Cost-effectiveness Of HIV Screening Research Articles

Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial

Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Cost-effectiveness of HIV screening in emergency departments: a systematic review

ABSTRACT In 2016 worldwide, 1.8 million people were newly infected with HIV. About 36.7 million had HIV but 14 million were unaware, did not seek treatment and were likely to infect others. Undiagnosed HIV infection is a major contributor to transmission. Therefore, screening is critical to prevention. Although CDC recommends routine screening in the emergency department (ED), implementation is not universal or sustained. Cost-effectiveness of ED-based screening could enhance implementation. We address the question: Is HIV screening in the ED cost-effective? Using the Joanna Briggs Institute guidelines, we conducted a systematic review of economic evaluations of ED-based HIV screening. We found 311 studies with 12 duplicates. We excluded 276 studies that did not conduct economic evaluations and another three for lack of quantitative data, leaving 20 articles for the full review. We reviewed cost-effectiveness ratios (CER), incremental cost-effectiveness ratios (ICER), and average costs per diagnosis, quality-adjusted life years, averted transmissions and per patient linked to care. CER and ICER were below CDC thresholds indicating that HIV screening in the ED is cost-effective. Therefore, ED-based HIV screening should be widely implemented, supported and sustained as a cost-effective tool for combating HIV/AIDS.

Cost-effectiveness of screening for HIV in primary care: a health economics modelling analysis

SummaryBackgroundEarly HIV diagnosis reduces morbidity, mortality, the probability of onward transmission, and their associated costs, but might increase cost because of earlier initiation of antiretroviral treatment (ART). We investigated this trade-off by estimating the cost-effectiveness of HIV screening in primary care.MethodsWe modelled the effect of the four-times higher diagnosis rate observed in the intervention arm of the RHIVA2 randomised controlled trial done in Hackney, London (UK), a borough with high HIV prevalence (≥0·2% adult prevalence). We constructed a dynamic, compartmental model representing incidence of infection and the effect of screening for HIV in general practices in Hackney. We assessed cost-effectiveness of the RHIVA2 trial by fitting model diagnosis rates to the trial data, parameterising with epidemiological and behavioural data from the literature when required, using trial testing costs and projecting future costs of treatment.FindingsOver a 40 year time horizon, incremental cost-effectiveness ratios were £22 201 (95% credible interval 12 662–132 452) per quality-adjusted life-year (QALY) gained, £372 207 (268 162–1 903 385) per death averted, and £628 874 (434 902–4 740 724) per HIV transmission averted. Under this model scenario, with UK cost data, RHIVA2 would reach the upper National Institute for Health and Care Excellence cost-effectiveness threshold (about £30 000 per QALY gained) after 33 years. Scenarios using cost data from Canada (which indicate prolonged and even higher health-care costs for patients diagnosed late) suggest this threshold could be reached in as little as 13 years.InterpretationScreening for HIV in primary care has important public health benefits as well as clinical benefits. We predict it to be cost-effective in the UK in the medium term. However, this intervention might be cost-effective far sooner, and even cost-saving, in settings where long-term health-care costs of late-diagnosed patients in high-prevalence regions are much higher (≥60%) than those of patients diagnosed earlier. Screening for HIV in primary care is cost-effective and should be promoted.FundingNHS City and Hackney, UK Department of Health, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care.

The Value of HIV Screening in the United States in the Era of Effective Treatment

The US Preventive Services Task Force (USPSTF) recently released a draft recommendation for routine HIV screening in the general adult population under age 65 in the US, consistent with the 2006 Centers for Disease Control and Prevention (CDC) recommendations. The USPSTF draft assigns a grade A to this recommendation, which means that if it is adopted, most adults with public or private insurance coverage will be able to receive an HIV test without an out-of-pocket expenditure. The benefits of HIV screening include documented reductions in risk behavior among those who learn that they are HIV infected; earlier access to antiretroviral therapy, leading to avoidance of morbidity and mortality; and a potential 96% reduction in transmission of HIV to heterosexual partners among HIV-infected adults adhering to antiretroviral therapy. Results from models of HIV disease progression and treatment evaluating the cost-effectiveness of HIV screening in the US were part of the rationale CDC used to support expanding access to HIV testing, and these models continue to be used to evaluate different testing implementation strategies, although the USPSTF did not consider modeling studies in its recent evidence review. The majority of published analyses of the costeffectiveness of HIV screening in the US project the lifetime benefits and costs of earlier detection and entry into care for HIV-infected individuals and weigh these costs and benefits when calculating cost-effectiveness ratios; population benefits from reduced transmission are estimated as secondary benefits. Although including transmission benefits can result in more attractive cost-effectiveness ratios for screening interventions, the effects are attenuated by the additional time between the secondary infection event and the point in HIV disease progression where clinical symptoms emerge. Recently, Farnham and colleagues published a paper in Medical Decision Making arguing that HIV screening can be economically justified based solely on the benefit of HIV transmissions avoided attributable to sexual risk behavior change associated with the knowledge of being HIV infected. Their findings rely on 2 key parameters: the benefit of reduced sexual transmission by patients who newly learn of their HIV infection, and the lifetime cost and loss of qualityadjusted life-years avoided by preventing a secondary HIV infection. The annual transmission benefit that these authors derive from the literature is large, but they conservatively assume that the effect lasts for only 1 year and do not consider further transmission dynamics that may result in additional benefits depending on antiretroviral coverage and risk group. The lifetime cost avoided that they use was derived from previous work by this author and colleagues and may not be fully relevant in in the current situation. With the increasing success of antiretroviral treatment, HIV-infected individuals are living long enough to incur medical expenses for non-HIV conditions that they might have incurred in the absence of HIV, and there was no adjustment for the proportion of HIV care costs going to these conditions in the analysis by Farnham and colleagues. The impact of HIV screening on avoiding qualityof-life losses associated with HIV infection may also be diminished by more effective and less toxic HIV treatments. In the current issue of Medical Decision Making, Isogai and colleagues report the results of a health utility prediction model based on assessments completed by more than 800 HIV patients in Ontario, Canada, between 2007 and 2009. The authors’ final model included CD4 count (a measure Received 21 March 2013 from the Department of Public Health, Weill Cornell Medical College, New York, NY. Revision accepted for publication 4 April 2013.

Resource Utilization and Cost-Effectiveness of Counselor- vs. Provider-Based Rapid Point-of-Care HIV Screening in the Emergency Department

BackgroundRoutine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor.MethodsWe employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs.ResultsEstimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs.ConclusionsThe cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.

Rapid HIV testing program implementation: lessons from the emergency department.

BackgroundThe US Centers for Disease Control and Prevention (CDC) guidelines and the World Health Organization (WHO) both recommend HIV testing in health-care settings. However, neither organization provides prescriptive details regarding how these recommendations should be adapted into clinical practice in an emergency department.MethodsWe have implemented an HIV-testing program in the ED of a major academic medical center within the scope of the Universal Screening for HIV Infection in the Emergency Room (USHER) Trial—a randomized clinical trial evaluating the feasibility and cost-effectiveness of HIV screening in this setting.Results and conclusionDrawing on our collective experiences in establishing programs domestically and internationally, we offer a practical framework of lessons learned so that others poised to embark on such HIV testing programs may benefit from our experiences.

Cost-effectiveness of HIV screening in patients older than 55 years of age.

Although HIV infection is more prevalent in people younger than age 45 years, a substantial number of infections occur in older persons. Recent guidelines recommend HIV screening in patients age 13 to 64 years. The cost-effectiveness of HIV screening in patients age 55 to 75 years is uncertain. To examine the costs and benefits of HIV screening in patients age 55 to 75 years. Markov model. Derived from the literature. Patients age 55 to 75 years with unknown HIV status. Lifetime. Societal. HIV screening program for patients age 55 to 75 years compared with current practice. Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness. For a 65-year-old patient, HIV screening using traditional counseling costs $55,440 per QALY compared with current practice when the prevalence of HIV was 0.5% and the patient did not have a sexual partner at risk. In sexually active patients, the incremental cost-effectiveness ratio was $30,020 per QALY. At a prevalence of 0.1%, HIV screening cost less than $60,000 per QALY for patients younger than age 75 years with a partner at risk if less costly streamlined counseling is used. Cost-effectiveness of HIV screening depended on HIV prevalence, age of the patient, counseling costs, and whether the patient was sexually active. Sensitivity analyses with other variables did not change the results substantially. The effects of age on the toxicity and efficacy of highly active antiretroviral therapy and death from AIDS were uncertain. Sensitivity analyses exploring these variables did not qualitatively affect the results. If the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 years reaches conventional levels of cost-effectiveness when counseling is streamlined and if the screened patient has a partner at risk. Screening patients with advanced age for HIV is economically attractive in many circumstances.

Cost-effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy

Cost-effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy

Cost-Effectiveness of Screening for HIV in the Era of Highly Active Anti-retroviral Therapy

Cost-Effectiveness of Screening for HIV in the Era of Highly Active Anti-retroviral Therapy

Cost-Effectiveness of Screening for HIV

Cost-Effectiveness of Screening for HIV

The cost-effectiveness of HIV testing: accounting for differential participation rates.

To understand the impact of differences in participation rates between infected and uninfected individuals on estimates of the cost-effectiveness of HIV screening. Costs per infection detected are modeled as function of both prevalence and serostatus-dependent testing rates. Data from national surveillance surveys, seroprevalence studies, and other sources are employed to suggest the magnitude of results. Differential participation produces a near-doubling in the estimated cost per infection identified. This result is sensitive to assumptions regarding the benefits of screening for seronegatives. Voluntary HIV screening programs may incur prohibitive costs by over-recruiting people at little risk of infection. Failure to account for differential participation can result in over-optimistic cost-effectiveness estimates. However, the relevance of this result--and the significance of both prevalence and participation as cost drivers--is overwhelmed by what is assumed about the benefits conferred to uninfected people by HIV screening.

Cost-Effectiveness of HIV Screening in Acute Care

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Cost-effectiveness of HIV screening in acute care settings

Cost-effectiveness of HIV screening in acute care settings

The cost-effectiveness of HIV screening in pregnancy: [formula omitted]x, Dept. Ob/Gyn, Univ. of CA., San Francisco, San Francisco, CA

The cost-effectiveness of HIV screening in pregnancy: [formula omitted]x, Dept. Ob/Gyn, Univ. of CA., San Francisco, San Francisco, CA