Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings.

Angela B Hutchinson,Berry Bennett,Timothy J Sullivan,Robert K Bolan,Paul G Farnham,Stephanie L Sansom,Bernard M Branson,Vimalanand S Prabhu,James D Heffelfinger,Peter R Kerndt,Pragna Patel,Seth C Kalichman

doi:10.1371/journal.pmed.1000342

Abstract

Detection of acute HIV infection (AHI) with pooled nucleic acid amplification testing (NAAT) following HIV testing is feasible. However, cost-effectiveness analyses to guide policy around AHI screening are lacking; particularly after more sensitive third-generation antibody screening and rapid testing. We conducted a cost-effectiveness analysis of pooled NAAT screening that assessed the prevention benefits of identification and notification of persons with AHI and cases averted compared with repeat antibody testing at different intervals. Effectiveness data were derived from a Centers for Disease Control and Prevention AHI study conducted in three settings: municipal sexually transmitted disease (STD) clinics, a community clinic serving a population of men who have sex with men, and HIV counseling and testing sites. Our analysis included a micro-costing study of NAAT and a mathematical model of HIV transmission. Cost-effectiveness ratios are reported as costs per quality-adjusted life year (QALY) gained in US dollars from the societal perspective. Sensitivity analyses were conducted on key variables, including AHI positivity rates, antibody testing frequency, symptomatic detection of AHI, and costs. Pooled NAAT for AHI screening following annual antibody testing had cost-effectiveness ratios exceeding US$200,000 per QALY gained for the municipal STD clinics and HIV counseling and testing sites and was cost saving for the community clinic. Cost-effectiveness ratios increased substantially if the antibody testing interval decreased to every 6 months and decreased to cost-saving if the testing interval increased to every 5 years. NAAT was cost saving in the community clinic in all situations. Results were particularly sensitive to AHI screening yield. Pooled NAAT screening for AHI following negative third-generation antibody or rapid tests is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings.

Highlights

Acute human immunodeficiency virus (HIV) infection (AHI) is the stage of disease immediately after HIV acquisition and before HIV antibodies are detectable, when viral replication and shedding peak [1]
enzyme immunoassay (EIA) to detect acute HIV infection (AHI) had a cost-effectiveness ratio of US$372,300 per quality-adjusted life year (QALY) gained for the counseling and testing sites, US$484,400 per QALY gained for the sexually transmitted disease (STD) clinics, and was cost-saving for the community clinic, assuming that the HIV infections detected through nucleic acid amplification testing (NAAT) screening would otherwise have been detected by repeat antibody testing 1 y later
AHI screening would remain cost-saving in the community clinic, but the cost-effectiveness ratios for the counseling and testing sites and STD clinics would increase to approximately US$1 million per QALY gained if these HIV infections were detected 6 mo later because of more frequent repeat antibody testing

Summary

Introduction

Acute HIV infection (AHI) is the stage of disease immediately after HIV acquisition and before HIV antibodies are detectable, when viral replication and shedding peak [1]. Pooled NAAT is routinely used to detect AHI in blood donors [3], and several studies have shown that pooled NAAT after HIV antibody screening is feasible in clinic settings [4,5,6,7,8,9]. These studies screened for HIV antibodies with first- or second-generation enzyme immunoassays (EIAs) that are less sensitive for early infection because they detect only immunoglobulin G (IgG). The final stage of infection (AIDS) is characterized by multiple severe infections and by the development of unusual cancers

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Results

Discussion

Conclusion