strategy to identify undiagnosed people living with HIV (PLHIV), but remains insufficiently implemented. We aimed to promote IC-guided HIV testing in seven ICs.

METHODS

Relevant departments in five hospitals of the Amsterdam region participated. HIV testing among adult patients without known HIV infection but with an IC was assessed using electronic health records during pre-intervention (January 2015-June 2020) and intervention (July 2020-June 2021) periods. The multifaceted intervention included audit and feedback. The primary endpoint was HIV testing ≤3 months before or after IC diagnosis and the effect of the intervention was evaluated using segmented Poisson regression.

FINDINGS

Data from 7986 patients were included, of whom 6730 (84·3%) were diagnosed with an IC in the pre-intervention period and 1256 (15·7%) in the intervention period. The proportion HIV tested ≤3 months before or after IC diagnosis increased from 36.8% to 47.0% (adjusted risk ratio [RR]= 1.16, 95% CI=1.03-1.30, p=0.02). For individual ICs, we observed significant increases in HIV testing among patients with cervical cancer or intraepithelial neoplasia grade 3 (adjusted RR=3.62, 95% CI=1.93-6.79) and peripheral neuropathy (adjusted RR=2.27 95% CI=1.48-3.49), but not the other ICs. Eighteen of 3068 tested patients were HIV positive (0.6%).

INTERPRETATION

Overall IC-guided testing improved after the intervention, but not for all ICs. Variations in effect by IC may have been due to variations in implemented developments, but the effect of separate elements could not be assessed.

FUNDING

HIV Transmission Elimination Amsterdam (H-TEAM) initiative, Aidsfonds (grant number: P-42702).

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.

Economic evaluation of HIV testing options for low-prevalence high-income countries: a systematic review

INTRODUCTION

This study reviewed the economic evidence of rapid HIV testing versus conventional HIV testing in low-prevalence high-income countries; evaluated the methodological quality of existing economic evaluations of HIV testing studies; and made recommendations on future economic evaluation directions of HIV testing approaches.

METHODS

A systematic search of selected databases for relevant English language studies published between Jan 1, 2001, and Jan 30, 2019, was conducted. The methodological design quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and the Drummond tool. We reported the systematic review according to the PRISMA guidelines.

RESULTS

Five economic evaluations met the eligibility criteria but varied in comparators, evaluation type, perspective, and design. The methodologic quality of the included studies ranged from medium to high. We found evidence to support the cost-effectiveness of rapid HIV testing approaches in low-prevalence high-income countries. Rapid HIV testing was associated with cost per adjusted life year (QALY), ranging from $42,768 to $90,498. Additionally, regardless of HIV prevalence, rapid HIV testing approaches were the most cost-effective option.

CONCLUSIONS

There is evidence for the cost-effectiveness of rapid HIV testing, including the use of saliva-based testing compared to usual care or hospital-based serum testing. Further studies are needed to draw evidence on the relative cost-effectiveness of the distinct options and contexts of rapid HIV testing.

Rapid, point-of-care diagnosis of tuberculosis with novel Truenat assay: Cost-effectiveness analysis for India's public sector

Background

Truenat is a novel molecular assay that rapidly detects tuberculosis (TB) and rifampicin-resistance. Due to the portability of its battery-powered testing platform, it may be valuable in peripheral healthcare settings in India.

Methods

Using a microsimulation model, we compared four TB diagnostic strategies for HIV-negative adults with presumptive TB: (1) sputum smear microscopy in designated microscopy centers (DMCs) (SSM); (2) Xpert MTB/RIF in DMCs (Xpert); (3) Truenat in DMCs (Truenat DMC); and (4) Truenat for point-of-care testing in primary healthcare facilities (Truenat POC). We projected life expectancy, costs, incremental cost-effectiveness ratios (ICERs), and 5-year budget impact of deploying Truenat POC in India’s public sector. We defined a strategy “cost-effective” if its ICER was <US$990/year-of-life saved (YLS). Model inputs included: TB prevalence, 15% (among those not previously treated for TB) and 27% (among those previously treated for TB); sensitivity for TB detection, 89% (Xpert) and 86% (Truenat); per test cost, $12.63 (Xpert) and $13.20 (Truenat); and linkage-to-care after diagnosis, 84% (DMC) and 95% (POC). We varied these parameters in sensitivity analyses.

Results

Compared to SSM, Truenat POC increased life expectancy by 0.39 years and was cost-effective (ICER $210/YLS). Compared to Xpert, Truenat POC increased life expectancy by 0.08 years due to improved linkage-to-care and was cost-effective (ICER $120/YLS). In sensitivity analysis, the cost-effectiveness of Truenat POC, relative to Xpert, depended on the diagnostic sensitivity of Truenat and linkage-to-care with Truenat. Deploying Truenat POC instead of Xpert increased 5-year expenditures by $270 million, due mostly to treatment costs. Limitations of our study include uncertainty in Truenat’s sensitivity for TB and not accounting for the “start-up” costs of implementing Truenat in the field.

Conclusions

Used at the point-of-care in India, Truenat for TB diagnosis should improve linkage-to-care, increase life expectancy, and be cost-effective compared with smear microscopy or Xpert.

Qualitative evaluation of a pilot educational intervention to increase primary care HIV-testing

BACKGROUND

UK guidelines recommend a 'routine offer of HIV testing' in primary care where HIV diagnosed prevalence exceeds 2 in 1000. However, current primary care HIV testing rates are low. Efforts to increase primary care HIV testing are needed. To examine how an educational intervention to increase HIV testing in general practice was experienced by healthcare professionals (HCPs) and to understand the perceived impacts on HIV testing.

METHOD

Qualitative interviews with general practitioners (GPs) and nurses 3-months after receiving an educational intervention developed from an adapted version of the Medical Foundation for HIV and Sexual Health (MEDFASH) HIV Testing In Practice (TIPs) online educational tool which included training on HIV associated clinical indicator conditions, why, who, and how to test. The intervention was delivered in 19 high-HIV prevalence general practices in Bristol. 27 semi-structured interviews were conducted across 13 practices with 16 GPs, 10 nurses and the sexual health clinician who delivered the intervention. Transcripts were analysed thematically informed by Normalisation Process Theory.

RESULTS

HCPs welcomed the opportunity to update their HIV knowledge through a tailored, interactive session. Post-training, HCPs reported increased awareness of HIV indicator conditions, confidence to offer HIV tests and consideration of HIV tests. Continued testing barriers include perceived lack of opportunity.

CONCLUSIONS

This qualitative study found that HIV education is perceived as valuable in relation to perceived awareness, confidence, and consideration of HIV testing. However, repetition and support from other strategies are needed to encourage HCPs to offer HIV tests. Future interventions should consider using behaviour change theory to develop a complex intervention that addresses not only HCP capability to offer an HIV test, but also issues of opportunity and motivation.

Evaluation of an educational intervention to increase HIV-testing in high HIV prevalence general practices: a pilot feasibility stepped-wedged randomised controlled trial

BACKGROUND

HIV-infected patients often present to primary care several times with HIV-indicator conditions before diagnosis but the opportunity to test by healthcare professionals (HCPs) is frequently missed. Current HIV testing rates in primary care are low and educational interventions to facilitate HCPs to increase testing and awareness of HIV are needed.

METHOD

We implemented a pilot feasibility stepped-wedged randomised controlled trial of an educational intervention in high HIV prevalence practices in Bristol. The training delivered to HCPs including General Practitioners (GP) aimed to increase HIV testing and included why, who, and how to test. The intervention was adapted from the Medical Foundation for HIV and Sexual Health HIV Testing in Practice (MEDFASH) educational tool. Questionnaires assessed HCP feedback and perceived impacts of the intervention. HIV testing rates were compared between control and intervention practices using 12 monthly laboratory totals.

RESULTS

169 HCPs (from 19 practices) received the educational intervention. 127 (75%) questionnaires were completed. Delivery of the intervention was received positively and was perceived as valuable for increasing awareness, confidence and consideration of testing, with HCPs gaining more awareness of HIV testing guidelines. The main pre-training HIV testing barrier reported by GPs was the patient not considering themselves at risk, whilst for nurses it was a concern about embarrassing or offending the patient. Most HCPs reported the intervention addressed these barriers. The HIV testing rate increased more in the control than in the intervention practices: mean difference 2.6 (95% CI 0.5,4.7) compared with 1.9 (- 0.5,4.3) per 1000 patients, respectively. The number of HIV tests across all practices increased from 1154 in the first 6 months to 1299 in the second 6 months, an annual increase in testing rate of 2.0 (0.7,3.4) from 16.3 to 18.3 per 1000 patients.

CONCLUSION

There was a small increase in HIV testing rates over the study period, but this could not be attributed to the educational intervention. More effective and sustainable programmes tailored to each practice context are needed to change testing culture and HCP behaviour. Repeated training, supported by additional measures, such as testing prompts, may be needed to influence primary care HIV testing.

Hispanic Students' Perceptions About HIV/STI Testing and Prevention: A Mixed-Methods Study in a Hispanic-Serving University

Hispanic young adults in the United States are disproportionately affected by HIV and should be considered a priority for prevention efforts. The purpose of this study was to explore perceptions and beliefs of English-speaking students (aged 18-24 years) at a Hispanic-serving university about HIV/sexually transmitted infection (STI) testing and prevention to increase acceptance and adoption of services. Four major themes emerged from four qualitative focus groups (n = 30 students) and were corroborated by an optional anonymous survey (n = 24 surveys): (a) preferences for HIV/STI testing services, (b) essential HIV/STI testing information, (c) preferred delivery method of HIV/STI testing information, and (d) culturally appropriate message design with Hispanic young adults. Findings suggest that Hispanic young adults perceive accessible testing to be important to their community and view normalization of these services as a necessary component of successful adoption and adherence. Although flyers were reported as a practical means for distributing on-campus testing and service information, social media was endorsed as one of the most effective ways to reach young adults. Among participants, there was less consensus regarding the need for cultural tailoring. Results provide practical insights into the development and application of health promotion strategies with an ethnic minority group and demonstrate how a mixed-methods approach can be employed to inform health promotional efforts.

Provider-initiated HIV counseling and testing of out patients at community hospitals in Thailand: an economic evaluation using the Markov model

Background: Provider-initiated HIV counseling and testing (PIHIVCT) is an important intervention that improves the access to care to HIV-infected patients and subsequently contributes to the success of national HIV/AIDS control efforts. However, in Thailand, the cost-effectiveness of this program is unknown. Objective: Determine the incremental cost-effectiveness ratios (ICER) in terms of Thai Baht per Quality Adjusted Life Year (QALY) of PIHIVCT for outpatient department (OPD) patients in community hospitals of Thailand compared with the current practice. Methods: A model-based health economic evaluation study was conducted based on results from cluster randomized controlled trials in 16 community hospitals of Thailand. The Markov model and the probabilistic sensitivity analysis were used. One-thousand two-hundred seventy-seven HIV-infected patients completed questionnaires on their household expenditure and quality of life using the visual analog scale. Results: In social perspectives, the PIHIVCT program increased a patient’s life span by 5.18 days or 4.15 qualityadjusted days per OPD case and the ICER was 63,588 Baht per QALY gained. The subgroup analysis showed that the PIHIVCT program would be cost-effective for cases younger than 50 years if the ceiling threshold of willing to pay equaled the per capita Gross Domestic Product (GDP). However, this intervention would be cost-effective for all cases of 13-64 year old if the ceiling threshold equaled three times of GDP. Conclusion: The provider-initiated HIV counseling and testing program for OPD patients is more cost-effective than the current practice and should be implemented in health care setting in Thailand.

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.

Routine or targeted HIV screening of Indonesian prisoners

PURPOSE

Routine HIV screening of prisoners is generally recommended, but rarely implemented in low-resource settings. Targeted screening can be used as an alternative. Both strategies may provide an opportunity to start HIV treatment but no formal comparisons have been done of these two strategies. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The authors compared yield and costs of routine and targeted screening in a narcotic prison in Indonesia. Routine HIV screening was done for all incoming prisoners from August 2007-February 2009, after it was switched for budgetary reasons to targeted ("opt-out") HIV screening of inmates classified as people who inject drugs (PWIDs), and "opt-in" HIV testing for all non-PWIDs.

FINDINGS

During routine screening 662 inmates were included. All 115 PWIDs and 93.2 percent of non-PWIDs agreed to be tested, 37.4 percent and 0.4 percent respectively were HIV-positive. During targeted screening (March 2009-October 2010), of 888 inmates who entered prison, 107 reported injecting drug use and were offered HIV testing, of whom 31 (29 percent) chose not to be tested and 25.0 percent of those tested were HIV-positive. Of 781 non-PWIDs, 187 (24 percent) came for testing (opt-in), and 2.1 percent were infected. During targeted screening fewer people admitted drug use (12.0 vs 17.4 percent). Routine screening yielded twice as many HIV-infected subjects (45 vs 23). The estimated cost per detected HIV infection was 338 USD for routine and 263 USD for targeted screening.

ORIGINALITY/VALUE

In a resource limited setting like Indonesia, routine HIV screening in prison is feasible and more effective than targeted screening, which may be stigmatizing. HIV infections that remain unrecognized can fuel ongoing transmission in prison and lead to unnecessary disease progression and deaths.

HIV testing in US tuberculosis care settings: a survey of current practice and perceived barriers

CONTEXT

Extent of and challenges to implementation of the Centers for Disease Control and Prevention (CDC) 2006 recommendation for routine HIV testing have not been reviewed specifically within tuberculosis (TB) care settings.

OBJECTIVE

To determine current adherence to the CDC's HIV testing recommendations in TB care settings and identify barriers.

DESIGN

An online survey was designed and distributed via Survey Monkey.

SETTING

The 2011 National TB Conference attendees, National TB Nurse Controllers, and the CDC's TB-educate mailing list were invited to participate via e-mail.

PARTICIPANTS

A total of 153 respondents from US states: 30 physicians, 91 nurses, 19 public health practitioners, and 13 other.

MAIN OUTCOME MEASURES

Perceived importance of HIV testing, current HIV testing practices, perceived barriers to HIV testing, and understanding of state HIV testing laws.

RESULTS

One hundred forty-one of 153 (92.2%) reported that patients with TB disease were "always" or "almost always" HIV tested; 65 of 153 (42.5%) reported the same for patients with latent TB infection (LTBI). Among those not routinely testing LTBI patients, "patient refusal of test" (53/88; 60.2%), "cost" (41/88; 46.6%), and "prevalence too low to justify" (33/88; 37.5%) were the most commonly identified barriers to opt-out testing. Forty-seven of 59 providers (79.7%) who reported that their state required written consent for HIV testing had incorrect knowledge regarding HIV testing legislation.

CONCLUSIONS

Rates of HIV testing are high for patients with TB disease, but fewer than half of providers' care settings routinely test LTBI patients. Knowledge of HIV status is required to appropriately interpret TST results and make decisions regarding treatment in TB infection, since HIV coinfection increases risk of progression to active TB. Lack of HIV testing in LTBI patients represents a missed opportunity to prevent TB disease and its resultant morbidity and mortality. In addition, incorrect knowledge regarding testing legislation was a common problem among our TB providers. Further work is necessary to improve HIV testing rates in patients who have not yet progressed to active TB disease.

Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England

OBJECTIVES

Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings.

METHODS

Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis.

RESULTS

In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs.

CONCLUSIONS

Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

HIV Treatment and Prevention: A Simple Model to Determine Optimal Investment

OBJECTIVE

To create a simple model to help public health decision makers determine how to best invest limited resources in HIV treatment scale-up and prevention.

METHOD

A linear model was developed for determining the optimal mix of investment in HIV treatment and prevention, given a fixed budget. The model incorporates estimates of secondary health benefits accruing from HIV treatment and prevention and allows for diseconomies of scale in program costs and subadditive benefits from concurrent program implementation. Data sources were published literature. The target population was individuals infected with HIV or at risk of acquiring it. Illustrative examples of interventions include preexposure prophylaxis (PrEP), community-based education (CBE), and antiretroviral therapy (ART) for men who have sex with men (MSM) in the US. Outcome measures were incremental cost, quality-adjusted life-years gained, and HIV infections averted.

RESULTS

Base case analysis indicated that it is optimal to invest in ART before PrEP and to invest in CBE before scaling up ART. Diseconomies of scale reduced the optimal investment level. Subadditivity of benefits did not affect the optimal allocation for relatively low implementation levels. The sensitivity analysis indicated that investment in ART before PrEP was optimal in all scenarios tested. Investment in ART before CBE became optimal when CBE reduced risky behavior by 4% or less. Limitations of the study are that dynamic effects are approximated with a static model.

CONCLUSIONS

Our model provides a simple yet accurate means of determining optimal investment in HIV prevention and treatment. For MSM in the US, HIV control funds should be prioritized on inexpensive, effective programs like CBE, then on ART scale-up, with only minimal investment in PrEP.

Swab2know: An HIV-Testing Strategy Using Oral Fluid Samples and Online Communication of Test Results for Men Who Have Sex With Men in Belgium

Background

As HIV remains a public health concern, increased testing among those at risk for HIV acquisition is important. Men who have sex with men (MSM) are the most important group for targeted HIV testing in Europe. Several new strategies have been developed and implemented to increase HIV-testing uptake in this group, among them the Swab2know project.

Objective

In this project, we aim to assess the acceptability and feasibility of outreach and online HIV testing using oral fluid samples as well as Web-based delivery of test results.

Methods

Sample collection happened between December 2012 and April 2014 via outreach and online sampling among MSM. Test results were communicated through a secured website. HIV tests were executed in the laboratory. Each reactive sample needed to be confirmed using state-of-the-art confirmation procedures on a blood sample. Close follow-up of participants who did not pick up their results, and those with reactive results, was included in the protocol. Participants were asked to provide feedback on the methodology using a short survey.

Results

During 17 months, 1071 tests were conducted on samples collected from 898 men. Over half of the samples (553/1071, 51.63%) were collected during 23 outreach sessions. During an 8-month period, 430 samples out of 1071 (40.15%) were collected from online sampling. Additionally, 88 samples out of 1071 (8.22%) were collected by two partner organizations during face-to-face consultations with MSM and male sex workers. Results of 983 out of 1071 tests (91.78%) had been collected from the website. The pickup rate was higher among participants who ordered their kit online (421/430, 97.9%) compared to those participating during outreach activities (559/641, 87.2%; P<.001). MSM participating during outreach activities versus online participants were more likely to have never been tested before (17.3% vs 10.0%; P=.001) and reported more sexual partners in the 6 months prior to participation in the project (mean 7.18 vs 3.23; P<.001). A total of 20 participants out of 898 (2.2%) were confirmed HIV positive and were linked to care. Out of 1071 tests, 28 (2.61%) with a weak reactive result could not be confirmed, and were thereby classified as false reactive results. Most of the 388 participants who completed posttest surveys (388/983, 39.5%) were very positive about their experience. The vast majority (371/388, 95.6%) were very satisfied, while 17 out of 388 (4.4%) reported mixed feelings.

Conclusions

Despite a high yield and a considerable number of false reactive results, satisfaction was high among participants. The project helped us to reach the target population, both in numbers of tests executed and in newly diagnosed HIV infections. Further optimization should be considered in the accuracy of the test, the functionalities of the website (including an online counseling tool), and in studying the cost effectiveness of the methodology.

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.

HIV test offers and acceptance: New York State findings from the behavioral risk factor surveillance system and the National HIV behavioral surveillance, 2011-2012

BACKGROUND

The New York State HIV testing law requires that patients aged 13-64 years be offered HIV testing in health care settings. We investigated the extent to which HIV testing was offered and accepted during the 24 months after law enactment.

METHODS

We added local questions to the Behavioral Risk Factor Surveillance System (BRFSS) and the National HIV Behavioral Surveillance (NHBS) surveys asking respondents aged 18-64 years whether they were offered an HIV test in health care settings, and whether they had accepted testing. Statewide prevalence estimates of test offers and acceptance were obtained from a combined 2011-2012 BRFSS sample (N = 6,223). Local estimates for 2 high-risk populations were obtained from NHBS 2011 men who have sex with men (N = 329) and 2012 injection drug users (N = 188) samples.

RESULTS

BRFSS data showed that 73% of New Yorkers received care in any health care setting in the past 12 months, of whom 25% were offered an HIV test. Sixty percent accepted the test when offered. The levels of test offer increased from 20% to 29% over time, whereas acceptance levels decreased from 68% to 53%. NHBS data showed that 81% of men who have sex with men received care, of whom 43% were offered an HIV test. Eighty-eight percent accepted the test when offered. Eighty-five percent of injection drug users received care, of whom 63% were offered an HIV test, and 63% accepted the test when offered.

CONCLUSIONS

We found evidence of partial and increasing implementation of the HIV testing law. Importantly, these studies demonstrated New Yorkers' willingness to accept an offered HIV test as part of routine care in health care settings.

Did CDC's 2006 revised HIV testing recommendations make a difference? Evaluation of HIV testing in the US household population, 2003-2010

OBJECTIVE

To examine changes in the prevalence of HIV testing among adults following the Centers for Disease Control and Prevention's 2006 revised HIV testing recommendations.

DESIGN

The 2003-2010 National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey of the noninstitutionalized US population.

METHODS

Weighted estimates and multivariable modeling to assess the prevalence of lifetime HIV testing, outside of blood donations, based on 13,975 respondents aged 18-59 years, comparing the 2003-2006 and 2007-2010 National Health and Nutrition Examination Survey.

RESULTS

Overall, HIV testing was 42.1% during 2003-2006 and 44.5% during 2007-2010 (P > 0.05). After adjusting for significant predictors in a multivariate model, HIV testing increased from 2003-2006 to 2007-2010 (adjusted odds ratio [aOR] 1.14, P < 0.05), mostly among males (aOR 1.33, P < 0.001) as compared with females (aOR 1.02, P > 0.05). HIV testing also increased significantly among non-Hispanic blacks, heterosexuals, those aged 50-59 years, those without a sexually transmitted infection history, those without health insurance, and those who did not access health care in the past year. HIV testing did not change significantly among high-risk groups, including men who have sex with men, those with a history of injection or illicit drug use, and those with a sexually transmitted infection history.

CONCLUSIONS

In multivariate modeling, we found a modest but significant increase in HIV testing overall and among males after publication of the revised recommendations for HIV testing. The significant increase in non-high-risk groups suggests an expansion in generalized HIV testing, as recommended. However, even in 2007-2010, 56% of the US population has never been tested for HIV.

A forgotten population: older adults with newly diagnosed HIV

Limited data are available regarding adults age ≥50 at initial HIV diagnosis. Improved understanding of this group is critical in designing interventions to facilitate earlier diagnosis and linkage to HIV care. We characterize individuals newly diagnosed with HIV, particularly those ≥50 years old, and examine the relationship between age and late diagnosis defined as concurrent HIV and AIDS diagnoses. This is a retrospective study of individuals newly diagnosed with HIV from 2006-2011 at an academic medical center in New York City. Multivariable logistic regression was performed to evaluate the effect of age, gender, race/ethnicity, risk factor, and prior medical visits on late diagnosis. Adults age ≥50 comprised 21.3% of all newly diagnosed individuals. Among these older adults, 70.0% were diagnosed as inpatients and 68.9% concurrent with AIDS, compared to 41.7% and 38.9% of younger adults, respectively. On adjusted analyses, age ≥50 (OR 3.13, 95% CI 1.63, 5.98) and injection drug use (OR 4.4, 95% CI 1.31, 14.75) were positively associated with late diagnosis, whereas female gender was negatively associated with late diagnosis (OR 0.52, 95% CI 0.28, 0.98). Our data suggest that HIV testing efforts targeting older adults are essential to address the unmet needs of this population, including implementation of HIV screening guidelines in primary care settings.

Increase in CD4 count among new enrollees in HIV care in the modern antiretroviral therapy era

BACKGROUND

Earlier HIV diagnosis and engagement in care improve outcomes and is cost effective, as a result, in 2006, the Centers for Disease Control and Prevention (CDC) revised the HIV-screening guidelines. We sought to determine whether the CD4 count (CD4) at presentation, a surrogate for time to presentation, increased during the study period. Our a priori hypothesis was that the CD4 at presentation increased during the study period, particularly after the CDC guideline revision.

METHODS

We performed a retrospective cohort study and analyzed data from the HIV Research Network, a consortium of 18 US clinics caring for HIV-infected patients. HIV-infected adults (≥18 years old) newly presenting for care between 2003 and 2011 were included in this study. Multivariable linear regression examined associations with CD4 at enrollment. Calendar year was modeled as a linear spline with a change in slope at 2008, allowing determination of the mean change in CD4 per year during 2003-2007 and 2008-2011.

RESULTS

Over 13,543 newly presenting subjects enrolled from 2003 to 2011. Median CD4 at enrollment rose from 285 to 317 cells per cubic millimeter between 2003-2007 and 2008-2011 (P < 0.001). After adjusting for age, race/ethnicity, gender, HIV risk factor, and clinic site, the mean increase in the CD4 count at presentation per year was 13.3 cells per cubic millimeter per year (95% confidence interval 6.4 to 20.1 cells per cubic millimeter per year) greater during 2008-2011 than during 2003-2007.

CONCLUSIONS

We demonstrate a small, but statistically significant, increase in CD4 at presentation after the CDC guideline revision. More efforts are needed to decrease time to presentation to HIV care.

Modelling the potential population impact and cost-effectiveness of self-testing for HIV: evaluation of data requirements

HIV testing uptake has increased dramatically in recent years in resource limited settings. Nevertheless, over 50 % of the people living with HIV are still unaware of their status. HIV self-testing (HIVST) is a potential new approach to facilitate further uptake of testing which requires consideration, taking into account economic factors. Mathematical models and associated economic analysis can provide useful assistance in decision-making processes, offering insight, in this case, into the potential long-term impact at a population level and the price-point at which free or subsidized HIVST would be cost-effective in a given setting. However, models are based on assumptions, and if the required data are sparse or limited, this uncertainty will be reflected in the results from mathematical models. The aim of this paper is to describe the issues encountered in modeling the cost-effectiveness of introducing HIVST, to indicate the evidence needed to support various modeling assumptions, and thus which data on HIVST would be most beneficial to collect.

Health service barriers to HIV testing and counseling among pregnant women attending Antenatal Clinic; a cross-sectional study

BACKGROUND

HIV testing and counseling (HTC) remains critical in the global efforts to reach a goal of universal access to prevention and timely human immunodeficiency virus (HIV) treatment and health care. Routine HIV testing has been shown to be cost-effective and life-saving by prolonging the life expectancy of HIV patients and reducing the annual HIV transmission rate. However, these benefits of routine HIV testing may not be seen among pregnant women attending antenatal clinic (ANC) due to health facility related factors. This paper presents the influence of health facility related factors on HTC to inform HTC implementation.

METHODS

The study was cross-sectional in design and used structured questionnaire and interview guides to gather information from 300 pregnant women aged 18 to 49 years and had attended ANC for more than twice at the time of the study. Twelve health workers were interviewed as key informants. Respondents were selected from the five sub metro health facilities in the Kumasi Metropolis through systematic random sampling from August to November 2011. Pregnant women who had not tested after two or more ANC visits were classified as not utilizing HTC. Data was analyzed with STATA 11. Logistic regression was run to assess the odds ratios at 95% confidence level.

RESULTS

Twenty-four percent of the pregnant women had not undergone HTC, with "never been told" emerging as the most cited reason as reported by 29.5% of respondents. Decisions by pregnant women to take up HTC were mostly influenced by factors such as lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff and fear of being positive.

CONCLUSIONS

Access to HTC health facility alone does not translate into utilization of HTC service. Improving health facility related factors such as health education and information, confidentiality, health staff turnaround time and health staff-client relationship related to HTC will improve implementation.

How useful is universal screening for HIV infection? A review of the evidence

ABSTRACT: 

Our objective is to describe the current evidence for universal HIV screening in terms of the cost–effectiveness, acceptance rates and number of new positives identified. The available data demonstrate that universal HIV screening is cost-effective, in terms of quality-adjusted life years gained, increase in life expectancy of infected individuals and in reduced HIV transmission rates; and acceptable in healthcare settings based on acceptance (7–99%) and seropositivity (0–2%) rates. Specific studies are needed that address many of the other intended outcomes of universal screening programs, such as reducing number of missed opportunities, increased linkage to care and earlier disease stage detection. Also, additional studies with direct comparisons between universal and targeted testing are necessary to provide greater evidence for where either testing approach may be best implemented.

Routine HIV screening in North Carolina in the era of the Affordable Care Act: update on laws, reimbursement, and tests

Eighteen percent of the 1.2 million human immunodeficiency virus (HIV)-infected individuals in the United States are undiagnosed, with North Carolina accounting for the eighth largest number of new HIV diagnoses in 2011. In an effort to identify more HIV-infected individuals by reducing physician barriers to HIV testing, the Centers for Disease Control and Prevention have expanded their HIV screening recommendations to adolescents and adults without HIV risk factors or behaviors, eliminated federal requirements for pretest counseling, and modified the informed consent process. In 2010, the Office of National AIDS (acquired immunodeficiency syndrome) Policy released the first-ever national HIV/AIDS strategy, with the goal of reducing new infections, increasing access to care, improving HIV outcomes, and reducing HIV racial/ethnic disparities. In 2013, the US Preventive Services Task Force released A-level recommendations recommending nonrisk-based HIV screening for adults and adolescents that are consistent with the recommendations of the Centers for Disease Control and Prevention. In concert with these federal recommendations, the majority of states have modified their consent and counseling requirements. The implementation of the Patient Protection and Affordable Care Act will add requirements and incentives for federal (Medicare), state (Medicaid), and private (insurance) payers to reimburse physicians and patients for nonrisk-based HIV screening.

Routine HIV screening in Portugal: clinical impact and cost-effectiveness

OBJECTIVE

To compare the clinical outcomes and cost-effectiveness of routine HIV screening in Portugal to the current practice of targeted and on-demand screening.

DESIGN

We used Portuguese national clinical and economic data to conduct a model-based assessment.

METHODS

We compared current HIV detection practices to strategies of increasingly frequent routine HIV screening in Portuguese adults aged 18-69. We considered several subpopulations and geographic regions with varying levels of undetected HIV prevalence and incidence. Baseline inputs for the national case included undiagnosed HIV prevalence 0.16%, annual incidence 0.03%, mean population age 43 years, mean CD4 count at care initiation 292 cells/μL, 63% HIV test acceptance, 78% linkage to care, and HIV rapid test cost €6 under the proposed routine screening program. Outcomes included quality-adjusted survival, secondary HIV transmission, cost, and incremental cost-effectiveness.

RESULTS

One-time national HIV screening increased HIV-infected survival from 164.09 quality-adjusted life months (QALMs) to 166.83 QALMs compared to current practice and had an incremental cost-effectiveness ratio (ICER) of €28,000 per quality-adjusted life year (QALY). Screening more frequently in higher-risk groups was cost-effective: for example screening annually in men who have sex with men or screening every three years in regions with higher incidence and prevalence produced ICERs of €21,000/QALY and €34,000/QALY, respectively.

CONCLUSIONS

One-time HIV screening in the Portuguese national population will increase survival and is cost-effective by international standards. More frequent screening in higher-risk regions and subpopulations is also justified. Given Portugal's challenging economic priorities, we recommend prioritizing screening in higher-risk populations and geographic settings.

The cost-effectiveness of expanded HIV screening in the United States

OBJECTIVE

The current Centers of Disease Control and Prevention (CDC) guidelines from 2006 recommend a one-time test for low-risk individuals and annual testing for those at high risk. These guidelines may not be aggressive enough, even for those at low risk of infection, due to the earlier initiation of HAART and a movement towards a test-and-treat environment. We evaluated the optimal testing frequencies for various risk groups in comparison to the CDC recommendations.

METHODS

We build a deterministic mathematical model optimizing the tradeoff between the societal cost of testing and the benefits over a patient's lifetime of earlier diagnosis.

RESULTS

Under a test-and-treat scenario with immediate initiation of HAART, the optimal testing frequency is every 2.4 years for low-risk (0.01% annual incidence) individuals; every 9 months for moderate risk (0.1% incidence) individuals; and every 3 months for high-risk (1.0% incidence) individuals. The incremental cost-effectiveness of the optimal policy is $ 36 ,342/quality-adjusted life-years (QALY) for low-risk individuals and $ 45 ,074/QALY for high-risk individuals compared with 20-year and annual testing, respectively.

CONCLUSION

The current CDC guidelines for HIV testing are too conservative, and more frequent testing is cost-effective for all risk groups.

The cost-effectiveness of rapid HIV testing in substance abuse treatment: results of a randomized trial

BACKGROUND

The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral.

METHODS

We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually.

RESULTS

Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit.

CONCLUSIONS

A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio <$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.

A role for research: an observation on preventive services for women

BACKGROUND

The Patient Protection and Affordable Care Act of 2010 (ACA) added preventive services for women, recommended by the IOM, to healthcare coverage requirements beginning in August 2011.

PURPOSE

The current review provides evidence on the economic impact of services that will be covered under the ACA, focusing on IOM-recommended measures that address women's health.

METHODS

This review analyzed the cost-effectiveness literature related to these services using the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which catalogs detailed information on cost-effectiveness studies published in English in the peer-reviewed literature. In order to keep the review relevant to current clinical practice, the analysis was restricted to studies published in 2000-2010. The data search and analysis were performed in 2011.

RESULTS

Cost-effectiveness studies have evaluated a limited subset of the preventive measures available for women. Further, few cost-effectiveness studies have evaluated the recommended counseling and screening services for women. Of 16 relevant studies found, eight focused on HIV screening, with results varying substantially depending on the specific groups screened and the screening frequency.

CONCLUSIONS

The current review underscores the finding that there is a substantial gap in the health economic literature on preventive care, especially with respect to screening and counseling of women in the primary care setting. There is some evidence that better access to preventive services can be maintained at a reasonable cost to the healthcare system, and that certain services may even lower healthcare costs.

Greater acceptance of routine HIV testing (opt-out) by patients attending an infectious disease unit in Spain

OBJECTIVE

Our objective was to determine attitudes and opinions of patients seen in our ID Unit on conducting HIV testing universally.

METHODS

The survey was conducted in patients between 18 and 65 years without known HIV infection. Requested information about the test was previous embodiment, reasons for rejection, opinion on the universal realization, benefits and/or drawbacks, possible test performance, and availability of results "test negative stigma."

RESULTS

We surveyed 91 patients (54.9% males). Surprisingly, up to 18.7% of patients mistakenly believed that HIV testing is routinely performed without consent. A great majority (98.9%) felt that universal performance on the test would benefit mainly in early diagnosing and/or preventing transmission. Patients younger than 42 years were significantly more prone to doing the test as a routine procedure. Only 4 (4.4%) patients did not participate because they believed they were "not infected." A vast majority (80.5%) of respondents would prefer to have results within the first 24 hours. In addition, 20.7% would have a problem with confidentiality if HIV serology testing was done.

CONCLUSIONS

In summary, the vast majority (95.6%) of the surveyed patients had a fair opinion about universal HIV testing. Only 4 patients (4.4%) would not consent to HIV testing (because of low-risk perception). Availability of rapid HIV tests can facilitate fast result delivery, facilitating linkage to care. Considering favorable patients' opinion, recent opt-out screening recommendations, highest HIV prevalence in admitted patients, and cost-effectiveness, studies favor universal HIV testing.

[HIV infection in France in 2012: reality, risks and challenges for a chronic multisystem disease]

Thirty years after the discovery of HIV and 15 years since the advent of Highly Active Antiretroviral Therapy (HAART), the features of HIV infection have evolved and need a new approach, which is both more comprehensive and specialized. Indeed, the burden of a chronic disease with multiple determining features has replaced the rapidly fatal infection of the past, which was almost exclusively related to the effects of immunosuppression. Physicians have to be concerned with "new risks" associated with treatment side effects; the consequences of ongoing inflammation and ageing of the HIV-infected population. These include metabolic, cardiovascular, neurocognitive and renal disease as well as lipodystrophy and malignancy. Antiretroviral treatment has been a major step forward, subject to accessibility, tolerance and adherence, but it has not solved all the problems associated with this infection, as it becomes a chronic illness.

Nurse-delivered universal point-of-care testing for HIV in an open-access returning traveller clinic

BACKGROUND

Early diagnosis of HIV infection reduces morbidity and mortality associated with late presentation. Despite UK guidelines, the HIV testing rate has not increased. We have introduced universal HIV screening in an open-access returning traveller clinic.

METHODS

Data were prospectively recorded for all patients attending the open-access returning traveller clinic between August 2008 and December 2010. HIV testing was offered to all patients from May 2009; initially testing with laboratory samples (phase 1) and subsequently a point-of-care test (POCT) (phase 2).

RESULTS

A total of 4965 patients attended the clinic; 1342 in phase 0, 792 in phase 1 and 2831 in phase 2. Testing rates for HIV increased significantly from 2% (38 of 1342) in phase 0 to 23.1% (183 of 792) in phase 1 and further increased to 44.5% (1261 of 2831) during phase 2 (P < 0.0001). Two new diagnoses of HIV-1 were identified in phase 1 (1.1% of tested); seven patients had a reactive POCT test in phase 2, of whom five (0.4% of those tested) were confirmed in a 4th generation assay. The patients with false reactive tests had a concurrent Plasmodium falciparum infection. Patients travelling to the Middle East and Europe were less likely to accept an HIV test with POCT.

CONCLUSIONS

A nurse-delivered universal point-of-care HIV testing service has been successfully introduced and sustained in an acute medical clinic in a low-prevalence country. Caution is required in communicating reactive results in low-prevalence settings where there may be alternative diagnoses or a low population prevalence of HIV infection.

Internal medicine and emergency medicine physicians lack accurate knowledge of current CDC HIV testing recommendations and infrequently offer HIV testing

OBJECTIVES

To evaluate the knowledge and attitudes of residents and attendings in emergency medicine (EM) and internal medicine (IM) about HIV.

METHODS

An electronic anonymous 41-question survey of IM and EM physicians at the University of Cincinnati Academic Health Center.

RESULTS

The survey was completed by 232 physicians (71.6%). EM residents were more likely to routinely offer HIV testing compared to IM residents (60.7% vs. 27.8%, P = 0.0009). Overall, there was no difference in offering HIV testing by sex (32% vs. 35.6%) or by residents versus attendings (33.8% vs. 33.3%). Only 70 physicians (30.9%) were aware of current CDC recommendations of HIV screening with attendings more knowledgeable than residents (41.7% vs. 26%, P = 0.017).

CONCLUSION

EM and IM residents and attendings fail to offer HIV testing or assess for HIV transmission risk factors with sufficient frequency. There is also a gap in knowledge of the current CDC recommendations.

Cost-utility analyses of diagnostic laboratory tests: a systematic review

OBJECTIVE

To review and evaluate the literature of cost-utility analyses (CUAs) regarding diagnostic laboratory testing.

METHODS

We reviewed all articles related to diagnostic laboratory testing in the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), which contains detailed information on over 2000 published CUAs through 2008. We analyzed the extent to which the studies adhered to recommended practices for conducting and reporting cost-effectiveness analyses. We also recorded whether the studies contained information on diagnostic test accuracy and costs, and whether any account was taken of potential benefits or harms of testing that are unrelated to subsequent treatment, such as the reassurance value of testing.

RESULTS

We identified 141 published CUAs pertaining to diagnostic laboratory testing published through 2008 which contained 433 separate incremental cost-effectiveness ratios. Prior to 2000, there were only 20 CUAs published, but the number averaged 13.4 annually thereafter. Most studies focused on hematology/oncology (n = 42, 30%) and obstetrics/gynecology (n = 36, 26%) applications. Approximately 63% (n = 89) of studies clearly reported information about the accuracy of the test, but only 10% (n = 14) mentioned test safety or possible risks. A small number (n = 10, 7%) mentioned or considered the potential value or harm of testing unrelated to treatment consequences. Over 55% of the reported incremental cost-effectiveness ratios (ICERs) were either dominant (more quality-adjusted life years for less cost), or below $50,000 per quality-adjusted life years gained (in 2008 US dollars).

CONCLUSION

The number of CUAs investigating laboratory diagnostic testing has increased substantially with applications to diverse clinical areas. The literature reveals many areas in which testing represents good value for money. The vast majority of studies have not considered preferences for test information unrelated to treatment consequences.

Resource utilization and cost-effectiveness of counselor- vs. provider-based rapid point-of-care HIV screening in the emergency department

Background

Routine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor.

Methods

We employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs.

Results

Estimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs.

Conclusions

The cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.

The Direct Medical Costs of Late Presentation (<350/mm) of HIV Infection over a 15-Year Period

We describe the immediate- and longer-term direct medical costs of care for individuals diagnosed with HIV at CD4 counts <350/mm(3) ("late presenters"). We collected and stratified by initial CD4 count all inpatient, outpatient, and drug costs for all newly diagnosed patients accessing HIV care within Southern Alberta from 1/1/1995 to 1/1/2010. 59% of new patients were late presenters. We found significantly higher costs for late presenters, especially inpatient costs, during the first year after accessing care. Direct medical costs remained almost twice as high for late presenters in subsequent years compared to patients presenting with CD4 counts >350/mm(3) despite significantly their improved CD4 counts. The sustained high cost for late presenters has implications for recent recommendations for wider routine HIV testing and the earlier initiation of cART. Earlier diagnosis and treatment, while increasing the immediate expenditures within a population, may produce both direct and indirect cost savings in the longer term.

Routine, rapid HIV testing of medicine service admissions in the emergency department

OBJECTIVE

We identify undiagnosed HIV among adult emergency department (ED) patients awaiting medicine admission through rapid testing, expedite their redirection to the inpatient HIV service, and improve linkage to ambulatory HIV care.

METHODS

Two ED health educators offered rapid testing to patients aged 18 to 64 years from the high-acuity ED area from which most medicine admissions originate. Heath educators obtained consent, obtained fingerstick blood, and performed point-of-care testing. Patients with reactive results received counseling, confirmatory testing, and appointments at the affiliated HIV clinic.

RESULTS

Between March 1, 2008, and February 28, 2009, 4,755 patients received testing. Thirty patients (0.6%) had received a new diagnosis of HIV; 26 were admitted and redirected to the HIV service. Characteristics of HIV positive patients were mean age 38 years, 87% men, 64% black, and 33% Hispanic; 76% had CD4 counts less than 200 cells/mm(3); 67% had HIV-related diagnoses; and 93% reported for ambulatory HIV care in a median of 10 days. During 2 preceding years, these patients had a mean of 3 previous health system visits without testing. During a 6-month quality assurance interval of the 5,340 ED medicine admissions, 31% of patients were eligible for testing, of whom 88% received testing (1% positive) and 12% declined; 29% of the 5,340 were not approached for testing; and 40% were deemed ineligible. Common reasons for ineligibility included older age, recent previous test, and known HIV-positive status.

CONCLUSION

Patients who receive a diagnosis of HIV in our ED before admission are extremely ill, most having AIDS. Targeted HIV screening of ED patients awaiting hospital admission facilitated timely diagnosis and reliable linkage to inpatient and outpatient HIV care.

Projected survival gains from revising state laws requiring written opt-in consent for HIV testing

BACKGROUND

Although the Centers for Disease Control and Prevention recommends HIV testing in all settings unless patients refuse (opt-out consent), many state laws require written opt-in consent.

OBJECTIVE

To quantify potential survival gains from passing state laws streamlining HIV testing consent.

DESIGN

We retrieved surveillance data to estimate the current annual HIV diagnosis rate in states with laws requiring written opt-in consent (19.3%). Published data informed the effect of removing that requirement on diagnosis rate (48.5% increase). These parameters then served as input for a model-driven projection of survival based on consent method. Other inputs included undiagnosed HIV prevalence (0.101%); and annual HIV incidence (0.023%).

PATIENTS

Hypothetical cohort of adults (>13 years) living in written opt-in states.

MEASUREMENTS

Life years gained (LYG).

RESULTS

In the base-case, of the 53,036,383 adult persons living in written opt-in states, 0.66% (350,040) will be infected with HIV. Due to earlier diagnosis, revised consent laws yield 1.5 LYG per HIV-infected person, corresponding to 537,399 LYG among this population. Sensitivity analyses demonstrate that diagnosis rate increases of 24.8-72.3% result in 304,765-724,195 LYG. Net survival gains vanish if the proportion of HIV-infected persons refusing all testing in response to revised laws exceeds 18.2%.

CONCLUSIONS

The potential survival gains of increased testing are substantial, suggesting that state laws requiring opt-in HIV testing should be revised.

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

Background

Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations.

Methods and Findings

We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients.

Conclusions

HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection.

Diagnosis and management of HIV infection

Infection with human immunodeficiency virus (HIV) is now increasingly common in the UK, but the diagnosis is often missed or overlooked. This article summarizes who to test and how best to offer testing to patients in whom HIV testing is clinically indicated.

A model for routine hospital-wide HIV screening: lessons learned and public health implications

BACKGROUND

Approximately 232700 (21%) of Americans are unaware of their HIV-seropositive status; this represents a potential for virus transmission. Revised recommendations from the Centers for Disease Control for HIV screening promote routine screening in the health care setting. We describe the implementation of a hospital-wide routine HIV screening program in the District of Columbia.

METHODS

Rapid HIV testing was conducted at Howard University Hospital on consenting patients at least 18 years of age using the OraSure OraQuick Advance Rapid HIV-1/2 Antibody Test. The study population includes Howard University Hospital patients who were offered HIV screening over a 12-month period at no cost. Screened patients received immediate test results and, for those patients found to be preliminarily reactive, confirmatory testing and linkage to care were offered.

RESULTS

Of the 12836 patients who were offered testing, 7528 (58.6%) consented. Preliminary reactive test results were identified in 176 patients (2.3%). Overall, 45.5% were confirmed, of which 82.5% were confirmed positive. Screening protocol changes have led to 100% confirmation since implementation.

CONCLUSIONS

Hospital-wide routine HIV screening is feasible and can be implemented effectively and efficiently. The HIV screening campaign instituted at Howard University Hospital identified a substantial number of HIV-positive individuals and provided critical connection to follow-up testing, counseling, and disease management services.

The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States

BACKGROUND

Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral therapy (ART) are limited, and all eligible persons are not currently receiving treatment.

OBJECTIVE

To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.

DESIGN

Dynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.

DATA SOURCES

Published literature.

TARGET POPULATION

High-risk (injection drug users and men who have sex with men) and low-risk persons aged 15 to 64 years in the United States.

TIME HORIZON

Twenty years and lifetime (costs and quality-adjusted life-years [QALYs]).

PERSPECTIVE

Societal.

INTERVENTION

Expanded HIV screening and counseling, treatment with ART, or both.

OUTCOME MEASURES

New HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

One-time HIV screening of low-risk persons coupled with annual screening of high-risk persons could prevent 6.7% of a projected 1.23 million new infections and cost $22,382 per QALY gained, assuming a 20% reduction in sexual activity after screening. Expanding ART utilization to 75% of eligible persons prevents 10.3% of infections and costs $20,300 per QALY gained. A combination strategy prevents 17.3% of infections and costs $21,580 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

With no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when a CD4 count is greater than 0.350 × 10(9) cells/L prevents 20% to 28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.

LIMITATION

The model of disease progression and treatment was simplified, and acute HIV screening was excluded.

CONCLUSION

Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.

The cost-effectiveness and population outcomes of expanded HIV screening and antiretroviral treatment in the United States

BACKGROUND

Although recent guidelines call for expanded routine screening for HIV, resources for antiretroviral therapy (ART) are limited, and all eligible persons are not currently receiving treatment.

OBJECTIVE

To evaluate the effects on the U.S. HIV epidemic of expanded ART, HIV screening, or interventions to reduce risk behavior.

DESIGN

Dynamic mathematical model of HIV transmission and disease progression and cost-effectiveness analysis.

DATA SOURCES

Published literature.

TARGET POPULATION

High-risk (injection drug users and men who have sex with men) and low-risk persons aged 15 to 64 years in the United States.

TIME HORIZON

Twenty years and lifetime (costs and quality-adjusted life-years [QALYs]).

PERSPECTIVE

Societal.

INTERVENTION

Expanded HIV screening and counseling, treatment with ART, or both.

OUTCOME MEASURES

New HIV infections, discounted costs and QALYs, and incremental cost-effectiveness ratios.

RESULTS OF BASE-CASE ANALYSIS

One-time HIV screening of low-risk persons coupled with annual screening of high-risk persons could prevent 6.7% of a projected 1.23 million new infections and cost $22,382 per QALY gained, assuming a 20% reduction in sexual activity after screening. Expanding ART utilization to 75% of eligible persons prevents 10.3% of infections and costs $20,300 per QALY gained. A combination strategy prevents 17.3% of infections and costs $21,580 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

With no reduction in sexual activity, expanded screening prevents 3.7% of infections. Earlier ART initiation when a CD4 count is greater than 0.350 × 10(9) cells/L prevents 20% to 28% of infections. Additional efforts to halve high-risk behavior could reduce infections by 65%.

LIMITATION

The model of disease progression and treatment was simplified, and acute HIV screening was excluded.

CONCLUSION

Expanding HIV screening and treatment simultaneously offers the greatest health benefit and is cost-effective. However, even substantial expansion of HIV screening and treatment programs is not sufficient to markedly reduce the U.S. HIV epidemic without substantial reductions in risk behavior.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse, National Institutes of Health, and Department of Veterans Affairs.

Economic evaluation, human immunodeficiency virus infection and screening: a review and critical appraisal of economic studies

OBJECTIVES

The aim of this study was to review, systematically and critically, evidence used to derive estimates of cost-effectiveness of human immunodeficiency virus (HIV) screening.

METHODS

A systematic review was conducted. Searched were three main electronic bibliographic databases from 1993 to 2008 using key words including HIV, mass screening, HAART, economic evaluation, cost-effectiveness analysis, modeling. We included studies of sexually transmitted HIV infection in both sexes, including studies comparing diagnostic testing protocols and partner notification. Outcomes included were cases of HIV infection detected, deterioration to the AIDS state, secondary transmission of HIV, the quality-adjusted life-years/survival, costs, and cost-effectiveness of HIV screening.

RESULTS

Eighty-four papers were identified; ten of which were formal economic evaluations, one cost study, three effectiveness studies, and three systematic reviews of HIV prevention programs. The predominant assertion was that HIV screening is cost-effective; methodological problems, such as the preponderance of static models which are inappropriate for infectious diseases, varying perspectives from which the studies were analyzed, and arbitrary threshold incremental cost-effectiveness ratio levels, limited the validity of these findings, and their usefulness in informing health policy decisions.

CONCLUSIONS

The majority of published economic evaluations are based on inappropriate static models. This flaw renders the results of these studies as inconclusive and the purported cost-effectiveness of HIV screening debatable. The results of this review could form a basis for consideration of further research and analysis by health economists into the cost-effectiveness of HIV screening.