Routine human immunodeficiency virus testing: An economic evaluation of current guidelines

Department of Health Policy and Management , Harvard University, Cambridge, Massachusetts, United States
The American Journal of Medicine (Impact Factor: 5). 04/2005; 118(3):292-300. DOI: 10.1016/j.amjmed.2004.07.055
Source: PubMed


The Centers for Disease Control and Prevention guidelines recommend human immunodeficiency virus (HIV) counseling, testing, and referral for all patients in hospitals with an HIV prevalence of >or=1%. The 1% screening threshold has not been critically examined since HIV became effectively treatable in 1995. Our objective was to evaluate the clinical effect and cost-effectiveness of current guidelines and of alternate HIV prevalence thresholds.
We performed a cost-effectiveness analysis using a computer simulation model of HIV screening and disease as applied to inpatients in U.S. hospitals.
At an undiagnosed inpatient HIV prevalence of 1% and an overall participation rate of 33%, HIV screening increased mean quality-adjusted life expectancy by 6.13 years per 1000 inpatients, with a cost-effectiveness ratio of 35,400 dollars per quality-adjusted life-year (QALY) gained. Expansion of screening to settings with a prevalence as low as 0.1% increased the ratio to 64,500 dollars per QALY gained. Increasing counseling and testing costs from 53 dollars to 103 dollars per person still yielded a cost-effectiveness ratio below 100,000 dollars per QALY gained at a prevalence of undiagnosed infection of 0.1%.
Routine inpatient HIV screening programs are not only cost-effective but would likely remain so at a prevalence of undiagnosed HIV infection 10 times lower than recommended thresholds. The current HIV counseling, testing, and referral guidelines should now be implemented nationwide as a way of linking infected patients to life-sustaining care.

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Available from: April D Kimmel
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    • "HTC is very important in efforts to ensure universal access to prevention and timely HIV treatment and care services. Previous studies have shown that HTC could be cost-effective and could increase the life expectancy of individuals with HIV [6] and it is a key factor in the PMTCT. It also provides clients the opportunity to confidentially learn of the HIV status, which is a gateway to accessing treatment [7,8]. "
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    ABSTRACT: Background HIV testing and counseling (HTC) remains critical in the global efforts to reach a goal of universal access to prevention and timely human immunodeficiency virus (HIV) treatment and health care. Routine HIV testing has been shown to be cost-effective and life-saving by prolonging the life expectancy of HIV patients and reducing the annual HIV transmission rate. However, these benefits of routine HIV testing may not be seen among pregnant women attending antenatal clinic (ANC) due to health facility related factors. This paper presents the influence of health facility related factors on HTC to inform HTC implementation. Methods The study was cross-sectional in design and used structured questionnaire and interview guides to gather information from 300 pregnant women aged 18 to 49 years and had attended ANC for more than twice at the time of the study. Twelve health workers were interviewed as key informants. Respondents were selected from the five sub metro health facilities in the Kumasi Metropolis through systematic random sampling from August to November 2011. Pregnant women who had not tested after two or more ANC visits were classified as not utilizing HTC. Data was analyzed with STATA 11. Logistic regression was run to assess the odds ratios at 95% confidence level. Results Twenty-four percent of the pregnant women had not undergone HTC, with “never been told” emerging as the most cited reason as reported by 29.5% of respondents. Decisions by pregnant women to take up HTC were mostly influenced by factors such as lack of information, perceptions of privacy and confidentiality, waiting time, poor relationship with health staff and fear of being positive. Conclusions Access to HTC health facility alone does not translate into utilization of HTC service. Improving health facility related factors such as health education and information, confidentiality, health staff turnaround time and health staff-client relationship related to HTC will improve implementation.
    Full-text · Article · Jun 2014 · BMC Health Services Research
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    • "It is anticipated that a substantial number of individuals identifying earlier with lower CD4 counts through this wider testing process will successfully engage in care, receive cART, decrease their infectivity (and the rate of secondary infections), and improve their own health. The costs of wider testing and the increased use of cART may be defrayed by decreasing the substantial and sustained direct medical costs from later presentation, the indirect costs to family from an avoidable illness (i.e., presentation with HIV/AIDS), and the opportunity costs to society by minimising lost productivity and reducing secondary infections [42, 43]. "
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    ABSTRACT: We describe the immediate- and longer-term direct medical costs of care for individuals diagnosed with HIV at CD4 counts <350/mm(3) ("late presenters"). We collected and stratified by initial CD4 count all inpatient, outpatient, and drug costs for all newly diagnosed patients accessing HIV care within Southern Alberta from 1/1/1995 to 1/1/2010. 59% of new patients were late presenters. We found significantly higher costs for late presenters, especially inpatient costs, during the first year after accessing care. Direct medical costs remained almost twice as high for late presenters in subsequent years compared to patients presenting with CD4 counts >350/mm(3) despite significantly their improved CD4 counts. The sustained high cost for late presenters has implications for recent recommendations for wider routine HIV testing and the earlier initiation of cART. Earlier diagnosis and treatment, while increasing the immediate expenditures within a population, may produce both direct and indirect cost savings in the longer term.
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    • "Both patient-and provider-initiated VCT can be provided at substance use treatment sites (Grusky et al., 2006; Gunn et al., 2005; Lally et al., 2005). There is increasing evidence, however, that opt-out, provider-initiated HIV testing may be more effective at identifying cases of HIV and has been demonstrated to be cost effective (Paltiel et al., 2005; Walensky et al., 2005). In settings where testing facilities are limited, providing HIV screening as well as screening for other infectious diseases (e.g., hepatitis B and C) at health clinics and rehabilitation programmes for drug users is one way to target individuals at greatest risk. "
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    ABSTRACT: Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.
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