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Published on January 31, 2008

Author: Desiderio

Source: authorstream.com

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The Case for Routine, Voluntary HIV Testing:  The Case for Routine, Voluntary HIV Testing Rochelle P. Walensky, MD, MPH Assistant Professor of Medicine Harvard Medical School Massachusetts General Hospital Brigham and Women’s Hospital Motivation:  Motivation Unidentified infection: 1,000,000 people in the US living with HIV 300,000 undiagnosed Poor follow-up: 25% of those testing HIV+ fail to return for results Inadequate linkage to care: only 2/3 of HIV-infected persons receive appropriate care Too little, too late: 40% learn there are HIV-infected in the year prior to AIDS 5% learn it within the month prior to death. CDC Guidelines:  CDC Guidelines 2001 CDC guidelines recommend HIV counseling, testing and referral (CTR): Routine, voluntary HIV CTR for all patients in hospitals with >1% HIV prevalence Routine CTR in settings serving populations at increased HIV risk Targeted HIV CTR in settings of <1% prevalence and low risk The Problem. . .:  The Problem. . . No definition of “HIV risk” No guidance on targeting strategy No analysis to support the 1% threshold Minimal mention of scarce resources The Bottom Line...:  The Bottom Line... Expanded HIV CTR services are feasible and can have high yield. HIV CTR can be justified at lower prevalences Routine HIV CTR is a highly cost-effective use of HIV care dollars in the United States. Failure to identify and link HIV infection has led to hundreds of thousands of years of life lost The Inpatient Experience:  The Inpatient Experience RP Walensky et al, Arch Int Med, 2002 The Inpatient Testing Experience Boston Medical Center 4/99-6/00:  The Inpatient Testing Experience Boston Medical Center 4/99-6/00 Patients admitted to the medical service were offered HIV counseling and testing MA DPH funded on-site counselors 473 (6.4%) of the 7,356 medical admissions were voluntarily tested for HIV The CTR program was compared to a period of historical control (1/98-3/99) RP Walensky et al, Arch Int Med, 2002 Results Inpatient Testing:  Results Inpatient Testing RP Walensky et al, Arch Int Med, 2002 Results: Monthly Positive Tests:  Results: Monthly Positive Tests The Atlanta Experience:  The Atlanta Experience Del Rio, MMWR, 2001 Atlanta: Urgent Care Center 3/00-9/00:  Atlanta: Urgent Care Center 3/00-9/00 All urgent care patients 18-65 y/o were offered voluntary HIV CTR over a 24-week period. Compared to historical control over same period one year prior. Del Rio, MMWR, 2001 Atlanta Urgent Care:  Atlanta Urgent Care The Outpatient Experience:  The Outpatient Experience Walensky et al, MMWR, 2004 Walensky et al, AJPH, 2005 Think HIV Objectives:  Think HIV Objectives 1) Establish “Think HIV” in 4 Massachusetts urgent care centers 2) Identify and refer to care patients with undiagnosed HIV infection 3) Determine the seroprevalence of undiagnosed infection Walensky et al., MMWR, 2004 Walensky et al., AJPH, 2005 Results:  Results January - September 2002 Think HIV offered >7,000 patients HIV testing 2,444 (37%) accepted testing 33,608 HIV tests statewide in same time period HIV Prevalence ________________________________________________________:  HIV Prevalence ________________________________________________________ ______________________________________ p=0.016 HIV Prevalence: Previous HIV Testing:  HIV Prevalence: Previous HIV Testing Think HIV Time of previous test <1 year prior 2.2% >1 year prior 1.9% Never tested before 1.9% Referral to Care:  Referral to Care 42/48 (88%) infected patients returned for test results All 42 who returned for results linked to care MA Dept of Public Health: Program Costs:  MA Dept of Public Health: Program Costs Cost for 9 months = $232,900 Cost per case identified = $4,850 Slide20:  “The price tag probably makes the program too expensive for most states. . . I don't think it will work in the UCC at a suburban mall” Is routine HIV screening cost-effective? If so, at what HIV prevalence? Cost-effectiveness of Routine HIV Testing:  Cost-effectiveness of Routine HIV Testing Objectives:  Objectives To evaluate the clinical impact and cost-effectiveness of the current CDC HIV CTR guidelines in the outpatient/inpatient setting. Methods:  Methods Computer simulation model of HIV infection Model includes HIV screening and symptom detection Data from MACS, clinical trials, ACSUS Prophylaxis for PCP, toxo, MAC, CMV, fungal infections Compares clinical outcomes, costs, cost-effectiveness Slide24:  Methods: The Model HIV diagnosed or undiagnosed HIV RNA and CD4 cell count Opportunistic infections and prophylaxis Antiretroviral therapy Acute Clinical Event Death Chronic HIV Infection Primary HIV Infection The CEPAC Model:  The CEPAC Model Bacterial pneumonia CMV Death QALYs: 8.47 Total costs: $142,400 Methods Overview:  Methods Overview Screening Module New HIV screening program Detection via background HIV Screening HIV Therapy ART and OI prophylaxis Undiagnosed HIV-infected patient Detection via development of an OI Cost-effectiveness of Routine HIV Testing:  Cost-effectiveness of Routine HIV Testing Outpatients AD Paltiel et al, NEJM, 2005 Three Target Populations:  Three Target Populations Undiagnosed Monthly HIV HIV Prevalence Incidence (%) (%)   High-Risk 3.0 0.1 CDC Threshold 1.0 0.01 US Overall 0.1 0.0012 Results Hi-Risk Population Cost-effectiveness High Risk:  Results Hi-Risk Population Cost-effectiveness High Risk Population HIV Cost Cost-effectiveness (QALMS) (QALMS) ($) ($/QALY) Std Practice 250.89 219.84 $32,700 --- Single EIA 251.26 220.74 $33,800 $36,000 EIA q 5 yrs 252.11 222.78 $37,300 $50,000 EIA q 3 yrs 252.40 223.46 $38,900 $63,000 Annual EIA 252.75 224.29 $41,700 $100,000 Paltiel et al, NEJM, 2005 Infections Averted High Risk Population - Drug User:  Infections Averted High Risk Population - Drug User Infections Averted Single EIA 300 EIA q 5 yrs 2,700 EIA q 3 yrs 3,600 Annual EIA 5,100 Paltiel et al, NEJM, 2005 Anticipate 44,000-60,000 new infections/100,000 Results Outpatient Cost-effectiveness :  Results Outpatient Cost-effectiveness In a high risk population, HIV testing every five years had a cost-effectiveness ratio of $50,000/QALY gained At the CDC threshold, HIV testing every five years had a cost-effectiveness ratio of $71,000/QALY gained Even in the “US Overall Population” a one-time HIV test may be cost-effective: $113,000/QALY gained Slide32:  “Failure to implement widespread routine screening for HIV infection represents a critical disservice to patients who are currently infected, those at risk for infection, and the future health of the nation.” Bozzette, NEJM 2005 Cost-effectiveness of Routine HIV Testing:  Cost-effectiveness of Routine HIV Testing Inpatients RP Walensky et al, AJM, 2005 Results Inpatient Cost-effectiveness:  Results Inpatient Cost-effectiveness Prevalence Population HIV+ Cost Cost-effectiveness (QALMS) (QALMS) ($) ($/QALY) 1.0% No Testing 204.10 72.30 $1,200 --- Testing 204.20 81.77 $1,500 $38,600 0.1% No Testing 205.30 72.30 $120 --- Testing 205.31 81.77 $160 $50,000 RP Walensky et al, Am J Med, 2005 Slide35:  Unidentified 10% Background Testing 37% Opportunistic Infection 53% Unidentified 7% Background Testing 25% Opportunistic Infection 36% New Screening Program 32% Without HIV CTR Program With HIV CTR Program Results Mechanisms of HIV Detection Results: Testing Costs:  Results: Testing Costs Results: Testing Costs:  Results: Testing Costs The HIV Testing Pathway :  HIV testing is a pathway of sequential processes: Failure in any one process results in overall failure The HIV Testing Pathway HIV Testing Pathway:  HIV Testing Pathway p(offer/accept) p(return/link) X Index of Participation (IOP) Base case: Index of Participation (IOP):  Base case: Index of Participation (IOP) Offer/Accept Return/Link to care IOP 37% 88% 88% 37% 33% 33% Walensky et al, Med Dec Making, 2005 Results: Index of Participation:  Results: Index of Participation 0.04, $43,400/QALY 0.33, $38,600/QALY Results: Index of Participation HIV Prevalence 1.0%:  Results: Index of Participation HIV Prevalence 1.0% Base Case Walensky et al, MDM 2005 Index of Participation (IOP):  We examined three alternative ways to achieve an index of participation of 0.16: All allow identical number of people through the testing program, at what cost? Index of Participation (IOP) Results: Index of Participation HIV Prevalence 0.1%:  Results: Index of Participation HIV Prevalence 0.1% CE Ratio ($/QALY) IOP = p(offer/accept) x p(return/link) Offer/accept ≥ Return/link Offer/accept < Return/link HIV Prevalence 0.1% p(offer/accept) = p(return/link) = 0.4:  HIV Prevalence 0.1% p(offer/accept) = p(return/link) = 0.4 Slide46:  Fungal proph. Fluconazole $123,700 Freedberg JAMA 1998 CMV proph. Valganciclovir $893,600 Paltiel Clin Inf Dis 2001 C-E Ratio Intervention Agent ($/QALY)* Reference PCP/Toxo proph. TMP-SMX $2,800 Freedberg JAMA 1998 ART AZT/3TC/EFV $11,700 Freedberg NEJM 2001 GART 2nd line --- $20,200 Weinstein Ann Int Med 2001 Inpt HIV screening --- $38,600 Current Analysis MAC proph. Azithromycin $43,300 Freedberg JAMA 1998 HIV screening q5y --- $50,000 Current Analysis high risk patients Cost-effectiveness Ratios for HIV Care *All costs adjusted to 2001 US dollars Cost-effectiveness Ratios for Other Screening Programs:  Cost-effectiveness Ratios for Other Screening Programs C-E ratio Screening Program ($/QALY)* Reference HIV screening inpatients $38,600 Current Analysis HIV screening every 5 years high risk patients $50,000 Current Analysis Breast cancer screening Salzmann Annual mammogram, 50–69 y/o $57,500 Ann Intern Med 1997 Colon cancer FOBT + SIG q5y, adults 50–85 y/o $57,700 Frazier JAMA 2000 Diabetes Mellitus, Type 2 fasting plasma glucose, adults >25 y/o $70,000 CDC JAMA 1998 *all costs adjusted to 2001 US dollars Conclusions :  Conclusions Routine HIV testing programs in the inpatient and outpatient setting are feasible and can have a high yield of HIV case identification (2.0-6.8%). C-E models show that screening every 5 years in high risk populations and even one-time HIV screening in the general US population is cost-effective. C-E models show that inpatient HIV screening is highly cost-effective at an undiagnosed HIV prevalence of 1.0% (likely 0.1%). Conclusions :  Conclusions Investments in linkage to HIV care once patients are identified through screening programs should be paramount. Identification and treatment of HIV infection can lead to per person survival benefits of over 13 years. Expansion of routine HIV CTR programs nationally should be a public health priority. Acknowledgements:  Acknowledgements Massachusetts Department of Public Health George E. Barton Laureen Malatesta, PA Jean F. McGuire, PhD Catherine A. O’Connor, CNS Site physicians, administrators, counselors, and patients Massachusetts General Hospital Kenneth A. Freedberg, MD, MSc Boston University School of Public Health Elena Losina, PhD Boston University Medical Center Paul Skolnik, MD Jon Hall CEPAC Investigators:  CEPAC Investigators Harvard Medical School Wendy Aaronson, MPH Nomita Divi, MSc Kenneth Freedberg, MD, MSc April Kimmel, MSc Elena Losina, PhD Zhigang Lu, MD Lauren Mercincavage Sara Sadownik Paul Sax, MD Heather Smith Rochelle Walensky, MD, MPH Lindsey Wolf Hong Zhang, SM Hui Zheng, PhD Harvard SPH Sue Goldie, MD, MPH George Seage, DSc, MPH Milton Weinstein, PhD Cornell Bruce Schackman, PhD, MBA Yale A. David Paltiel, PhD Lille, France Yazdan Yazdanpanah, MD, PhD Acknowledgements:  Acknowledgements National Institute of Mental Health National Institute of Allergy & Infectious Diseases National Institute on Drug Abuse Centers for Disease Control and Prevention Massachusetts Department of Public Health

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