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Islam MH, Shrestha RK, Hoch JS, Farnham PG. Estimating the Cost-Effectiveness of HIV Self-Testing in the United States Using Net Benefit Regression. J Acquir Immune Defic Syndr 2024; 95:138-143. [PMID: 37831617 PMCID: PMC11305482 DOI: 10.1097/qai.0000000000003325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Cost-effectiveness analysis of HIV self-testing using patient-level data from a randomized clinical trial can inform HIV prevention funding decisions. Cost-effectiveness analysis using net-benefit regression addresses the sampling uncertainty in the trial data and the variability of policymakers' willingness to pay (WTP). METHODS We used published data from a 12-month longitudinal randomized clinical trial that enrolled 2665 men who had sex with men randomly assigned to the self-testing arm (participants receiving self-test kits) and control arm (participants receiving standard-of-care), and the self-testing arm identified 48 additional new HIV cases. We used net-benefit regression to investigate the cost-effectiveness of an HIV self-testing intervention, which compared the incremental cost per new HIV diagnosis with policymakers' WTP thresholds. We addressed the uncertainties in estimating the incremental cost and the policymakers' WTP per new diagnosis through the incremental net-benefit (INB) regression and cost-effectiveness acceptability curve (CEAC) analyses. RESULTS From the health care provider's perspective, the INB analysis showed a positive net benefit of HIV self-testing compared with standard-of-care when policymakers' WTP per new HIV diagnosis was $9365 (95% confidence interval: $5700 to $25,500) or higher. The CEAC showed that the probability of HIV self-testing being cost-effective compared with standard-of-care was 58% and >99% at a WTP of $10 000 and $50 000 per new HIV diagnosis, respectively. CONCLUSION The INB and CEAC analyses suggest that HIV self-testing has the potential to be cost-effective for relatively low values of policymakers' WTP.
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Affiliation(s)
- Md Hafizul Islam
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention
| | - Ram K. Shrestha
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention
| | - Jeffrey S. Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis
| | - Paul G. Farnham
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention
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Shrestha RK, Hecht J, Chesson HW. Analyzing the Costs and Impact of the TakeMeHome Program, a Public-Private Partnership to Deliver HIV Self-Test Kits in the United States. J Acquir Immune Defic Syndr 2024; 95:144-150. [PMID: 37831623 PMCID: PMC10841436 DOI: 10.1097/qai.0000000000003323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND HIV testing is an entry point to access HIV care and prevention services. Building Healthy Online Communities developed a website ( TakeMeHome.org ) where participants can order HIV home test kits. The purpose of this study was to analyze the costs and impact of the TakeMeHome program. METHODS We estimated the costs of TakeMeHome across all participating jurisdictions for the first year of the program. We estimated program costs using purchase orders and invoices, contracts, and allocation of staff time, and the costs included website design, participant recruitment, administration and overhead, HIV self-test kits, and shipping and handling. Primary outcomes of the analysis were total program cost, cost per HIV test, and cost per new HIV diagnosis. RESULTS The TakeMeHome program distributed 5323 HIV self-tests to 4859 participants over a 12-month period. The total program cost over this period was $314,870. The cost per HIV test delivered was estimated at $59, and the cost per person tested was $65. The program identified 18 confirmed new HIV diagnoses (0.6% positivity) verified with surveillance data in 7 health jurisdictions at $169,890. The cost per confirmed new HIV diagnosis was estimated at $9440. CONCLUSIONS The TakeMeHome program delivered HIV self-testing at a reasonable cost, and the program may be a cost-effective use of HIV prevention resources. The public-private partnership can be an effective mechanism to validate HIV diagnoses identified with self-testing and provide HIV prevention and linkage to care services.
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Affiliation(s)
- Ram K Shrestha
- Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Atlanta, GA; and
| | - Jennifer Hecht
- Building Healthy Online Communities and Springboard HealthLab, Richmond, CA
| | - Harrell W Chesson
- Centers for Disease Control and Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention, Atlanta, GA; and
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Pepiot A, Supervie V, Breban R. Impact of voluntary testing on infectious disease epidemiology: A game theoretic approach. PLoS One 2023; 18:e0293968. [PMID: 37934734 PMCID: PMC10629633 DOI: 10.1371/journal.pone.0293968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 10/23/2023] [Indexed: 11/09/2023] Open
Abstract
The World Health Organization recommends test-and-treat interventions to curb and even eliminate epidemics of HIV, viral hepatitis, and sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis and trichomoniasis). Epidemic models show these goals are achievable, provided the participation of individuals in test-and-treat interventions is sufficiently high. We combine epidemic models and game theoretic models to describe individual's decisions to get tested for infectious diseases within certain epidemiological contexts, and, implicitly, their voluntary participation to test-and-treat interventions. We develop three hybrid models, to discuss interventions against HIV, HCV, and sexually transmitted infections, and the potential behavioral response from the target population. Our findings are similar across diseases. Particularly, individuals use three distinct behavioral patterns relative to testing, based on their perceived costs for testing, besides the payoff for discovering their disease status. Firstly, if the cost of testing is too high, then individuals refrain from voluntary testing and get tested only if they are symptomatic. Secondly, if the cost is moderate, some individuals will test voluntarily, starting treatment if needed. Hence, the spread of the disease declines and the disease epidemiology is mitigated. Thirdly, the most beneficial testing behavior takes place as individuals perceive a per-test payoff that surpasses a certain threshold, every time they get tested. Consequently, individuals achieve high voluntary testing rates, which may result in the elimination of the epidemic, albeit on temporary basis. Trials and studies have attained different levels of participation and testing rates. To increase testing rates, they should provide each eligible individual with a payoff, above a given threshold, each time the individual tests voluntarily.
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Affiliation(s)
- Amandine Pepiot
- Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP), Sorbonne Université, INSERM, Paris, France
| | - Virginie Supervie
- Institut Pierre Louis d’Epidémiologie et de Santé Publique (IPLESP), Sorbonne Université, INSERM, Paris, France
| | - Romulus Breban
- Institut Pasteur, Unité d’Epidémiologie des Maladies Emergentes, Paris, France
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Hoenigl M, Lo M, Coyne CJ, Wagner GA, Blumenthal J, Mathur K, Horton LE, Martin TC, Vilke GM, Little SJ. 4th Generation HIV screening in the emergency department: net profit or loss for hospitals? AIDS Care 2023; 35:714-718. [PMID: 34839750 PMCID: PMC9135954 DOI: 10.1080/09540121.2021.1995838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.
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Affiliation(s)
- Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
- Department of Pathology, University of California San Diego, San Diego, California, United States
- Division of Infectious Diseases, Medical University of Graz, Graz, Austria
| | - Megan Lo
- School of Medicine, University of San Diego, San Diego, California, United States
| | - Christopher J. Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Gabriel A. Wagner
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Kushagra Mathur
- School of Medicine, University of San Diego, San Diego, California, United States
| | - Lucy E. Horton
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Thomas C.S. Martin
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Gary M. Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Susan J. Little
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
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Hársfalvi P, Reiczigel J. Profile likelihood confidence interval for the prevalence assessed by an imperfect diagnostic test. Prev Vet Med 2023; 214:105886. [PMID: 36913890 DOI: 10.1016/j.prevetmed.2023.105886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/25/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023]
Abstract
We present a new confidence interval for the prevalence of a disease for a situation when sensitivity and specificity of the diagnostic test are estimated from validation samples independent of the study sample. The new interval is based on profile likelihood and incorporates an adjustment improving the coverage probability. Its coverage probability and expected length were assessed by simulation and compared to two other methods for this problem, namely those by Lang and Reiczigel (2014) and Flor et al. (2020). Expected length of the new interval is less than that of the Lang and Reiczigel interval while its coverage is about the same. Comparison to the Flor interval resulted in similar expected length but higher coverage probabilities for the new interval. All in all, the new interval proved to be better than both its competitors.
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Affiliation(s)
- Péter Hársfalvi
- University of Veterinary Medicine Budapest, Department of Biostatistics, Budapest, Hungary; BiTrial Clinical Research, Budapest, Hungary.
| | - Jenő Reiczigel
- University of Veterinary Medicine Budapest, Department of Biostatistics, Budapest, Hungary
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Serag H, Clark I, Naig C, Lakey D, Tiruneh YM. Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:457. [PMID: 36612775 PMCID: PMC9819288 DOI: 10.3390/ijerph20010457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.
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Affiliation(s)
- Hani Serag
- Department of International Medicine, School of Medicine, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - Isabel Clark
- HIV/STD Prevention & Care Unit, Texas Department of State Health Services, Austin, TX 78714, USA
| | - Cherith Naig
- MPH Program, School of Public and Population Health, University of Texas Medical Branch (UTMB), Galveston, TX 77555, USA
| | - David Lakey
- Administration Division, University of Texas System, Austin, TX 78701, USA
| | - Yordanos M. Tiruneh
- Department of Preventive Medicine and Population Health, School of Medicine, University of Texas Tyler, Tyler, TX 75799, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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7
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Liu J. HIV Digital Vaccine Strategy: Proposal for Applying Blockchain in Preventing the Spread of HIV. JMIR Res Protoc 2022; 11:e37133. [PMID: 35700007 PMCID: PMC9237779 DOI: 10.2196/37133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background The HIV epidemic imposes a heavy burden on societal development. Protection of susceptible populations is the most feasible method for eliminating the spread of HIV. In the absence of a biological vaccine, the definitive solution is enabling susceptible populations to recognize and avoid high-risk sexual behavior. Objective The objective of this study is to use specific technologies and strategies to establish a system by which high-HIV-risk individuals can determine the HIV infection status of one another anonymously, conveniently, and credibly. Methods This study proposes an HIV digital vaccine (HDV) strategy, a decentralized application (Dapp) based on blockchain for use by individuals with a high risk of HIV and accredited testing agencies (ATAs). Following testing, only the HIV-negative results (or linked information) are uploaded to the blockchain, which results in high-risk individuals being able to determine the HIV-negative status of each other anonymously, conveniently, and credibly. Results Future work includes the following: (1) a survey of the willingness to use Dapps among high-HIV-risk populations, (2) a larger framework containing both HDV and people living with HIV (PLH) and discussing the influence of HDV on PLH and its possible solutions, and (3) coordinating with the blockchain development team, ATAs, community-based organizations, and third-party organizations to raise funds, develop the Dapp, formulate detailed plans, and publicize and promote it. The exact timeline for achieving these objectives cannot be determined at present. Conclusions The HDV strategy may reduce the occurrence of high-risk sexual behavior and effectively protect susceptible populations; combined with current strategies, it is a promising solution to prevent the spread of HIV. The included concepts of decentralized surveillance and surveillance as intervention may spark a change in current infectious disease prevention and control modes to introduce beneficial innovations in public health systems globally. International Registered Report Identifier (IRRID) PRR1-10.2196/37133
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Affiliation(s)
- Jia Liu
- Henan Center for Disease Control and Prevention, Zhengzhou, China
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8
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Williams AM, Eppink ST, Guy JN, Seña AC, Berruti AA. Costs Associated With Incorporation of Network Approaches Into Sexually Transmitted Disease Program Activities. Sex Transm Dis 2022; 49:325-329. [PMID: 35001018 PMCID: PMC9018482 DOI: 10.1097/olq.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Network approaches can be used to study sociosexual partnerships and identify individuals at high risk of infection. Little is known about the cost structure of these services and their association with STD diagnoses. METHOD We collected costs associated with using a peer network strategy to recruit men who have sex with men and transwomen of color in 4 counties in North Carolina: Guilford, Forsyth, Durham, and Wake from February through October 2019. We used a comprehensive costing approach to gather detailed retrospective information on the intervention cost, broken down by category and programmatic activity. RESULTS The sociosexual networks collected consisted of 31 initial seeds (index cases) and 49 peers of those seeds. In peers, 5 cases of human immunodeficiency virus (HIV) and 10 cases of syphilis were identified. The cost per case (HIV or syphilis) identified was $7325. Personnel costs accounted for 80% of total expenditures, followed by laboratory expenses (12%). Personnel cost was distributed between disease intervention specialist patient navigators (51%), nonclinical (37%), and management (12%) staff. General administration was the costliest programmatic activity (37%), followed by case management and field services (37%), and study activities (11%). The estimated average cost per patient tested was $2242. CONCLUSIONS Finding positive peer cases in nonclinical settings is costly but may be crucial for limiting the spread of sexually transmitted diseases. The cost of staff was the major driver. This study demonstrates that using a network strategy can be a cost-effective way to identify, test, and refer patients at high risk of syphilis and HIV infections to care.
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Affiliation(s)
- Austin M. Williams
- Division of Sexually Transmitted Disease Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Samuel T. Eppink
- Division of Sexually Transmitted Disease Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jalila N. Guy
- Institute for Global Health and Infectious Diseases, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Arlene C. Seña
- Institute for Global Health and Infectious Diseases, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Andrés A. Berruti
- Division of Sexually Transmitted Disease Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Costs and Cost-Effectiveness of the Patient-Centered HIV Care Model: A Collaboration Between Community-Based Pharmacists and Primary Medical Providers. J Acquir Immune Defic Syndr 2021; 85:e48-e54. [PMID: 32732767 DOI: 10.1097/qai.0000000000002458] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The patient-centered HIV care model (PCHCM) is an evidence-informed structural intervention that integrates community-based pharmacists with primary medical providers to improve rates of HIV viral suppression. This report assesses the costs and cost-effectiveness of the PCHCM. SETTING Patient-centered HIV care model. METHODS Three project sites, each composed of a medical clinic and 1 or 2 community-based HIV-specialized pharmacies, were included in the analyses. PCHCM required patient data sharing between medical providers and pharmacists and collaborative therapy-related decision making. Intervention effectiveness was measured as the incremental number of patients virally suppressed (HIV RNA <200 copies/mL at the last test in a 12-month measurement period). Microcosting direct measurement methods were used to estimate intervention costs. The cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were calculated from the health care providers' perspective. Additionally, the number of HIV transmissions averted, lifetime HIV treatment cost saved, quality-adjusted life years (QALYs) saved, and cost per QALY saved were calculated from the societal perspective, using standard methods and reported values from the published literature. RESULTS Overall, the PCHCM annual intervention cost for the 3 project sites was $226,741. The average cost per patient, cost per patient visit, and incremental cost per patient virally suppressed were $813, $48, and $5,039, respectively. The intervention averted 2.75 HIV transmissions and saved 12.22 QALYs and nearly $1.28 million in lifetime HIV treatment costs. The intervention was cost saving overall and at each project site. CONCLUSIONS The PCHCM can be delivered at a relatively low cost and is a cost-saving intervention to assist patients in achieving viral suppression and preventing HIV transmission.
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Jalali A, Ryan DA, McCollister KE, Marsch LA, Schackman BR, Murphy SM. Economic evaluation in the National Drug Abuse Treatment Clinical Trials Network: Past, present, and future. J Subst Abuse Treat 2020; 112S:18-27. [PMID: 32220406 DOI: 10.1016/j.jsat.2020.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 01/01/2023]
Abstract
Economic evaluations provide evidence that informs stakeholders on how to efficiently allocate real and financial healthcare resources. The purpose of this study was to review and discuss the integration of economic evaluations into the National Drug Abuse Treatment Clinical Trials Network (CTN) since its inception, as well as expectations for the future of this relationship. A systematic review was performed on published and planned CTN economic evaluations in the CTN dissemination library and PubMed. The well-established Drummond checklist was used to evaluate the comprehensiveness and methodological rigor of published articles. One hundred thirty-eight ancillary, follow-up, or original protocols were reviewed, and 78 potentially relevant published articles were identified. A total number of 14 protocols included an economic evaluation. Of these, 6 protocols were completed, 2 were reported as active, and 6 were reported as in-development at the time of this review. Of the 78 published articles, 9 met the inclusion criteria. As gauged by the Drummond checklist, the quality of CTN published economic evaluations were found to improve over time, and recent published articles were identified as guides to cutting-edge economic research. As the CTN continues to grow and mature, it is imperative that high-quality economic evaluations are incorporated alongside trials in order to maximize the public health impact of the CTN.
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Affiliation(s)
- Ali Jalali
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA.
| | - Danielle A Ryan
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Kathryn E McCollister
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Bruce R Schackman
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Sean M Murphy
- Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
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Wagner Z, Montoy JCC, Drabo EF, Dow WH. Incentives Versus Defaults: Cost-Effectiveness of Behavioral Approaches for HIV Screening. AIDS Behav 2020; 24:379-386. [PMID: 30953306 DOI: 10.1007/s10461-019-02425-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many HIV positive individuals are still undiagnosed, which has led health systems to try many approaches to expand HIV testing. In a randomized controlled trial, we found that behavioral economics interventions (opt-out testing and financial incentives) each improved HIV testing rates and these approaches are being implemented by several hospital systems. However, it is unclear if these strategies are cost-effective. We quantified the cost-effectiveness of different behavioral approaches to HIV screening-opt-out testing, financial incentives, and their combination-in terms of cost per new HIV diagnosis and infections averted. We estimated the incremental number of new HIV diagnoses and program costs using a mathematical screening model, and infections averted using and HIV transmission model. We used a 1-year time horizon and a hospital perspective. Switching from opt-into opt-out results in 39 additional diagnoses (56% increase) after 1-year at a cost of $3807 per new diagnosis. Switching from no incentive to a $1, $5, or $10 incentive adds 14, 13, and 28 new diagnoses (20, 19, and 41% increases) at a cost of $11,050, $17,984, and $15,298 per new diagnosis, respectively. Layering on financial incentives to opt-out testing enhances program effectiveness, though at a greater marginal cost per diagnosis. We found a similar pattern for infections averted. This is one of the first cost-effectiveness analyses of behavioral economics interventions in public health. Changing the choice architecture from opt-into opt-out and giving financial incentives for testing are both cost-effective in terms of detecting HIV and reducing transmission. For hospitals interested in increasing HIV screening rates, changing the choice architecture is an efficient strategy and more efficient than incentives.
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Affiliation(s)
- Zachary Wagner
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA.
| | - Juan Carlos C Montoy
- Department Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Emmanuel F Drabo
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - William H Dow
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
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Shrestha RK, Chavez PR, Noble M, Sansom SL, Sullivan PS, Mermin JH, MacGowan RJ. Estimating the costs and cost-effectiveness of HIV self-testing among men who have sex with men, United States. J Int AIDS Soc 2020; 23:e25445. [PMID: 31960580 PMCID: PMC6970935 DOI: 10.1002/jia2.25445] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 12/04/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION HIV testing is an essential prerequisite for accessing treatment with antiretroviral therapy or prevention using pre-exposure prophylaxis. Internet distribution of HIV self-tests is a novel approach, and data on the programmatic cost of this approach are limited. We analyse the costs and cost-effectiveness of a self-testing programme. METHODS Men who have sex with men (MSM) reporting unknown or negative HIV status were enrolled from March to August 2015 into a 12-month trial of HIV self-testing in the United States. Participants were randomly assigned either to the self-testing arm or the control arm. All participants received information on HIV testing services and locations in their community. Self-testing participants received up to four self-tests each quarter, which they could use themselves or distribute to their social network associates. Quarterly follow-up surveys collected testing outcomes, including number of tests used and new HIV diagnoses. Using trial expenditure data, we estimated the cost of implementing a self-testing programme. Primary outcomes of this analysis included total programme implementation costs, cost per self-test completed, cost per person tested, cost per new HIV diagnosis among those self-tested and cost per quality adjusted life year (QALY) saved. RESULTS A total of 2665 men were assigned either to the self-testing arm (n = 1325) or the control arm (n = 1340). HIV testing was reported by 971 self-testing participants who completed a total of 5368 tests. In the control arm, 619 participants completed 1463 HIV tests. The self-testing participants additionally distributed 2864 self-tests to 2152 social network associates. Testing during the trial identified 59 participants and social network associates with newly diagnosed HIV infection in the self-testing arm; 11 control participants were newly diagnosed with HIV. The implementation cost of the HIV self-testing programme was $449,510. The cost per self-test completed, cost per person tested at least once, and incremental cost per new HIV diagnosis was $61, $145 and $9365 respectively. We estimated that self-testing programme potentially averted 3.34 transmissions, saved 14.86 QALYs and nearly $1.6 million lifetime HIV treatment costs. CONCLUSIONS The HIV self-testing programme identified persons with newly diagnosed HIV infection at low cost, and the programme is cost saving.
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Affiliation(s)
- Ram K Shrestha
- Centers for Disease Control and PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionAtlantaGAUSA
| | - Pollyanna R Chavez
- Centers for Disease Control and PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionAtlantaGAUSA
| | | | - Stephanie L Sansom
- Centers for Disease Control and PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionAtlantaGAUSA
| | - Patrick S Sullivan
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGAUSA
| | - Jonathan H Mermin
- Centers for Disease Control and PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionAtlantaGAUSA
| | - Robin J MacGowan
- Centers for Disease Control and PreventionNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB PreventionAtlantaGAUSA
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Hoenigl M, Mathur K, Blumenthal J, Brennan J, Zuazo M, McCauley M, Horton LE, Wagner GA, Reed SL, Vilke GM, Coyne CJ, Little SJ. Universal HIV and Birth Cohort HCV Screening in San Diego Emergency Departments. Sci Rep 2019; 9:14479. [PMID: 31597939 PMCID: PMC6785532 DOI: 10.1038/s41598-019-51128-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/25/2019] [Indexed: 12/11/2022] Open
Abstract
Universal HIV and HCV screening in emergency departments (ED) can reach populations who are less likely to get tested otherwise. The objective of this analysis was to evaluate universal opt-out HIV and HCV screening in two EDs in San Diego. HIV screening for persons aged 13-64 years (excluding persons known to be HIV+ or reporting HIV testing within last 12 months) was implemented using a 4th generation HIV antigen/antibody assay; HCV screening was offered to persons born between 1945 and 1965. Over a period of 16 months, 12,575 individuals were tested for HIV, resulting in 33 (0.26%) new HIV diagnoses, of whom 30 (90%) were successfully linked to care. Universal screening also identified 74 out-of-care for >12-months HIV+ individuals of whom 50 (68%) were successfully relinked to care. Over a one-month period, HCV antibody tests were conducted in 905 individuals with a seropositivity rate of 9.9% (90/905); 61 seropositives who were newly identified or never treated for HCV had HCV RNA testing, of which 31 (51%) resulted positive (3.4% of all participants, including 18 newly identified RNA positives representing 2% of all participants), and 13/31 individuals (42%) were linked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >7-fold, underlining the importance of HCV screening in EDs.
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Affiliation(s)
- Martin Hoenigl
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States.
| | - Kushagra Mathur
- University of San Diego School of Medicine, San Diego, California, United States
| | - Jill Blumenthal
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Jesse Brennan
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Miriam Zuazo
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Melanie McCauley
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Lucy E Horton
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Gabriel A Wagner
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
| | - Sharon L Reed
- Department of Pathology, University of California San Diego, San Diego, California, United States
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, California, United States
| | - Susan J Little
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, United States
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Friedman EE, Dean HD, Duffus WA. Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Public Health Rep 2018; 133:392-412. [PMID: 29874147 DOI: 10.1177/0033354918774788] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article). RESULTS Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.
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Affiliation(s)
- Eleanor E Friedman
- 1 Association of Schools and Programs of Public Health/CDC Public Health Fellowship Program, Atlanta, GA, USA.,2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.,3 Chicago Center for HIV Elimination and University of Chicago Department of Medicine, Chicago, IL, USA
| | - Hazel D Dean
- 4 Office of the Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wayne A Duffus
- 2 Office of Health Equity, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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15
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Cost-effectiveness of HIV screening in high-income countries: A systematic review. Health Policy 2018; 122:533-547. [PMID: 29606287 DOI: 10.1016/j.healthpol.2018.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/31/2018] [Accepted: 03/09/2018] [Indexed: 11/23/2022]
Abstract
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.
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16
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Jülicher P, Galli C. Identifying cost-effective screening algorithms for active hepatitis C virus infections in a high prevalence setting. J Med Econ 2018; 21:1-10. [PMID: 28881157 DOI: 10.1080/13696998.2017.1369983] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of different screening patterns for active chronic hepatitis C virus (HCV) infections utilizing the hepatitis C core antigen test compared to standard care in the context of a general screening program in a high-prevalence country. METHODS This study developed a decision analytic model to estimate the cost-effectiveness of four screening algorithms for the detection of active HCV infections among asymptomatic individuals with an unknown HCV status in a context of high (>5%) HCV prevalence. Three algorithms started with a serological test for antibodies (AB) followed by a nucleic acid test for HCV-RNA (RNA), the HCVAg (AG) assay, or both. An additional single marker screening strategy with AG was added to the analysis. By the example of the Republic of Georgia, strategies were compared in terms of total costs for screening and diagnosis of an active infection from a health system perspective. RESULTS Replacing RNA with AG for confirmation of positive AB identified fewer active infections (-110 per 100,000 screened subjects) at significantly reduced total costs (-$2.74 per screened) and costs per diagnosed infection (-$44). Adding a subsequent RNA confirmatory test on AG negative results captured at least the same rate compared to the standard (AB followed by RNA) at still reduced costs (-$1.16 per subject screened, -$22 per case detected). Utilizing AG as the frontline test revealed the highest detection rate (97.9%) at the highest costs (+$3.80 per subject, +$323 per case detected vs standard). CONCLUSION A combined pattern of HCV AB screening followed by sequential confirmation with AG and RNA on AG negatives would provide equal or better diagnostic performance at lower cost over a broad range of scenarios. Potential long-term consequences of screening strategies to patients and society have to be considered, since the latency period for HCV to develop into severe liver disease is long.
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Affiliation(s)
- Paul Jülicher
- a International Health Economics and Outcomes Research, Medical Affairs, Abbott Diagnostics , Wiesbaden , Germany
| | - Claudio Galli
- b Medical Scientific Liaison Europe, Abbott Diagnostics , Roma , Italy
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Clutterbuck D, Asboe D, Barber T, Emerson C, Field N, Gibson S, Hughes G, Jones R, Murchie M, Nori AV, Rayment M, Sullivan A. 2016 United Kingdom national guideline on the sexual health care of men who have sex with men. Int J STD AIDS 2018:956462417746897. [PMID: 29334885 DOI: 10.1177/0956462417746897] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.
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Affiliation(s)
| | - David Asboe
- 2 Chelsea and Westminster Healthcare NHS Foundation Trust, London, UK
| | - Tristan Barber
- 2 Chelsea and Westminster Healthcare NHS Foundation Trust, London, UK
| | | | - Nigel Field
- 4 Public Health England, London, UK
- 5 University College London, London, UK
| | | | | | - Rachael Jones
- 2 Chelsea and Westminster Healthcare NHS Foundation Trust, London, UK
| | | | - Achyuta V Nori
- 8 8945 Guy's and St Thomas' NHS Foundation Trust , London, UK
| | - Michael Rayment
- 2 Chelsea and Westminster Healthcare NHS Foundation Trust, London, UK
| | - Ann Sullivan
- 9 BASHH CEG, BASHH 2017 Registered Office, Macclesfield, UK
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18
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Johnson BL, Tesoriero J, Feng W, Qian F, Martin EG. Cost Analysis and Performance Assessment of Partner Services for Human Immunodeficiency Virus and Sexually Transmitted Diseases, New York State, 2014. Health Serv Res 2017; 52 Suppl 2:2331-2342. [PMID: 28799163 DOI: 10.1111/1475-6773.12748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the programmatic costs of partner services for HIV, syphilis, gonorrhea, and chlamydial infection. STUDY SETTING New York State and local health departments conducting partner services activities in 2014. STUDY DESIGN A cost analysis estimated, from the state perspective, total program costs and cost per case assignment, patient interview, partner notification, and disease-specific key performance indicator. DATA COLLECTION Data came from contracts, a time study of staff effort, and statewide surveillance systems. PRINCIPAL FINDINGS Disease-specific costs per case assignment (mean: $580; range: $502-$1,111), patient interview ($703; $608-$1,609), partner notification ($1,169; $950-$1,936), and key performance indicator ($2,697; $1,666-$20,255) varied across diseases. Most costs (79 percent) were devoted to gonorrhea and chlamydial infection investigations. CONCLUSIONS Cost analysis complements cost-effectiveness analysis in evaluating program performance and guiding improvements.
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Affiliation(s)
- Britney L Johnson
- Oak Ridge Institute for Science and Education (ORISE), Centers for Disease Control and Prevention, Brookhaven, GA, 30329
| | - James Tesoriero
- New York State Department of Health, AIDS Institute, Albany, NY
| | - Wenhui Feng
- Rockefeller Institute of Government, Albany, NY.,Rockefeller College of Public Affairs & Policy, University at Albany, State University of New York, Albany, NY
| | - Feng Qian
- University at Albany School of Public Health, State University of New York, Rensselaer, NY
| | - Erika G Martin
- Rockefeller Institute of Government, Albany, NY.,Rockefeller College of Public Affairs & Policy, University at Albany, State University of New York, Albany, NY
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Hoenigl M, Chaillon A, Mehta SR, Smith DM, Graff-Zivin J, Little SJ. Screening for acute HIV infection in community-based settings: Cost-effectiveness and impact on transmissions. J Infect 2016; 73:476-484. [PMID: 27521468 DOI: 10.1016/j.jinf.2016.07.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/30/2016] [Accepted: 07/30/2016] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To determine cost-effectiveness of three community-based acute HIV infection (AHI) testing algorithms compared to HIV antibody testing alone by focusing on the potential of averting new infections occurring within a one-year time horizon among men who have sex with men (MSM). METHODS Data sources for model parameters included actual cost and prevalence data derived from a community-based AHI screening program in San Diego, and published studies. Main outcome measure was costs per infection averted (IA). The lower end of the cost range of discounted lifetime costs of an HIV infection (i.e. $236,948) was used for defining cost-effectiveness. RESULTS The most sensitive algorithm for AHI detection, which was based on HIV nucleic acid amplification testing, was estimated to prevent between 5 and 45 transmissions, with simulated costs per infection averted between $965 and $141,256 when compared to HIV antibody testing alone. CONCLUSION AHI testing was cost-effective in preventing new HIV infections among at risk MSM in San Diego, and also among other MSM populations with similar HIV prevalence but lower proportions of AHI diagnoses. These results indicate that community-based AHI testing among MSM in the United States can pay for itself over the long run.
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Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, University of California San Diego (UCSD), 220 Dickinson Street, Suite A, San Diego, CA 92103, United States; Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 20, 8036 Graz, Austria; Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
| | - Antoine Chaillon
- Division of Infectious Diseases, University of California San Diego (UCSD), 220 Dickinson Street, Suite A, San Diego, CA 92103, United States
| | - Sanjay R Mehta
- Division of Infectious Diseases, University of California San Diego (UCSD), 220 Dickinson Street, Suite A, San Diego, CA 92103, United States; Veterans Affairs Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Davey M Smith
- Division of Infectious Diseases, University of California San Diego (UCSD), 220 Dickinson Street, Suite A, San Diego, CA 92103, United States; Veterans Affairs Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Joshua Graff-Zivin
- School of International Relations and Pacific Studies, Department of Economics, UCSD, 9500 Gilman Dr. # 0520, La Jolla, CA 92093, United States
| | - Susan J Little
- Division of Infectious Diseases, University of California San Diego (UCSD), 220 Dickinson Street, Suite A, San Diego, CA 92103, United States
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20
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Lin F, Farnham PG, Shrestha RK, Mermin J, Sansom SL. Cost Effectiveness of HIV Prevention Interventions in the U.S. Am J Prev Med 2016; 50:699-708. [PMID: 26947213 DOI: 10.1016/j.amepre.2016.01.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 12/22/2015] [Accepted: 01/20/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The purpose of this study was to assess and compare the cost effectiveness of current HIV prevention interventions in the U.S. using a consistent, standardized methodology. METHODS The cost effectiveness of common and emerging HIV biomedical and behavioral prevention interventions as delivered to men who have sex with men, injection drug users, and sexually active heterosexuals was estimated. Data on program costs, intervention efficacy, risk behaviors, and per contact transmission probabilities were collected from peer-reviewed papers and health department reports. These data were combined with 2010 national HIV incidence and prevalence surveillance data in a Bernoulli process model to estimate the reduced annual risk of HIV transmission or acquisition associated with these interventions. The cost per prevented case of HIV and the cost per saved quality-adjusted life year were then calculated. Analyses were conducted between 2014 and 2015. RESULTS Interventions to diagnose HIV and provide ongoing care and treatment had the lowest cost per prevented case. Among interventions targeted at specific risk groups, interventions for men who have sex with men were the most cost effective. The least cost-effective interventions typically addressed people at risk of acquiring HIV rather than those at risk of transmitting the disease. CONCLUSIONS HIV prevention interventions targeted at high-risk populations, those associated with the care continuum, and those that reduce the transmission risk of HIV-infected people are typically the most cost effective. Decision makers can consider these results in planning an efficient allocation of HIV prevention resources.
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Affiliation(s)
- Feng Lin
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - Paul G Farnham
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - Ram K Shrestha
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia.
| | - Jonathan Mermin
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
| | - Stephanie L Sansom
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia
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Hoenigl M, Graff-Zivin J, Little SJ. Costs per Diagnosis of Acute HIV Infection in Community-based Screening Strategies: A Comparative Analysis of Four Screening Algorithms. Clin Infect Dis 2015; 62:501-511. [PMID: 26508512 DOI: 10.1093/cid/civ912] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 10/20/2015] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND In nonhealthcare settings, widespread screening for acute human immunodeficiency virus (HIV) infection (AHI) is limited by cost and decision algorithms to better prioritize use of resources. Comparative cost analyses for available strategies are lacking. METHODS To determine cost-effectiveness of community-based testing strategies, we evaluated annual costs of 3 algorithms that detect AHI based on HIV nucleic acid amplification testing (EarlyTest algorithm) or on HIV p24 antigen (Ag) detection via Architect (Architect algorithm) or Determine (Determine algorithm) as well as 1 algorithm that relies on HIV antibody testing alone (Antibody algorithm). The cost model used data on men who have sex with men (MSM) undergoing community-based AHI screening in San Diego, California. Incremental cost-effectiveness ratios (ICERs) per diagnosis of AHI were calculated for programs with HIV prevalence rates between 0.1% and 2.9%. RESULTS Among MSM in San Diego, EarlyTest was cost-savings (ie, ICERs per AHI diagnosis less than $13.000) when compared with the 3 other algorithms. Cost analyses relative to regional HIV prevalence showed that EarlyTest was cost-effective (ie, ICERs less than $69.547) for similar populations of MSM with an HIV prevalence rate >0.4%; Architect was the second best alternative for HIV prevalence rates >0.6%. CONCLUSIONS Identification of AHI by the dual EarlyTest screening algorithm is likely to be cost-effective not only among at-risk MSM in San Diego but also among similar populations of MSM with HIV prevalence rates >0.4%.
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Affiliation(s)
- Martin Hoenigl
- Division of Infectious Diseases, University of California-San Diego.,Division of Pulmonology.,Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, Austria
| | - Joshua Graff-Zivin
- School of International Relations and Pacific Studies and Department of Economics, University of California-San Diego
| | - Susan J Little
- Division of Infectious Diseases, University of California-San Diego
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22
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Huang YLA, Lasry A, Hutchinson AB, Sansom SL. A systematic review on cost effectiveness of HIV prevention interventions in the United States. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:149-156. [PMID: 25536927 DOI: 10.1007/s40258-014-0142-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- Ya-Lin A Huang
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop E-48, Atlanta, GA, 30329, USA,
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23
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Hutchinson AB, Ethridge SF, Wesolowski LG, Shrestha RK, Pentella M, Bennett B, Farnham PG, Sullivan T, Patel P, Branson BM. Costs and outcomes of laboratory diagnostic algorithms for the detection of HIV. J Clin Virol 2014; 58 Suppl 1:e2-7. [PMID: 24342475 DOI: 10.1016/j.jcv.2013.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 09/27/2013] [Accepted: 10/01/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND An alternative HIV testing algorithm, designed to improve the detection of acute and early infections and differentiate between HIV-1 and HIV-2 antibodies, has been developed by the Centers for Disease Control and Prevention and the Association of Public Health Laboratories. While it promises greater sensitivity, it also raises concerns about costs. OBJECTIVE We sought to compare the most commonly used algorithm which was developed in 1989, a third-generation (3G) immunoassay (IA) and Western blot confirmatory test, to a newer algorithm. The new algorithm includes either a 3G or a fourth-generation (4G) initial IA, followed by confirmatory testing with a HIV-1/HIV-2 differentiation IA and, if needed, a nucleic acid amplification test (NAT). STUDY DESIGN We conducted an analysis of HIV testing costs from the perspective of the laboratory, and classified costs according to IA testing volume. We developed a decision analytic model, populated with cost data from 17 laboratories and published assay performance data, to compare the cost-effectiveness of the testing algorithms for a cohort of 30,000 specimens with a 1% HIV prevalence and 0.1% acute HIV infection prevalence. RESULTS Costs were lower in high-volume laboratories regardless of testing algorithm. For specimens confirmed positive for HIV antibody, the alternative algorithm (IA, Multispot) was less costly than the current algorithm (IA, WB); however, there was wide variation in reported testing costs. For our cohort, the alternative algorithm initiated with a 3G IA and 4G IA identified 15 and 25 more HIV infections, respectively, than the 1989 algorithm. In medium-volume laboratories, the 1989 algorithm was more costly and less effective than the alternative algorithm with a 3G IA; in high-volume laboratories, the alternative algorithm with 3G IA costs $162 more per infection detected. The alternative algorithm with 4G instead of 3G incurred an additional cost of $14,400 and $4865 in medium- and high-volume labs, respectively. DISCUSSION HIV testing costs varied with IA testing volumes. The additional cost of 4G over 3G IA might be justified by the additional cases of HIV detected and transmissions averted due to earlier detection. CONCLUSION The alternative HIV testing algorithm compares favorably to the 1989 algorithm in terms of cost and effectiveness.
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Affiliation(s)
| | - Steven F Ethridge
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | - Ram K Shrestha
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Michael Pentella
- State Hygienic Laboratory, University of Iowa, Iowa City, Iowa, United States
| | - Berry Bennett
- Florida Bureau of Public Health Laboratories, Jacksonville, FL, United States
| | - Paul G Farnham
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Timothy Sullivan
- Wadsworth Center, New York State Department of Health, Albany, NY, United States
| | - Pragna Patel
- Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Bernard M Branson
- Centers for Disease Control and Prevention, Atlanta, GA, United States
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24
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Kintziger KW, Duffus WA. How useful is universal screening for HIV infection? A review of the evidence. Future Virol 2014. [DOI: 10.2217/fvl.13.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Kristina W Kintziger
- Department of Biostatistics & Epidemiology, Medical College of Georgia, Georgia Regents University – Augusta, 1120 15th Street, Augusta, GA 30912, USA
| | - Wayne A Duffus
- Division of Infectious Diseases, University of South Carolina School of Medicine, 2 Medical Park, Columbia, SC 29203, USA
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Lifetime costs and quality-adjusted life years saved from HIV prevention in the test and treat era. J Acquir Immune Defic Syndr 2013; 64:e15-8. [PMID: 24047975 DOI: 10.1097/qai.0b013e3182a5c8d4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Metsch LR, Feaster DJ, Gooden L, Schackman BR, Matheson T, Das M, Golden MR, Huffaker S, Haynes LF, Tross S, Malotte CK, Douaihy A, Korthuis PT, Duffus WA, Henn S, Bolan R, Philip SS, Castro JG, Castellon PC, McLaughlin G, Mandler RN, Branson B, Colfax GN. Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial. JAMA 2013; 310:1701-10. [PMID: 24150466 PMCID: PMC4110051 DOI: 10.1001/jama.2013.280034] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. OBJECTIVE To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). DESIGN, SETTING, AND PARTICIPANTS From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. INTERVENTIONS Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient's specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test. MAIN OUTCOMES AND MEASURES The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis. RESULTS There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group. CONCLUSION AND RELEVANCE Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01154296.
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Affiliation(s)
- Lisa R. Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL
| | - Daniel J. Feaster
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL
| | - Lauren Gooden
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL
| | - Bruce R. Schackman
- Department of Public Health, Weill Cornell Medical College, New York, NY
| | - Tim Matheson
- HIV Prevention and Research Section, San Francisco Department of Public Health, San Francisco, CA
| | - Moupali Das
- HIV Prevention and Research Section, San Francisco Department of Public Health, San Francisco, CA
- University of California, San Francisco, San Francisco, CA
| | - Matthew R. Golden
- Center for AIDS and STD, University of Washington, Seattle, WA and Public Health—Seattle & King County, Seattle, WA
| | - Shannon Huffaker
- HIV Prevention and Research Section, San Francisco Department of Public Health, San Francisco, CA
| | - Louise F. Haynes
- Department of Psychiatry and Behavioral Science, Medical University of South Carolina, Charleston, SC
| | - Susan Tross
- Columbia University College of Physicians and Surgeons, New York, NY, and HIV Center For Clinical and Behavioral Studies, New York, NY
| | - C. Kevin Malotte
- Center for Health Care Innovation and Department of Health Science, California State University, Long Beach, Long Beach, CA
| | | | - P. Todd Korthuis
- Department of Medicine and Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, OR
| | - Wayne A. Duffus
- Division of Infectious Diseases, Department of Medicine, University of South Carolina School Of Medicine, Columbia, SC
| | - Sarah Henn
- Elizabeth Taylor Medical Center, Whitman-Walker Health, Washington, DC
| | - Robert Bolan
- Jeffrey Goodman Special Care Clinic, Los Angeles Gay & Lesbian Center, Los Angeles, CA
| | - Susan S. Philip
- STD Prevention and Control, San Francisco Department of Public Health, San Francisco, CA
| | - Jose G. Castro
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL
| | - Pedro C. Castellon
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY
| | | | - Raul N. Mandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | - Bernard Branson
- Division of HIV/AIDS Prevention, National Center for HIV, Hepatitis, STD & TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Grant N. Colfax
- HIV Prevention and Research Section, San Francisco Department of Public Health, San Francisco, CA
- University of California, San Francisco, San Francisco, CA
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Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention. AIDS Behav 2013; 17 Suppl 2:S220-6. [PMID: 23138877 DOI: 10.1007/s10461-012-0353-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We are not aware of published cost-effectiveness studies addressing community transitional programs for HIV-infected jail detainees. To address this gap, data from 9 sites of EnhanceLink, a project that enrolled HIV-infected releasees from jails across the US, were examined. Figures on the number of clients served, cost of linkage services, number of linkages and 6-month sustained linkages to community HIV care, and number of clients achieving viral suppression were assessed for subjects released in the first quarter of 2010 (n = 543). The cost analysis included all costs that participating service agencies incurred. A cost-effectiveness analysis was conducted to estimate the new HIV cases averted by EnhanceLink and the cost per quality-adjusted life year saved by the program. The mean cost per linked client was $4,219; the mean cost per 6-month sustained linkage was $4,670; and the mean cost per client achieving viral suppression was $8,432. Compared to standard care, the cost per additional quality-adjusted life year saved was $72,285, suggesting that the EnhanceLink interventions were cost-effective from the societal perspective.
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Holtgrave DR, Wolitski RJ, Pals SL, Aidala A, Kidder DP, Vos D, Royal S, Iruka N, Briddell K, Stall R, Bendixen AV. Cost-utility analysis of the housing and health intervention for homeless and unstably housed persons living with HIV. AIDS Behav 2013; 17:1626-31. [PMID: 22588529 DOI: 10.1007/s10461-012-0204-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We present a cost-utility analysis based on data from the Housing and Health (H&H) Study of rental assistance for homeless and unstably housed persons living with HIV in Baltimore, Chicago and Los Angeles. As-treated analyses found favorable associations of housing with HIV viral load, emergency room use, and perceived stress (an outcome that can be quantitatively linked to quality of life). We combined these outcome data with information on intervention costs to estimate the cost-per-quality-adjusted-life-year (QALY) saved. We estimate that the cost-per-QALY-saved by the HIV-related housing services is $62,493. These services compare favorably (in terms of cost-effectiveness) to other well-accepted medical and public health services.
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Schackman BR. The Value of HIV Screening in the United States in the Era of Effective Treatment. Med Decis Making 2013; 33:457-9. [DOI: 10.1177/0272989x13486978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bruce R. Schackman
- Department of Public Health, Weill Cornell Medical College, New York, NY
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Abstract
PURPOSE OF REVIEW The US Food and Drug Administration (FDA) recently approved the use of tenofovir-emtricitabine for pre-exposure prophylaxis (PrEP) for HIV prevention. PrEP is also being investigated in clinical trials as a component of HIV prevention in resource-limited settings. Cost-effectiveness models are useful in identifying health programs with the greatest societal value and projecting long-term program impacts. This review examines six recent studies of the cost-effectiveness of PrEP for preventing HIV transmission in the USA and South Africa. RECENT FINDINGS Studies used both individual-level and population-level transmission models. PrEP was found to be a cost-effective HIV-prevention intervention in high-risk MSM with HIV incidence at least 2% in the USA (<US$100 000 per quality-adjusted life year) and in young women in South Africa (cost per life year <GDP per capita). Results were sensitive to the cost and efficacy of PrEP and to assumptions about HIV testing and access to treatment in the absence of PrEP. SUMMARY Future cost effectiveness studies should consider PrEP implementation issues (uptake in high-risk versus low-risk groups, duration on PrEP, adherence), budget impact, and the role of PrEP as part of combination HIV-prevention strategies including expanded testing and treatment access.
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Abstract
Each year, the US AIDS drug assistance program (ADAP) provides access to prescription drugs-including antiretrovirals-to more than 110,000 persons living with HIV (PLWH) who lack adequate medical insurance. PLWH on effective antiretroviral therapy live longer lives, with enhanced quality of life, and are less likely to transmit HIV to others. There are thus significant benefits associated with the ADAP program. But there also are substantial costs. A mathematical model was used to assess the cost-effectiveness of the US ADAP program. Findings indicate that by providing antiretrovirals to underinsured persons, the ADAP program prevented 3,191 secondary infections and saved 24,922 quality-adjusted life years in 2008. The net cost per quality-adjusted life year saved was $11,955, which suggests that the ADAP program is cost-effective by conventional standards.
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Holtgrave DR, Hall HI, Wehrmeyer L, Maulsby C. Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS strategy in the United States: a closing window for success? AIDS Behav 2012; 16:1365-72. [PMID: 22610372 DOI: 10.1007/s10461-012-0207-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Three key policy questions are explored here: Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015? If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective? Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies outlined in the NHAS in terms of effectiveness and cost-effectiveness? Eight policy scenarios were constructed based on three factors (two levels each): expansion (or not) of HIV diagnostic services; assumptions regarding levels of effectiveness of HIV treatment in achieving suppressed viral load; and possible levels of expansion of prevention services for PLWH. All scenarios assumed that the NHAS goal of 85 % linkage to HIV care would be fully achieved by 2015. Standard methods of economic evaluation and epidemiologic modeling were employed. Each of the eight policy scenarios was compared to a flat transmission rate comparison condition; then, key policy dyads were compared pairwise. Without expansion of diagnostic services and of prevention services for PLWH, scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for PLWH does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner.
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Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI. Behavioral factors in assessing impact of HIV treatment as prevention. AIDS Behav 2012; 16:1085-91. [PMID: 22491813 DOI: 10.1007/s10461-012-0186-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.
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Affiliation(s)
- David R Holtgrave
- Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA.
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