Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial

Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 03/2010; 25(6):556-63. DOI: 10.1007/s11606-010-1265-5
Source: PubMed


The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results.
To examine the costs and benefits of strategies to improve HIV testing and receipt of results.
Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. SETTING/TARGET POPULATION: Primary-care patients with unknown HIV status.
Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling.
Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness.
Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses.
In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.

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Available from: Henry D Anaya, Oct 20, 2014
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    • "A greater number of patients agreed to testing with the nurse-initiated screening (89.33%) as compared with the traditional model. A subsequent analysis of the same study concluded that the model with rapid testing and nurse-initiated screening was the most cost effective (Sanders et al., 2010). Consistent with Anaya and colleagues' (2008) findings, Cunningham and colleagues (2009) found positive results with greater patient acceptability of opt-out testing in an urban community health center when nurses offered the screening compared to physicians. "
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    ABSTRACT: The Centers for Disease Control and Prevention (CDC) expanded HIV screening of adults ages 13-64 years in 2006 from risk based to routine. Early detection and treatment improve patient outcomes and prevent disease transmission. This article describes a pilot program in which nurses in an adult inpatient unit at an acute care hospital offer HIV testing to all patients ages 18-64 upon admission through standing orders. The pilot, Standing Orders for Routine Testing (SORT), is a response to changes in state law and regulations in the majority of states including Rhode Island, which have occurred following the CDC policy change. The SORT pilot involves collaboration with interdisciplinary partners and education of unit nurses.
    The Journal of the Association of Nurses in AIDS Care: JANAC 12/2012; 24(5). DOI:10.1016/j.jana.2012.09.007 · 1.27 Impact Factor
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    • "It is estimated that a POC test of moderate sensitivity (63%) combined with immediate treatment on-site may lead to the treatment of more infected individuals than an ultra-sensitive and specific NAAT alone when patient return is low [8]. Moreover, counselling messages are most efficient when a diagnosis can be communicated during the same consultation [9]. These advantages are relevant for industrialized countries as well, even if POC tests have a lower sensitivity than standard NAAT. "
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    PLoS ONE 02/2012; 7(2):e32122. DOI:10.1371/journal.pone.0032122 · 3.23 Impact Factor
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    • "References Setting Methods Cost measure Effectiveness measure Time horizon Discount rate Perspective Strategy number Compared interventions Results Sensitivity analysis Menzies et al. 2009 [25] Uganda Decision tree with Monte Carlo simulations Medical care costs HIV-positive infants correctly diagnosed None None Provider S1 Pre-test counseling + DNA- PCR $1489/infected infant correctly diagnosed HIV prevalence, HIV incidence, sensitivity and specificity and costs S2 Pre-test counseling + Rapid HIV test + DNA-PCR Reference group Vickerman et al. 2006 [40] Benin Dynamic mathematical model; data from SIDA2 project Medical care costs Ng/Ct cases averted and HIV cases averted None None Health care provider S1 Currently used syndromic approach to diagnosis Reference group Costs and sensitivity of POC test S2 Modified syndromic management including POC tests $81.0/HIV infection averted for a test costing $1, $151.4 for a test costing $2, $221.8 for a test costing $3, $292.2 for a test costing $4 Sanders et al. 2010 [34] US Randomized trial; Markov statetransition model Medical care costs Life-years saved; quality-adjusted life-years Lifetime 3% Societal S1 Traditional counseling and testing Reference group HIV prevalence; sensitivity and specificity; costs S2 Nurse-initiated routine screening with traditional HIV testing and counseling Extended dominance; Extended dominance S3 Nurse-initiated routine screening with rapid HIV testing and streamlined counselling $16,259/LY; $10,660/QALY Shillcutt et al. 2008 [35] "
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    Clinical Microbiology and Infection 08/2010; 16(8):1070-6. DOI:10.1111/j.1469-0691.2010.03280.x · 5.77 Impact Factor
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