Abstract
ObjectiveTo compare the clinical outcomes and cost-effectiveness of routine HIV screening in Portugal to the current practice of targeted and on-demand screening.DesignWe used Portuguese national clinical and economic data to conduct a model-based assessment.MethodsWe compared current HIV detection practices to strategies of increasingly frequent routine HIV screening in Portuguese adults aged 18-69. We considered several subpopulations and geographic regions with varying levels of undetected HIV prevalence and incidence. Baseline inputs for the national case included undiagnosed HIV prevalence 0.16%, annual incidence 0.03%, mean population age 43 years, mean CD4 count at care initiation 292 cells/μL, 63% HIV test acceptance, 78% linkage to care, and HIV rapid test cost €6 under the proposed routine screening program. Outcomes included quality-adjusted survival, secondary HIV transmission, cost, and incremental cost-effectiveness. ResultsOne-time national HIV screening increased HIV-infected survival from 164.09 quality-adjusted life months (QALMs) to 166.83 QALMs compared to current practice and had an incremental cost-effectiveness ratio (ICER) of €28,000 per quality-adjusted life year (QALY). Screening more frequently in higher-risk groups was cost-effective: for example screening annually in men who have sex with men or screening every three years in regions with higher incidence and prevalence produced ICERs of €21,000/QALY and €34,000/QALY, respectively.ConclusionsOne-time HIV screening in the Portuguese national population will increase survival and is cost-effective by international standards. More frequent screening in higher-risk regions and subpopulations is also justified. Given Portugal’s challenging economic priorities, we recommend prioritizing screening in higher-risk populations and geographic settings.
Highlights
By comparison to its European neighbors, Portugal bears an unusually severe HIV/AIDS burden
We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, a widely-published microsimulation of HIV disease, to forecast mean costs, lifeexpectancy, and quality-adjusted life expectancy in months (QALM) in both HIV-infected and HIV-uninfected individuals under each strategy [9,10,11,12,13,14,15,16,17]
We applied the guidance of the World Health Organization (WHO) Commission on Macroeconomics and Health, which suggests that an intervention be labeled “cost-effective” in a given country if its incremental cost-effectiveness ratio (ICER) is less than three times the nation’s per capita Gross Domestic Product (GDP) [18]
Summary
By comparison to its European neighbors, Portugal bears an unusually severe HIV/AIDS burden. Incidence estimates range from 0.005% to 1.08% per year, depending on risk group, and Portugal has the second highest incidence rate in the European Union [3]. To encourage earlier detection of infection and initiation of HIV care, the Portuguese parliament recently adopted a resolution to expand routine, population-based HIV testing [4]. This policy mirrors the recommendations of the World Health Organization (WHO), the United States Centers for Disease Control and Prevention, and the French Haute Autorité de Santé [5,6,7]
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