Abstract
BackgroundDespite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.MethodsWe used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population (“national population”), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for “cost-effective” was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for “very cost-effective” was <1x the annual per capita GDP ($1,300/YLS).ResultsCompared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.ConclusionsIn India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.
Highlights
India is home to one of the largest HIV epidemics in the world with an estimated 2.3 to 2.5 million infected individuals [1]
Despite expanding access to antiretroviral therapy (ART) in India, the majority of those infected are unaware of their HIV status and unable to access lifesaving treatment [6,7,8,9]
Given the heterogeneity of the Indian HIV epidemic, current screening guidelines developed by India’s National AIDS Control Organization (NACO) emphasize increased HIV testing among population subgroups identified as being at high risk for HIV infection, injection drug users (IDU), men who have sex with men (MSM), female sex workers (FSW), and migrants [10]
Summary
India is home to one of the largest HIV epidemics in the world with an estimated 2.3 to 2.5 million infected individuals [1]. National surveillance data demonstrate elevated HIV prevalence among high-risk groups, including 8.7% among injection drug users (IDU), 5.7% among men who have sex with men (MSM), and 5.4% among female sex workers (FSW) [2]. Given the heterogeneity of the Indian HIV epidemic, current screening guidelines developed by India’s National AIDS Control Organization (NACO) emphasize increased HIV testing among population subgroups identified as being at high risk for HIV infection, IDU, MSM, FSW, and migrants [10]. Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear
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