Last data update: May 06, 2024. (Total: 46732 publications since 2009)
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Query Trace: Hutchinson AB[original query] |
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The testing imperative: Why the US ending the human immunodeficiency virus (HIV) epidemic program needs to renew efforts to expand HIV testing in clinical and community-based settings
Nosyk B , Fojo AT , Kasaie P , Enns B , Trigg L , Piske M , Hutchinson AB , DiNenno EA , Zang X , Del Rio C . Clin Infect Dis 2023 76 (12) 2206-2208 Data from several modeling studies demonstrate that large-scale increases in human immunodeficiency virus (HIV) testing across settings with a high burden of HIV may produce the largest incidence reductions to support the US Ending the HIV Epidemic (EHE) initiative's goal of reducing new HIV infections 90% by 2030. Despite US Centers for Disease Control and Prevention's recommendations for routine HIV screening within clinical settings and at least yearly screening for individuals most at risk of acquiring HIV, fewer than half of US adults report ever receiving an HIV test. Furthermore, total domestic funding for HIV prevention has remained unchanged between 2013 and 2019. The authors describe the evidence supporting the value of expanded HIV testing, identify challenges in implementation, and present recommendations to address these barriers through approaches at local and federal levels to reach EHE targets. |
Sexual practice changes post-HIV diagnosis among men who have sex with men in the United States: A systematic review and meta-analysis
Malekinejad M , Jimsheleishvili S , Barker EK , Hutchinson AB , Shrestha RK , Volberding P , Kahn JG . AIDS Behav 2022 27 (1) 257-278 Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse. |
Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail
Hutchinson AB , MacGowan RJ , Margolis AD , Adee MG , Wen W , Bowden CJ , Spaulding AC . Am J Prev Med 2021 61 S32-s38 INTRODUCTION: This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia. METHODS: A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020. RESULTS: Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system. CONCLUSIONS: Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals. |
Change in condom use in populations newly aware of HIV diagnosis in the United States and Canada: A systematic review and meta-analysis
Malekinejad M , Blodgett J , Horvath H , Parriott A , Hutchinson AB , Shrestha RK , McCabe D , Volberding P , Kahn JG . AIDS Behav 2021 25 (6) 1839-1855 HIV-infected individuals "aware" of their infection are more likely to use condoms, compared to HIV-infected "unaware" persons. To quantify this likelihood, we undertook a systematic review and meta-analysis of U.S. and Canadian studies. Twenty-one eligible studies included men who have sex with men (MSM; k = 15), persons who inject drugs (PWID; k = 2), and mixed populations of high-risk heterosexuals (HRH; k = 4). Risk ratios (RR) of "not always using condoms" with partners of any serostatus were lower among aware MSM (RR 0.44 [not significant]), PWID (RR 0.70) and HRH (RR 0.27); and, in aware MSM, with partners of HIV-uninfected or unknown status (RR 0.46). Aware individuals had lower "condomless sex likelihood" with HIV-uninfected or unknown status partners (MSM: RR 0.58; male PWID: RR 0.44; female PWID: RR 0.65; HRH: RR 0.35) and with partners of any serostatus (MSM only, RR 0.72). The association diminished over time. High risk of bias compromised evidence quality. |
Health utility estimates and their application to HIV prevention in the United States: Implications for cost-effectiveness modeling and future research needs
Whitham HK , Hutchinson AB , Shrestha RK , Kuppermann M , Grund B , Shouse RL , Sansom SL . MDM Policy Pract 2020 5 (2) 2381468320936219 Objectives. Health utility estimates from the current era of HIV treatment, critical for cost-effectiveness analyses (CEA) informing HIV health policy, are limited. We examined peer-reviewed literature to assess the appropriateness of commonly referenced utilities, present previously unreported quality-of-life data from two studies, and discuss future implications for HIV-related CEA. Methods. We searched a database of cost-effectiveness analyses specific to HIV prevention efforts from 1999 to 2016 to identify the most commonly referenced sources for health utilities and to examine practices around using and reporting health utility data. Additionally, we present new utility estimates from the Centers of Disease Control and Prevention's Medical Monitoring Project (MMP) and the INSIGHT Strategies for Management of Anti-Retroviral Therapy (SMART) trial. We compare data collection time frames, sample characteristics, assessment methods, and key estimates. Results. Data collection for the most frequently cited utility estimates ranged from 1985 to 1997, predating modern HIV treatment. Reporting practices around utility weights are poor and lack details on participant characteristics, which may be important stratifying factors for CEA. More recent utility estimates derived from MMP and SMART were similar across CD4+ count strata and had a narrower range than pre-antiretroviral therapy (ART) utilities. Conclusions. Despite the widespread use of ART, cost-effectiveness analysis of HIV prevention interventions frequently apply pre-ART health utility weights. Use of utility weights reflecting the current state of the US epidemic are needed to best inform HIV research and public policy decisions. Improved practices around the selection, application, and reporting of health utility data used in HIV prevention CEA are needed to improve transparency. |
Recommendations for HIV screening of gay, bisexual, and other men who have sex with men - United States, 2017
DiNenno EA , Prejean J , Irwin K , Delaney KP , Bowles K , Martin T , Tailor A , Dumitru G , Mullins MM , Hutchinson AB , Lansky A . MMWR Morb Mortal Wkly Rep 2017 66 (31) 830-832 CDC's 2006 recommendations for human immunodeficiency virus (HIV) testing state that all persons aged 13-64 years should be screened for HIV at least once, and that persons at higher risk for HIV infection, including sexually active gay, bisexual, and other men who have sex with men (MSM), should be rescreened at least annually (1). Authors of reports published since 2006, including CDC (2), suggested that MSM, a group that is at highest risk for HIV infection, might benefit from being screened more frequently than once each year. In 2013, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to specify an HIV rescreening interval but recommended annual screening for MSM as a reasonable approach (3). However, some HIV providers have begun to offer more frequent screening, such as once every 3 or 6 months, to some MSM. A CDC work group conducted a systematic literature review and held four expert consultations to review programmatic experience to determine whether there was sufficient evidence to change the 2006 CDC recommendation (i.e., at least annual HIV screening of MSM in clinical settings). The CDC work group concluded that the evidence remains insufficient to recommend screening more frequently than at least once each year. CDC continues to recommend that clinicians screen asymptomatic sexually active MSM at least annually. Each clinician can consider the benefits of offering more frequent screening (e.g., once every 3 or 6 months) to individual MSM at increased risk for acquiring HIV infection, weighing their patients' individual risk factors, local HIV epidemiology, and local testing policies. |
Effectiveness of community-based condom distribution interventions to prevent HIV in the United States: A systematic review and meta-analysis
Malekinejad M , Parriott A , Blodgett JC , Horvath H , Shrestha RK , Hutchinson AB , Volberding P , Kahn JG . PLoS One 2017 12 (8) e0180718 BACKGROUND: Despite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood. METHODS: We systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986-2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE. RESULTS: We reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: "Ongoing" (unlimited access to condoms), "Ongoing-plus" (unlimited access to condoms, with co-interventions), and "Coupon-based" (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was "very low" for all outcomes. CONCLUSIONS: CDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence. |
Acute infections, cost and time to reporting of HIV test results in three U.S. State Public Health Laboratories
Nasrullah M , Wesolowski LG , Ethridge SF , Cranston K , Pentella M , Myers RA , Rudrik JT , Hutchinson AB , Bennett SB , Werner BG . J Infect 2016 73 (2) 164-72 OBJECTIVE: In three U.S. State Public Health Laboratories (PHLs) using a fourth-generation immunoassay (IA), an HIV-1/HIV-2 differentiation antibody IA and a nucleic acid test (NAT), we characterized the yield and time to reporting of acute infections, and cost per positive specimen. METHODS: Routine HIV testing data were collected from July 1, 2012-June 30, 2013 for Massachusetts and Maryland PHLs, and from November 27, 2012-June 30, 2013 for Michigan PHL. Massachusetts and Michigan used fourth-generation and differentiation IAs with NAT conducted by a referral laboratory. In Maryland, fourth-generation IA repeatedly reactive specimens were followed by a Western blot (WB), and those with negative or indeterminate results were tested with a differentiation IA and HIV-1 NAT, and if positive by NAT, confirmed by a different HIV-1 NAT. Specimens from WB-positive persons at risk for HIV-2 were tested with a differentiation IA and, if positive, with an HIV-2 WB and/or differential HIV-1/HIV-2 proviral DNA polymerase chain reaction. RESULTS: Among 7914 specimens from Massachusetts PHL, 6069 from Michigan PHL, and 36,266 from Maryland PHL, 0.10%, 0.02% and 0.05% acute infections were identified, respectively. Massachusetts and Maryland PHLs each had 1 HIV-2 positive specimen. The median time from specimen receipt to laboratory reporting of results for acute infections at Massachusetts, Michigan and Maryland PHLs was 8, 11, and 7 days respectively. The laboratory cost per HIV positive specimen was $336 (Massachusetts), $263 (Michigan) and $210 (Maryland). CONCLUSIONS: Acute and established infections were found by PHLs using fourth-generation IA in conjunction with antibody tests and NAT. Time to reporting of acute HIV test results to clients was suboptimal, and needs to be streamlined to expedite treatment and interrupt transmission. |
Acute infections, cost per infection and turnaround time in three United States hospital laboratories using fourth-generation antigen-antibody human immunodeficiency virus immunoassays
Wesolowski LG , Nasrullah M , Coombs RW , Rosenberg E , Ethridge SF , Hutchinson AB , Dragavon J , Rychert J , Nolte FS , Madory JE , Werner BG . Open Forum Infect Dis 2016 3 (1) ofv188 BACKGROUND: To improve clinical and public health outcomes through early human immunodeficiency virus (HIV) detection, fourth-generation antigen/antibody immunoassay (4IA) and supplemental testing results must be returned rapidly. METHODS: We examined HIV testing data at Harborview Medical Center (HMC), Massachusetts General Hospital (MGH), and the Medical University of South Carolina (MUSC), which used 4IA and supplemental antibody and nucleic acid tests (NATs). At MGH and MUSC, HIV-1 Western blot (WB) and HIV-2 testing were conducted at a reference laboratory. We compared time from specimen collection to laboratory result for established (positive WB) and acute infections (reactive 4IA, negative/indeterminate WB, detectable NAT), and we calculated testing cost per positive-test result. RESULTS: From 3731 (MUSC) to 19 774 (MGH) tests were conducted; 0.01% (MGH) to 0.05% (HMC) were acute infections. Each laboratory had reactive 4IA, WB-negative, or indeterminate specimens without NAT (ie, potential acute infections). Time to result was 1.5 (HMC) to 5.2 days (MGH) for acute and 1.0 (HMC) to 5.2 days (MGH) for established infections. Costs were $1054 (MGH) to $1521 (MUSC). CONCLUSIONS: Conducting supplemental testing in-house lowered turnaround times, which may be further reduced with rapid HIV-1/HIV-2 differentiation tests. Hospitals may benefit from quantitative NATs not requiring physician orders, so all potential acute infections receive NAT. |
Nearly half of US adults living with HIV received federal disability benefits in 2009
Huang YL , Frazier EL , Sansom SL , Farnham PG , Shrestha RK , Hutchinson AB , Fagan JL , Viall AH , Skarbinski J . Health Aff (Millwood) 2015 34 (10) 1657-65 The effects of HIV infection on national labor-force participation have not been rigorously evaluated. Using data from the Medical Monitoring Project and the National Health Interview Survey, we present nationally representative estimates of the receipt of disability benefits by adults living with HIV receiving care compared with the general US adult population. We found that in 2009, adults living with HIV were nine times more likely than adults in the general population to receive disability benefits. The risk of being on disability is also greater for younger and more educated adults living with HIV compared to the general population, which suggests that productivity losses can result from HIV infection. To prevent disability, early diagnosis and treatment of HIV are essential. This study offers a baseline against which to measure the impacts of recently proposed or enacted changes to Medicaid and private insurance markets, including the Affordable Care Act and proposed revisions to the Social Security Administration's HIV Infection Listings. |
Notification following new positive HIV test results
Huang YA , Hutchinson AB , Hollis ND , Sansom SL . Int J STD AIDS 2015 27 (10) 868-72 Client notification of a new HIV diagnosis is critical for timely access to treatment and reduction in behaviours associated with HIV infection. It is also an important input in HIV transmission and disease progression models. We used national, Centers for Disease Control and Prevention-funded HIV testing events data collected through the National HIV Prevention Program Monitoring and Evaluation system to update estimates of the proportion of newly identified HIV-positives notified of their status. We compared estimates from 2008 to 2010 across test technologies, settings, and HIV risk groups. In 2010, notification following a positive rapid test was 99.6% compared with 99.3% in 2008. Notification following a positive conventional test was 81.5% in 2010 compared with 80.8% in 2008. To realise the full promise of early HIV diagnosis and treatment for the prevention of additional HIV cases, efforts to ensure prompt notification following a new HIV diagnosis will be crucial. |
Cost-effectiveness of frequent HIV testing of high risk populations in the United States
Hutchinson AB , Farnham PG , Sansom SL , Yaylali E , Mermin JH . J Acquir Immune Defic Syndr 2015 71 (3) 323-30 PURPOSE: Data showing a high incidence of HIV infection among men who have sex with men (MSM) who had annual testing suggest that more frequent HIV testing may be warranted. Testing technology is also a consideration given the availability of sensitive testing modalities as well as the increased use of less sensitive rapid, point-of-care antibody tests. We assessed the cost-effectiveness of HIV testing of MSM and injection drug users (IDUs) at 3- and 6-month intervals using fourth-generation and rapid tests. METHODS: We used a published mathematical model of HIV transmission to evaluate testing intervals for each population using cohorts of 10,000 MSM and IDU. We incorporated HIV transmissions averted due to serostatus awareness and viral suppression. We included costs for HIV testing and treatment initiation, as well as treatment costs saved from averted transmissions. RESULTS: For MSM, HIV testing was cost-saving or cost-effective over a 1-year time period for both 6-month compared to annual testing, and quarterly compared to 6-month testing using either test. Testing IDU every 6 months compared to annually was moderately cost-effective over a 1-year time period with a fourth-generation test, while testing with rapid, point-of care tests or quarterly was not cost-effective. MSM results remained robust in sensitivity analysis, while IDU results were sensitive to changes in HIV incidence and continuum-of-care parameters. Threshold analyses on costs suggested additional implementation costs could be incurred for more frequent testing for MSM while remaining cost-effective. CONCLUSION: HIV testing of MSM as frequently as quarterly is cost-effective compared to annual testing, but testing IDU more frequently than annually is generally not cost-effective. |
A systematic review on cost effectiveness of HIV prevention interventions in the United States
Huang YA , Lasry A , Hutchinson AB , Sansom SL . Appl Health Econ Health Policy 2014 13 (2) 149-56 BACKGROUND: The Centers for Disease Control and Prevention (CDC) focus on funding HIV prevention interventions likely to have high impact on the HIV epidemic. In its most recent funding announcement to state and local health department grantees, CDC required that health departments allocate the majority of funds to four HIV prevention interventions: HIV testing, prevention with HIV-positives and their partners, condom distribution and policy initiatives. OBJECTIVE: We conducted a systematic review of the published literature to determine the extent of the cost-effectiveness evidence for each of those interventions. METHODOLOGY: We searched for US-based studies published through October 2012. The studies that qualified for inclusion contained original analyses that reported costs per quality-adjusted life-year saved, life-year saved, HIV infection averted, or new HIV diagnosis. For each study, paired reviewers performed a detailed review and data extraction. We reported the number of studies related to each intervention and summarized key cost-effectiveness findings according to intervention type. Costs were converted to 2011 US dollars. RESULTS: Of the 50 articles that met the inclusion criteria, 33 related to HIV testing, 15 assessed prevention with HIV-positives and partners, three reported on condom distribution, and one reported on policy initiatives. Methodologies and cost-effectiveness metrics varied across studies and interventions, making them difficult to compare. CONCLUSION: Our review provides an updated summary of the published evidence of cost effectiveness of four key HIV prevention interventions recommended by CDC. With the exception of testing-related interventions, including partner services, where economic evaluations suggest that testing often can be cost effective, more cost-effectiveness research is needed to help guide the most efficient use of HIV prevention funds. |
Costs and outcomes of laboratory diagnostic algorithms for the detection of HIV
Hutchinson AB , Ethridge SF , Wesolowski LG , Shrestha RK , Pentella M , Bennett B , Farnham PG , Sullivan T , Patel P , Branson BM . J Clin Virol 2013 58 Suppl 1 e2-7 BACKGROUND: An alternative HIV testing algorithm, designed to improve the detection of acute and early infections and differentiate between HIV-1 and HIV-2 antibodies, has been developed by the Centers for Disease Control and Prevention and the Association of Public Health Laboratories. While it promises greater sensitivity, it also raises concerns about costs. OBJECTIVE: We sought to compare the most commonly used algorithm which was developed in 1989, a third-generation (3G) immunoassay (IA) and Western blot confirmatory test, to a newer algorithm. The new algorithm includes either a 3G or a fourth-generation (4G) initial IA, followed by confirmatory testing with a HIV-1/HIV-2 differentiation IA and, if needed, a nucleic acid amplification test (NAT). STUDY DESIGN: We conducted an analysis of HIV testing costs from the perspective of the laboratory, and classified costs according to IA testing volume. We developed a decision analytic model, populated with cost data from 17 laboratories and published assay performance data, to compare the cost-effectiveness of the testing algorithms for a cohort of 30,000 specimens with a 1% HIV prevalence and 0.1% acute HIV infection prevalence. RESULTS: Costs were lower in high-volume laboratories regardless of testing algorithm. For specimens confirmed positive for HIV antibody, the alternative algorithm (IA, Multispot) was less costly than the current algorithm (IA, WB); however, there was wide variation in reported testing costs. For our cohort, the alternative algorithm initiated with a 3G IA and 4G IA identified 15 and 25 more HIV infections, respectively, than the 1989 algorithm. In medium-volume laboratories, the 1989 algorithm was more costly and less effective than the alternative algorithm with a 3G IA; in high-volume laboratories, the alternative algorithm with 3G IA costs $162 more per infection detected. The alternative algorithm with 4G instead of 3G incurred an additional cost of $14,400 and $4865 in medium- and high-volume labs, respectively. DISCUSSION: HIV testing costs varied with IA testing volumes. The additional cost of 4G over 3G IA might be justified by the additional cases of HIV detected and transmissions averted due to earlier detection. CONCLUSION: The alternative HIV testing algorithm compares favorably to the 1989 algorithm in terms of cost and effectiveness. |
Updates of lifetime costs of care and quality of life estimates for HIV-infected persons in the United States: late versus early diagnosis and entry into care
Farnham PG , Gopalappa C , Sansom SL , Hutchinson AB , Brooks JT , Weidle PJ , Marconi VC , Rimland D . J Acquir Immune Defic Syndr 2013 64 (2) 183-9 BACKGROUND: Lifetime costs of care and quality of life estimates for human immunodeficiency virus (HIV)-infected persons depend upon the disease stage at which these persons are diagnosed, enter care, and start antiretroviral therapy (ART). Using updated estimates, we analyzed the effect of late versus early diagnosis/entry on U.S. lifetime care costs, quality of life estimates, and HIV transmissions. METHODS: We used the Progression and Transmission of HIV/AIDS (PATH) model to estimate discounted (3%) lifetime treatment costs ($US 2011) and quality of life variables from time of infection for cohorts of 10,000 HIV-infected index patients in four categories of CD4 count (cells/microL) at diagnosis: (I) ≤ 200; (II) 201 - 350; (III) 351 - 500 and (IV) 501 - 900. We assumed index patient diagnoses were uniformly distributed across the CD4 count range in each category and that patients entered care at the time of diagnosis, remained in care, and were eligible to initiate ART at a CD4 count of 500 cells/microL. We also estimated lifetime transmissions of the index patients. RESULTS: Discounted average lifetime costs varied from $253,000 for category (I) index patients to $402,000 for category (IV) patients. Discounted quality-adjusted life years lost decreased from 7.95 to 4.45 across these categories, additional years of life expectancy increased from 30.8 to 38.1, and lifetime transmissions decreased from 1.40 to 0.72. CONCLUSIONS: Early diagnosis and treatment of HIV infection increases lifetime costs but improves length and quality of life and reduces by nearly 50% the number of new infections transmitted. |
How much should we pay for a new HIV diagnosis? A mathematical model of HIV screening in US clinical settings
Farnham PG , Sansom SL , Hutchinson AB . Med Decis Making 2012 32 (3) 459-69 OBJECTIVE: To develop a model to assist clinical setting decision makers in determining how much they can spend on human immunodeficiency virus (HIV) screening and still be cost-effective. DESIGN: The authors developed a simple mathematical model relating the program cost per new HIV diagnosis to the cost per HIV infection averted and the cost per quality-adjusted life year (QALY) saved by screening. They estimated outcomes based on behavioral changes associated with awareness of HIV infection and applied the model to US sexually transmitted disease clinics. METHODS: The authors based the cost per new HIV diagnosis (2009 US dollars) on the costs of testing and the proportion of persons who tested positive. Infections averted were calculated from the reduction in annual transmission rates between persons aware and unaware of their infections. The authors defined program costs from the sexually transmitted disease clinic perspective and treatment costs and QALYs saved from the societal perspective. They undertook numerous sensitivity analyses to determine the robustness of the base case results. RESULTS: In the base case, the cost per new HIV diagnosis was $2528, the cost per infection averted was $40,516, and the cost per QALY saved was less than zero, or cost-saving. Given the model inputs, the cost per new diagnosis could increase to $22,909 to reach the cost-saving threshold and to $63,053 for the cost-effectiveness threshold. All sensitivity analyses showed that the cost-effectiveness results were consistent for extensive variation in the values of model inputs. CONCLUSIONS: HIV screening in a clinical setting is cost-effective for a wide range of testing costs, variations in positivity rates, reductions in HIV transmissions, and variation in the receipt of test results. |
Cost-effectiveness of the National HIV/AIDS Strategy (NHAS) goal of increasing linkage to care for HIV-infected persons
Gopalappa C , Farnham PG , Hutchinson AB , Sansom SL . J Acquir Immune Defic Syndr 2012 61 (1) 99-105 BACKGROUND: One of the goals of the National HIV/AIDS Strategy (NHAS) is to increase the proportion of HIV-infected individuals linked to care within 3 months of diagnosis (early linkage) from 65% to 85%. Earlier access to care, and eventually, to treatment, increases life-expectancy and quality of life for HIV-infected persons. However, longer treatment is also associated with higher costs, especially for antiretroviral drugs. We evaluated the cost-effectiveness of achieving the NHAS goal and estimated the maximum cost that HIV programs could spend on linkage to care and remain cost-effective. METHODS: We used the Progression and Transmission of HIV/AIDS (PATH) model to estimate the effects on life-measures and costs associated with increasing early linkage to care from 65% to 85%. We estimated an incremental cost-effectiveness ratio as the additional cost required to reach the target divided by the quality-adjusted life-years (QALYs) gained and assumed that programs costing $100,000 or less per QALY gained are cost-effective. RESULTS: Achieving the NHAS linkage-to-care goal increased life expectancy by 0.4 years and delayed the onset of AIDS by 1.2 years on average for every HIV-diagnosed person. Increasing early linkage to care cost an extra $62,200 per quality-adjusted life-year gained, considering only benefits to index persons. The maximum that could be cost-effectively spent on early linkage-to-care interventions was approximately $ 5,100 per HIV-diagnosed person. CONCLUSION: Considerable investment can be cost-effectively made to achieve the NHAS goal on early linkage to care. |
Return on public health investment: CDC's expanded HIV testing initiative
Hutchinson AB , Farnham PG , Duffy N , Wolitski RJ , Sansom SL , Dooley SW , Cleveland JC , Mermin JH . J Acquir Immune Defic Syndr 2011 59 (3) 281-6 BACKGROUND: Over a three-year period, CDC invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative, for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. METHODS: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared to when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1 -5 year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. RESULTS: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3,381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 - $2.01 for alternative testing intervals of one to five years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. CONCLUSION: The Expanded Testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs. |
Emergency department HIV screening with rapid tests: a cost comparison of alternative models
Hutchinson AB , Farnham PG , Lyss SB , White DA , Sansom SL , Branson BM . AIDS Educ Prev 2011 23 58-69 Although previous studies have shown that HIV screening in emergency departments (EDs) is feasible, the costs and outcomes of alternative methods of implementing ED screening have not been examined. We compared the costs and outcomes of a model that used the hospital's ED staff to conduct screening, a supplemental staff model that used non-ED staff hired to conduct screening and a hypothetical hybrid model that combined aspects of both approaches. We developed a decision analytic model to estimate the cost per HIV-infected patient identified using alternative ED testing models. The cost per new HIV infection identified was $3,319, $2,084 and $1,850 under the supplemental, existing staff and hybrid models, respectively. Assuming an annual ED census of 50,000 patients, the existing staff model identified 29 more HIV infections than the supplemental model and the hybrid model identified 76 more infections than the existing staff model. Our findings suggest that a hybrid model should be favored over either a supplemental staff or existing staff model in terms of cost per outcome achieved. |
Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis
Prabhu VS , Farnham PG , Hutchinson AB , Soorapanth S , Heffelfinger JD , Golden MR , Brooks JT , Rimland D , Sansom SL . PLoS One 2011 6 (5) e19936 BACKGROUND: Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations. METHODS AND FINDINGS: We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/microL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/microL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients. CONCLUSIONS: HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection. |
Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings
Hutchinson AB , Patel P , Sansom SL , Farnham PG , Sullivan TJ , Bennett B , Kerndt PR , Bolan RK , Heffelfinger JD , Prabhu VS , Branson BM . PLoS Med 2010 7 (9) e1000342 BACKGROUND: Detection of acute HIV infection (AHI) with pooled nucleic acid amplification testing (NAAT) following HIV testing is feasible. However, cost-effectiveness analyses to guide policy around AHI screening are lacking; particularly after more sensitive third-generation antibody screening and rapid testing. METHODS AND FINDINGS: We conducted a cost-effectiveness analysis of pooled NAAT screening that assessed the prevention benefits of identification and notification of persons with AHI and cases averted compared with repeat antibody testing at different intervals. Effectiveness data were derived from a Centers for Disease Control and Prevention AHI study conducted in three settings: municipal sexually transmitted disease (STD) clinics, a community clinic serving a population of men who have sex with men, and HIV counseling and testing sites. Our analysis included a micro-costing study of NAAT and a mathematical model of HIV transmission. Cost-effectiveness ratios are reported as costs per quality-adjusted life year (QALY) gained in US dollars from the societal perspective. Sensitivity analyses were conducted on key variables, including AHI positivity rates, antibody testing frequency, symptomatic detection of AHI, and costs. Pooled NAAT for AHI screening following annual antibody testing had cost-effectiveness ratios exceeding US$200,000 per QALY gained for the municipal STD clinics and HIV counseling and testing sites and was cost saving for the community clinic. Cost-effectiveness ratios increased substantially if the antibody testing interval decreased to every 6 months and decreased to cost-saving if the testing interval increased to every 5 years. NAAT was cost saving in the community clinic in all situations. Results were particularly sensitive to AHI screening yield. CONCLUSIONS: Pooled NAAT screening for AHI following negative third-generation antibody or rapid tests is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings. |
Cost-effectiveness of using social networks to identify undiagnosed HIV infection among minority populations
Shrestha RK , Sansom SL , Kimbrough L , Hutchinson AB , Daltry D , Maldonado W , Simpson-May GM , Illemszky S . J Public Health Manag Pract 2010 16 (5) 457-64 CONTEXT: In 2003, the Centers for Disease Control and Prevention launched the Advancing HIV Prevention project to implement new strategies for diagnosing human immunodeficiency virus (HIV) infections outside medical settings and prevent new infections by working with HIV-infected persons and their partners. OBJECTIVES: To assess the cost and effectiveness of a social network strategy to identify new HIV diagnoses among minority populations. DESIGN, SETTINGS, AND PARTICIPANTS: Four community-based organizations (CBOs) in Boston, Philadelphia, and Washington, District of Columbia, implemented a social network strategy for HIV counseling and testing from October 2003 to December 2005. We used standardized cost collection forms to collect program costs attributable to staff time, travel, incentives, test kits, testing supplies, office space, equipment, and utilities. The CBOs used the networks of high-risk and HIV-infected persons (recruiters) who referred their partners and associates for HIV counseling and testing. We obtained HIV-testing outcomes from project databases. MAIN OUTCOME MEASURES: Number of HIV tests, number of new HIV-diagnoses notified, total program cost, cost per person tested, cost per person notified of new HIV diagnosis. RESULTS: Two CBOs, both based in Philadelphia, identified 25 and 17 recruiters on average annually and tested 136 and 330 network associates, respectively. Among those tested, 12 and 13 associates were notified of new HIV diagnoses (seropositivity: 9.8%, 4.4%). CBOs in Boston, Massachusetts, and Washington, District of Columbia, identified 26 and 24 recruiters per year on average and tested 228 and 123 network associates. Among those tested, 12 and 11 associates were notified of new HIV diagnoses (seropositivity: 5.1%, 8.7%). The cost per associate notified of a new HIV diagnosis was $11 578 and $12 135 in Philadelphia, and $16 437 and $16 101 in Boston, Massachusetts, and Washington, District of Columbia. CONCLUSIONS: The cost of notifying someone with a new HIV diagnosis using social networks varied across sites. Our analysis provides useful information for program planning and evaluation. |
Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males
Sansom SL , Prabhu VS , Hutchinson AB , An Q , Hall HI , Shrestha RK , Lasry A , Taylor AW . PLoS One 2010 5 (1) e8723 BACKGROUND: HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, we modeled the potential effect of newborn male circumcision on a U.S. male's lifetime risk of HIV, including associated costs and quality-adjusted life-years saved. METHODOLOGY/PRINCIPAL FINDINGS: Given published estimates of U.S. males' lifetime HIV risk, we calculated the fraction of lifetime risk attributable to heterosexual behavior from 2005-2006 HIV surveillance data. We assumed 60% efficacy of circumcision in reducing heterosexually-acquired HIV over a lifetime, and varied efficacy in sensitivity analyses. We calculated differences in lifetime HIV risk, expected HIV treatment costs and quality-adjusted life years (QALYs) among circumcised versus uncircumcised males. The main outcome measure was cost per HIV-related QALY saved. Circumcision reduced the lifetime HIV risk among all males by 15.7% in the base case analysis, ranging from 7.9% for white males to 20.9% for black males. Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males. The net cost of newborn circumcision per QALY saved was $87,792 for white males. Results were most sensitive to the discount rate, and circumcision efficacy and cost. CONCLUSIONS/SIGNIFICANCE: Newborn circumcision resulted in lower expected HIV-related treatment costs and a slight increase in QALYs. It reduced the 1.87% lifetime risk of HIV among all males by about 16%. The effect varied substantially by race and ethnicity. Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful. |
Costs and effectiveness of partner counseling and referral services with rapid testing for HIV in Colorado and Louisiana, United States
Shrestha RK , Begley EB , Hutchinson AB , Sansom SL , Song B , Voorhees K , Busby A , Carrel J , Burgess S . Sex Transm Dis 2009 36 (10) 637-641 OBJECTIVE: Health departments offer partner counseling and referral services (PCRS) to HIV-infected index patients and their partners. Point-of-care rapid HIV testing makes it possible for partners of index patients to learn their HIV serostatus in nonclinical settings. STUDY DESIGN: We assessed costs and effectiveness of PCRS with rapid HIV testing in Colorado and Louisiana (April 2004-January 2006). Colorado provided PCRS to the index patients and partners statewide; Louisiana provided PCRS to those in Baton Rouge and New Orleans. The key effectiveness measures were number of partners tested and number of partners informed of a new HIV diagnosis after rapid testing. We obtained program costs for personnel, travel, utilities, supplies, equipment, and facility space. RESULTS: Colorado identified a yearly average of 328 index patients and 253 partners and tested 43 partners. Louisiana identified a yearly average of 81 index patients and 138 partners and tested 83 partners. The rates of previously undiagnosed HIV infection among partners tested were 6.6% in Colorado and 9.9% in Louisiana. The average costs per partner tested and per partner informed of a new HIV diagnosis were $1459 and $22,243 in Colorado and $714 and $7231 in Louisiana. CONCLUSIONS: Program costs varied substantially by location. Our analysis helps program managers and health care providers to understand the resources needed for implementing the PCRS in diverse settings. Copyright copyright 2009 American Sexually Transmitted Diseases Association All rights reserved. |
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