Walensky RP, Wood R, Fofana MO, Martinson NA, Losina E, April MD, et al. The clinical impact and cost-effectiveness of routine, voluntary HIV screening in South Africa

Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 11/2010; 56(1):26-35. DOI: 10.1097/QAI.0b013e3181fb8f24
Source: PubMed


Although 900,000 HIV-infected South Africans receive antiretroviral therapy, the majority of South Africans with HIV remain undiagnosed.
We use a published simulation model of HIV case detection and treatment to examine 3 HIV screening scenarios, in addition to current practice as follows: (1) one-time; (2) every 5 years; and (3) annually. South African model input data include the following: 16.9% HIV prevalence, 1.3% annual incidence, 49% test acceptance rate, HIV testing costs of $6.49/patient, and a 47% linkage-to-care rate (including 2 sequential antiretroviral therapy regimens) for identified cases. Outcomes include life expectancy, direct medical costs, and incremental cost-effectiveness.
HIV screening one-time, every 5 years, and annually increase HIV-infected quality-adjusted life expectancy (mean age 33 years) from 180.6 months (current practice) to 184.9, 187.6, and 197.2 months. The incremental cost-effectiveness of one-time screening is dominated by screening every 5 years. Screening every 5 years and annually each have incremental cost-effectiveness ratios of $1570/quality-adjusted life year and $1720/quality-adjusted life year. Screening annually is very cost-effective even in settings with the lowest incidence/prevalence, with test acceptance and linkage rates both as low as 20%, or when accounting for a stigma impact at least four-fold that of the base case.
In South Africa, annual voluntary HIV screening offers substantial clinical benefit and is very cost-effective, even with highly constrained access to care and treatment.

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Available from: Robin Wood
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    • "It could be argued that, even at the low levels of linkage to care found in this study, there may still be benefits arising from routinising HIV screening in this setting. Modelling of the effectiveness of routine annual HIV screening in South Africa concluded that it offered medical, prevention and cost-effectiveness benefits, even in highly constrained service delivery settings where the test acceptance rate and linkage to care rate could be as low as 20% [33]. Even so, efforts to improve linkage to care will become more critical given the increased demand on the health services from the change in ART-eligibility criteria (CD4 ≤ 350), and the increased numbers of people who have been testing since the introduction of the National Department of Health’s National HIV campaign that started in 2010 [34]. "
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    ABSTRACT: BackgroundWe examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care.MethodsIn a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms.ResultsThere was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p = 0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p = 0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p = 0.007).ConclusionThe PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies.Trial registrationCurrent Controlled Trials ISRCTN93692532Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-350) contains supplementary material, which is available to authorized users.
    Full-text · Article · Aug 2014 · BMC Health Services Research
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    • "Our analysis demonstrates substantial survival benefits in a scenario of future increased linkage to care of untreated HIV-infected persons eligible for ART but not yet receiving treatment [44]. Indeed, the UNAIDS estimates that one-third of HIV-infected persons living in South Africa who are eligible for ART are not yet receiving treatment [1], posing an opportunity to expand access to life-extending medication [11, 45]. Such expansion will require 2 components. "
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    ABSTRACT: Background: We sought to quantify the survival benefits attributable to antiretroviral therapy (ART) in South Africa since 2004. Methods: We used the Cost-Effectiveness of Preventing AIDS Complications-International model (CEPAC) to simulate 8 cohorts of human immunodeficiency virus (HIV)-infected patients initiating ART each year during 2004-2011. Model inputs included cohort-specific mean CD4(+) T-cell count at ART initiation (112-178 cells/µL), 24-week ART suppressive efficacy (78%), second-line ART availability (2.4% of ART recipients), and cohort-specific 36-month retention rate (55%-71%). CEPAC simulated survival twice for each cohort, once with and once without ART. The sum of the products of per capita survival differences and the total numbers of persons initiating ART for each cohort yielded the total survival benefits. Results: Lifetime per capita survival benefits ranged from 9.3 to 10.2 life-years across the 8 cohorts. Total estimated population lifetime survival benefit for all persons starting ART during 2004-2011 was 21.7 million life-years, of which 2.8 million life-years (12.7%) had been realized by December 2012. By 2030, benefits reached 17.9 million life-years under current policies, 21.7 million life-years with universal second-line ART, 23.3 million life-years with increased linkage to care of eligible untreated patients, and 28.0 million life-years with both linkage to care and universal second-line ART. Conclusions: We found dramatic past and potential future survival benefits attributable to ART, justifying international support of ART rollout in South Africa.
    Full-text · Article · Dec 2013 · The Journal of Infectious Diseases
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    • "Lately, a wide range of mathematical modelling studies have analysed the population health effects as well as costs and cost-effectiveness (or efficiency) of early versus late onset of treatment, many incorporating the transmission benefits of ART [11,18-30]. Although models agree that HIV incidence can be substantially reduced through expanded access to ART, models differ substantially on predicted impact and cost-effectiveness of such an intervention [9,31]. "
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    ABSTRACT: South Africa, the country with the largest HIV epidemic worldwide, has been scaling up treatment since 2003 and is rapidly expanding its eligibility criteria. The HIV treatment programme has achieved significant results, and had 1.8 million people on treatment per 2011. Despite these achievements, it is now facing major concerns regarding (i) efficiency: alternative treatment policies may save more lives for the same budget; (ii) equity: there are large inequalities in who receives treatment; (iii) feasibility: still only 52% of the eligible population receives treatment. Hence, decisions on the design of the present HIV treatment programme in South Africa can be considered suboptimal. We argue there are two fundamental reasons to this. First, while there is a rapidly growing evidence-base to guide priority setting decisions on HIV treatment, its included studies typically consider only one criterion at a time and thus fail to capture the broad range of values that stakeholders have. Second, priority setting on HIV treatment is a highly political process but it seems no adequate participatory processes are in place to incorporate stakeholders’ views and evidences of all sorts. We propose an alternative approach that provides a better evidence base and outlines a fair policy process to improve priority setting in HIV treatment. The approach integrates two increasingly important frameworks on health care priority setting: accountability for reasonableness (A4R) to foster procedural fairness, and multi-criteria decision analysis (MCDA) to construct an evidence-base on the feasibility, efficiency, and equity of programme options including trade-offs. The approach provides programmatic guidance on the choice of treatment strategies at various decisions levels based on a sound conceptual framework, and holds large potential to improve HIV priority setting in South Africa.
    Full-text · Article · Oct 2013 · Cost Effectiveness and Resource Allocation
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