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

Management of asymptomatic sexually transmitted infections in Europe: towards a differentiated, evidence-based approach

Most sexually transmitted infections (STIs) can be accurately diagnosed and treated during asymptomatic carriage. Widespread screening for these STIs is therefore assumed to be an effective way to reduce their prevalence and associated disease. In this review, we provide evidence that this is the case for HIV and syphilis. However, for other STIs such as Neisseria gonorrhoeae and Chlamydia trachomatis, our review reveals that the evidence that screening reduces infection prevalence and associated disease is weak. There is also growing evidence of harms from screening that might outweigh any benefits. The harms include the increased consumption of antimicrobials that follows frequent screening and increased detection of asymptomatic STIs in key populations, such as men who have sex with men taking HIV pre-exposure prophylaxis, and associated risk of antimicrobial resistance in target and non-target organisms. There may also be psycho-social harm associated with an STI diagnosis. We conclude that in the absence of symptoms, in high STI prevalence populations frequent STI screening should be limited to HIV and syphilis.

Prevalence, characteristics and challenges of late HIV diagnosis in Germany: an expert narrative review

PURPOSE

We aimed to review the landscape of late HIV diagnosis in Germany and discuss persisting and emerging barriers to earlier diagnosis alongside potential solutions.

METHODS

We searched PubMed for studies informing the prevalence, trends, and factors associated with late HIV diagnosis in Germany. Author opinions were considered alongside relevant data.

RESULTS

In Germany, older individuals, heterosexuals, and migrants living with HIV are more likely to be diagnosed late. The rate of late diagnosis in men who have sex with men (MSM), however, continues to decrease. Indicator conditions less often prompt HIV testing in women and non-MSM. During the COVID-19 pandemic, the absolute number of late diagnoses fell in Germany, but the overall proportion increased, probably reflecting lower HIV testing rates. The Ukraine war and subsequent influx of Ukrainians living with HIV may have substantially increased undiagnosed HIV cases in Germany. Improved indicator testing (based on unbiased assessments of patient risk) and universal testing could help reduce late diagnoses. In patients who receive a late HIV diagnosis, rapid treatment initiation with robust ART regimens, and management and prevention of opportunistic infections, are recommended owing to severely compromised immunity and increased risks of morbidity and mortality.

CONCLUSION

Joint efforts are needed to ensure that UNAIDS 95-95-95 2030 goals are met in Germany. These include greater political will, increased funding of education and testing campaigns (from government institutions and the pharmaceutical industry), continued education about HIV testing by HIV experts, and broad testing support for physicians not routinely involved in HIV care.

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.

National medical specialty guidelines of HIV indicator conditions in Europe lack adequate HIV testing recommendations: a systematic guideline review

BackgroundAdequate identification and testing of people at risk for HIV is fundamental for the HIV care continuum. A key strategy to improve timely testing is HIV indicator condition (IC) guided testing.AimTo evaluate the uptake of HIV testing recommendations in HIV IC-specific guidelines in European countries.MethodsBetween 2019 and 2021, European HIV experts reviewed guideline databases to identify all national guidelines of 62 HIV ICs. The proportion of HIV IC guidelines recommending HIV testing was reported, stratified by subgroup (HIV IC, country, eastern/western Europe, achievement of 90-90-90 goals and medical specialty).ResultsOf 30 invited European countries, 15 participated. A total of 791 HIV IC guidelines were identified: median 47 (IQR: 38-68) per country. Association with HIV was reported in 69% (545/791) of the guidelines, and 46% (366/791) recommended HIV testing, while 42% (101/242) of the AIDS-defining conditions recommended HIV testing. HIV testing recommendations were observed more frequently in guidelines in eastern (53%) than western (42%) European countries and in countries yet to achieve the 90-90-90 goals (52%) compared to those that had (38%). The medical specialties internal medicine, neurology/neurosurgery, ophthalmology, pulmonology and gynaecology/obstetrics had an HIV testing recommendation uptake below the 46% average. None of the 62 HIV ICs, countries or medical specialties had 100% accurate testing recommendation coverage in all their available HIV IC guidelines.ConclusionFewer than half the HIV IC guidelines recommended HIV testing. This signals an insufficient adoption of this recommendation in non-HIV specialty guidelines across Europe.

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.

Cost-Effectiveness of HIV Retention and Re-engagement Interventions in High-Income Countries: A Systematic Literature Review

Engagement in lifelong HIV care is critical for both patient and public health, yet there are limited resources to invest in improving HIV outcomes. We systematically reviewed evidence on the cost-effectiveness of retention and re-engagement interventions. We searched five databases for peer-reviewed studies published between 2010 and 2020. We assessed reporting and methods quality, extracted data on target populations, interventions, and cost-effectiveness, and evaluated overall strength of evidence. Eleven studies met inclusion criteria, and eight had moderate-high quality. Cost-effectiveness estimates ranged from cost-saving to over $1,000,000/quality-adjusted life year (QALY) gained. Of the 73 cost-effectiveness ratios reported, 64% were < $100,000/QALY gained. Interventions were more likely to be cost-effective when targeted to high-risk groups, implemented in locations where baseline retention levels were low, and when used in combination with other high-impact HIV interventions (such as prevention). Overall, existing evidence is moderately strong that retention and/or re-engagement interventions can be cost-effective in high-income countries.

Interventions to Increase HIV Testing Uptake in Global Settings

Purpose of Review

HIV testing is the critical first step to direct people living with HIV (PLWH) to treatment. However, progress is still being made towards the UNAIDS benchmark of 95% of PLWH knowing their status by 2030. Here, we discuss recent interventions to improve HIV testing uptake in global settings.

Recent Findings

Successful facility-based HIV testing interventions involve couples and index testing, partner notification, and offering of incentives. Community-based interventions such as home-based self-testing, mobile outreach, and hybrid approaches have improved HIV testing in low-resource settings and among priority populations. Partnerships with trusted community leaders have also increased testing among populations disproportionally impacted by HIV.

Summary

Recent HIV testing interventions span a breadth of facility- and community-based approaches. Continued research is needed to engage men in sub-Saharan Africa, people who inject drugs, and people who avoid biomedical care. Interventions should consider supporting linkage to care for newly diagnosed PLWH.

Understanding Individual Barriers to HIV Testing Among Undergraduate University Students: Results From a Cross-Sectional Study in Italy

Background

In Europe during 2019, just over half of those with HIV were diagnosed at a late stage of infection. Even though HIV testing is crucial for all strategies related to care, prevention and treatment of HIV/AIDS, we hypothesized that it is less practiced among university students, and, therefore, this study aimed to assess the uptake and factors associated with HIV testing in southern part of Italy.

Methods

A cross-sectional study was conducted from 1st to 31st July 2020 among undergraduate university students aged 18–29 years. Data were collected through an anonymous online questionnaire and included questions on socio-demographic and sexual history characteristics, knowledge and attitudes toward HIV infection, sexual and testing behaviors, and sources of information about HIV.

Findings

Among 1007 students, 41.5 and 54.7% knew that in Italy the test for early detection of HIV infection has not to be prescribed by a physician and that it is provided to anyone free of charge, respectively. Only 16.2% of the eligible students reported having ever tested for HIV and a very similar proportion (17.8%) was displayed among those who reported risky sexual behaviors. The multiple logistic regression analysis results indicated that the strongest predictor of HIV testing was attending medical or life sciences majors.

Interpretation

The uptake of HIV testing was low among Italian university students. Effective strategies to increase HIV testing and diagnoses have to aim at overarching individual barriers, such as lack of knowledge about information around the test itself.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Delayed presentation of HIV among older individuals: a growing problem

Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.

Promoting HIV indicator condition-guided testing in hospital settings (PROTEST 2.0): study protocol for a multicentre interventional study

Background

Late presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting.

Methods

We designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC.

Discussion

This protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands.

Trial registration

Dutch trial registry: NL7521. Registered 14 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06183-8.

Brazilian Protocol for Sexually Transmitted Infections, 2020: HIV infection in adolescents and adults

HIV infection is presented in the chapters of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Health professionals and managers must learn the signs and symptoms of HIV infection and know how to diagnose it to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease. Its treatment includes addressing common comorbidities such as arterial hypertension, diabetes, and dyslipidemia, in addition to cardiac risk assessment, cancer prevention, and guidance on immunization. Initiation of treatment for HIV patients is recommended regardless of clinical or immunological criteria as adopted by the Ministry of Health since 2013. Lately, it has been simplified with more tolerable first-line medications and fewer drug interactions, making its management easy to implement, including by primary health care.

HIV cases are concentrated in specific population groups, such as sex workers, men who have sex with men, transexuals, people who use alcohol or other drugs, and vulnerable people, such as black, incarcerated, or people living on the streets.

Missed opportunities for HIV testing persist despite a single educational intervention: how can we close this evidence-practice gap?

BACKGROUND

In Australia, one-third of human immunodeficiency virus (HIV) diagnoses occur late, with an estimated 11% of people with HIV unaware of their diagnosis. Undiagnosed and untreated HIV infection increases morbidity in the HIV positive person and allows onward transmission of HIV.

AIM

To determine the rate of HIV testing in acute general medicine patients with HIV indicator conditions (IC) and evaluate the effectiveness of an educational intervention in improving testing rates.

METHODS

Single-centre, tertiary hospital, before-after study of general medicine inpatients with IC for 12 weeks prior and 10 weeks post an educational intervention focusing on recommendations for HIV testing including IC. The REASON Cohort Discovery Tool was used to search for the IC using ICD-10 codes and laboratory data. The presence of IC was estimated, and HIV testing rates before and after the intervention were compared. Regression analysis was utilised to identify characteristics associated with HIV testing.

RESULTS

Of 1414 admissions in the baseline period and 946 in the post-period, 161 (11.4%) and 132 (14.0%) had at least one IC present respectively. There were 18 (11.2%) HIV tests performed for admissions with IC in the pre-period which increased to 27 (20.5%) (P = 0.028) in the post-period. Younger patients were more likely to be tested and regression analysis identified the educational intervention (adjusted odds ratio) 2.2 (1.1, 4.4) to be significantly associated with testing.

CONCLUSIONS

Although HIV testing rates for IC doubled following the intervention, they remained unacceptably low. The recently introduced electronic medical record presents opportunities to prompt HIV testing.

[Brazilian Protocol for Sexually Transmitted Infections 2020: HIV infection in adolescents and adults]

HIV infection is the subject of one of the chapters of the "Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections", published by the Brazilian Ministry of Health in 2020. It is important that health professionals and managers learn the signs and symptoms of HIV infection and know how to diagnose it, in order to provide appropriate treatment and reduce complications. HIV infection has become a chronic disease and its treatment includes addressing common comorbidities in clinical practice such as arterial hypertension, diabetes and dyslipidemia, in addition to cardiac risk assessment, cancer prevention and guidance on immunization. Initiation of treatment for all HIV patients, regardless of clinical or immunological criteria, adopted by the Ministry of Health since 2013, has now been simplified with more tolerable first-line medications and with fewer drug interactions, which makes its management easy to implement, including by Primary Health Care.

Brief Report: Use of the Consolidated Framework for Implementation Research (CFIR) to Characterize Health Care Workers' Perspectives on Financial Incentives to Increase Pediatric HIV Testing

BACKGROUND

A prior randomized control trial showed financial incentives increase HIV testing rates for children of unknown HIV status. Translating evidence-based interventions such as these to scale requires an implementation science approach.

METHODS

A qualitative study evaluating health care providers' perceptions of barriers and facilitators of a previously completed financial incentives intervention for pediatric HIV testing was conducted at health care facilities in Kisumu, Kenya. Six focus group discussions with 52 providers explored determinants of acceptability, feasibility, and sustainability of financial incentive scale-up for pediatric HIV testing using the Consolidated Framework for Implementation Research to inform question guides and thematic analysis.

RESULTS

Providers found the use of financial incentive interventions for pediatric HIV testing to be highly acceptable. First, providers believed financial incentives had a relative advantage over existing strategies, because they overcame cost barriers and provided additional motivation to test; however, concerns about how financial incentives would be implemented influenced perceptions of feasibility and sustainability. Second, providers expressed concern that already overburdened staff and high costs of financial incentive programs would limit sustainability. Third, providers feared that financial incentives may negatively affect further care because of expectations of repeated financial support and program manipulation.

CONCLUSIONS

Providers viewed financial incentives as an acceptable intervention to scale programmatically to increase uptake of pediatric testing. To ensure feasibility and sustainability of financial incentives in pediatric HIV testing programs, it will be important to clearly define target populations, manage expectations of continued financial support, and establish systems to track testing.

Exploring dental students' knowledge of HIV and attitudes towards saliva screening for HIV

INTRODUCTION

Early detection of human immunodeficiency virus (HIV) allows antiretroviral therapy to commence, improving patient outcomes. Screening for HIV with saliva can be undertaken by dental practitioners. Research has found the procedure to be better accepted by patients than traditional blood testing. However, lack of knowledge and time constraints were identified as barriers to implementation for dental practitioners. This study aimed to explore dental students' knowledge of HIV and their attitudes towards implementing saliva screening for HIV in a dental setting.

METHODS

Convenience sampling was used to recruit four focus groups of six to nine dentistry students from the University of Queensland. Participants also completed a questionnaire prior to the focus group.

RESULTS

Thirty-three students participated in the focus groups. Students recognised their knowledge of HIV was limited, and 46% (n = 15) reported having treated a HIV-positive patient in the last year. Three key themes emerged from discussions; knowledge and experience of HIV; barriers and enablers; and scope of practice. Students identified stigma, lack of training, cost and time restraints as barriers to implementing saliva screening for HIV. Opinions varied on if screening was within a dental practitioner's scope of practice.

CONCLUSIONS

Whilst students were open to conducting saliva screening for HIV, they identified prominent barriers limiting its implementation within a dental setting. Education on saliva screening for HIV, patient counselling and referral pathways could be integrated into dentistry curriculums to reduce these barriers. Further investigation is needed into the cost-effectiveness of implementing screening for HIV in a dental setting.

HIV screening in the dental setting in New York State

While primary care providers in New York State (NYS) are mandated to offer all patients a HIV test, still many NYS residents miss the HIV screening opportunity. To fill the gap, and as the CDC recommends, this study aimed to examine the feasibility of implementing HIV screening in dental setting, identify patient characteristics associated with acceptance of HIV rapid testing, and discuss best practices of HIV screening in dental setting. New York State Department of Health (NYSDOH) collaborated with the Northeast/Caribbean AIDS Education and Training Center (NECA AETC) and three dental schools in New York State to offer free HIV screening tests as a component of routine dental care between February 2016 and March 2018. Ten clinics in upstate New York and Long Island participated in the study. HIV screening was performed using the OraQuick™ In-Home HIV Test. 14,887 dental patients were offered HIV screening tests; 9,057 (60.8%) were screened; and one patient (0.011%) was confirmed HIV positive and linked to medical care. Of all dental patients, 33% had never been screened for HIV; and 56% had not had a primary care visit or had not been offered an HIV screening test by primary care providers in the previous 12 months. Multi-level generalized linear modeling analysis indicated that test acceptance was significantly associated with patient's age, race/ethnicity, gender, country of origin, primary payer (or insurance), past primary care visits, past HIV testing experiences, and the poverty level of patient's community. HIV screening is well accepted by dental patients and can be effectively integrated into routine dental care. HIV screening in the dental setting can be a good option for first-time testers, those who have not seen a primary care provider in the last 12 months, and those who have not been offered HIV screening at their last primary care visit.

Improving the evidence for indicator condition guided HIV testing in Europe: Results from the HIDES II Study - 2012 - 2015

BACKGROUND

It is cost-effective to perform an HIV test in people with specific indicator conditions (IC) with an undiagnosed HIV prevalence of at least 0.1%. Our aim was to determine the HIV prevalence for 14 different conditions across 20 European countries.

METHODS

Individuals aged 18-65 years presenting for care with one of 14 ICs between January 2012 and June 2014 were included and routinely offered an HIV test. Logistic regression assessed factors associated with testing HIV positive. Patients presenting with infectious mononucleosis-like syndrome (IMS) were recruited up until September 2015.

RESULTS

Of 10,877 patients presenting with an IC and included in the analysis, 303 tested positive (2.8%; 95% CI 2.5-3.1%). People presenting with an IC in Southern and Eastern Europe were more likely to test HIV positive as were people presenting with IMS, lymphadenopathy and leukocytopenia/ thrombocytopenia. One third of people diagnosed with HIV after presenting with IMS reported a negative HIV test in the preceding 12 months. Of patients newly diagnosed with HIV where data was available, 92.6% were promptly linked to care; of these 10.4% were reported lost to follow up or dead 12 months after diagnosis.

CONCLUSION

The study showed that 10 conditions had HIV prevalences > 0.1%. These 10 ICs should be adopted into HIV testing and IC specialty guidelines. As IMS presentation can mimic acute HIV sero-conversion and has the highest positivity rate, this IC in particular affords opportunities for earlier diagnosis and public health benefit.

Cost-effectiveness and budget impact of immediate antiretroviral therapy initiation for treatment of HIV infection in Côte d'Ivoire: A model-based analysis

Introduction

The Temprano and START trials provided evidence to support early ART initiation recommendations. We projected long-term clinical and economic outcomes of immediate ART initiation in Côte d’Ivoire.

Methods

We used a mathematical model to compare three potential ART initiation criteria: 1) CD4 <350/μL (ART<350/μL); 2) CD4 <500/μL (ART<500/μL); and 3) ART at presentation (Immediate ART). Outcomes from the model included life expectancy, 10-year medical resource use, incremental cost-effectiveness ratios (ICERs) in $/year of life saved (YLS), and 5-year budget impact. We simulated people with HIV (PWH) in care (mean CD4: 259/μL, SD 198/μL) and transmitted cases. Key input parameters to the analysis included first-line ART efficacy (80% suppression at 6 months) and ART cost ($90/person-year). We assessed cost-effectiveness relative to Côte d’Ivoire’s 2017 per capita annual gross domestic product ($1,600).

Results

Immediate ART increased life expectancy by 0.34 years compared to ART<350/μL and 0.17 years compared to ART<500/μL. Immediate ART resulted in 4,500 fewer 10-year transmissions per 170,000 PWH compared to ART<350/μL. In cost-effectiveness analysis, Immediate ART had a 10-year ICER of $680/YLS compared to ART<350/μL, ranging from cost-saving to an ICER of $1,440/YLS as transmission rates varied. ART<500/μL was “dominated” (an inefficient use of resources), compared with Immediate ART. Immediate ART increased the 5-year HIV care budget from $801.9M to $812.6M compared to ART<350/μL.

Conclusions

In Côte d’Ivoire, immediate compared to later ART initiation will increase life expectancy, decrease HIV transmission, and be cost-effective over the long-term, with modest budget impact. Immediate ART initiation is an appropriate, high-value standard of care in Côte d’Ivoire and similar settings.

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.