Cost-Effectiveness of HIV Prevention Interventions in the United States: A Systematic Review
Cost-Effectiveness of HIV Prevention Interventions in the United States: A Systematic Review Ya-lin A. Huang, PhD Arielle Lasry, PhD Angela B. Hutchinson, PhD Stephanie L. Sansom, PhD Acknowledgement CDC Prevention Modeling and Economic Team members National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
BACKGROUND Goals of National HIV/AIDS Strategy (NHAS) To reduce new HIV infections To increase access to care and strengthen treatment outcomes To reduce HIV-related health disparities ECHPP (Enhanced Comprehensive HIV Prevention Plans) For 12 selected jurisdictions with the highest AIDS prevalence to develop and implement the best mix of prevention interventions 14 intervention/strategies were required to be included and prioritized based on local epidemic profile, costs, and scalability
OBJECTIVES To perform a comprehensive systematic review of published CEA literature that evaluated HIV intervention implemented in the US To highlight gaps in the literature
METHODS Literature Search Electronically • 6 databases: PubMed/ PsycInfo/ Embase/Cochrance/ CINAHL/EconLit • Searched from the earliest date available to January 25th, 2011 • Used keywords and MeSH terms that reflect both “Cost-effectiveness” and “HIV” categories Manually • Reference lists of relevant articles • Suggestions of experts in the field
METHODS Study Selection Criteria Reported cost-utility or cost-effectiveness ratios • e.g. , cost per QALY saved Original studies • e.g., empirical or model-based US-based studies Evaluated ECHPP-defined intervention strategies Abstraction Using a pre-specified 28-item abstraction form • e.g., study characteristics, key aspects of analysis, sources of data and key results Two reviewers coded independently Discrepancies were resolved through discussion
RESULTS — Selection Process 3,977 identified published studies 621 articles presented CE outcomes 506 original studies 249 US-based studies45 studies related to ECHPP-required HIV prevention interventions for review
RESULTS — Study Distribution Nb. Of CEECHPP Required Intervention Strategy StudiesRoutine, opt-out screening for HIV in clinical settings of patients ages 913-64Ongoing partner services 9Prevention of perinatal transmission 8Interventions or strategies promoting adherence to antiretroviral 5medicationsHIV testing in non-clinical settings to identify undiagnosed HIV 3infectionProvision of Post-Exposure Prophylaxis to populations at greatest risk 3Policies and procedures that will lead to the provision of antiretroviral 3treatment in accordance with current guidelines
RESULTS — Study Distribution (Cont’d) Nb. Of CEECHPP Required Intervention Types StudiesBehavioral risk screening followed by risk reduction interventions for 2HIV-positive personsCondom distribution prioritized to target HIV-positive and high-risk 1populationsEfforts to change existing structures, policies, and regulations 1Linkage to HIV care, treatment, and prevention services for those 1testing positive and not currently in careInterventions or strategies promoting retention in or re-engagement 0in careSTD screening according to current guidelines 0Linkage to other medical and social services (e.g., mental health 0treatment, drug treatment, housing assistance)
RESULTS — CE Summary Type of CE Inter-QuartileIntervention Outcome Median* Range* CommentRoutine opt-out HIV Cost/QALY saved $34,411 -- Testing in primary care settingscreening in clinical settings Cost/New diagnosis $3,365 ($2,123 - $5,856) Testing in primary care settings, UCC, ED, STD clinicsEvaluation of expanded HIV Cost/QALY saved $46,000 ($40,500-$56,922) Prevalence-based studiesscreening based on (range of undiagnosedprevalence in general pop. seroprevalence: 0.05 % to 3 %)Partner services Cost/New diagnosis $7,824 ($6,054 - $14,045)Prevention of perinatal Cost/HIV infection $90,678 ($90,277 - $91,080) Universal screening ontransmission averted pregnant women Cost/Life year saved $68,270 -- Second testing on high risk pregnant womenAdherence to antiretroviral Cost/QALY saved $34,500 ($13,650 - $52,000) Patients with early stage andmedications advanced stage of HIV infectionHIV testing in non-clinical Cost/New diagnosis $12,211 ($7,845 - $16,657) Testing by CBOs or insettings prisons/jailsNon-occupational post- Cost/QALY saved $24,367 ($23,482 - $25,251) Overall sexual/IDU exposure (exposure prophylaxis (PEP) 46% source known HIV+ )Early initiation of HAART Cost/QALY saved $17,617 ($11,064 - $34,000) General HIV-infected adults and uninsured HIV-infected adults * All the dollar values in this table are inflated to 2009 US dollars.
DISCUSSION The identified CE results within intervention types were generally consistent with one another Most of the medians of the CE results suggested cost-effective Gaps in Current Cost-Effectiveness Knowledge Lack of CE data for some interventions: • Linkage and retention to care • Structural intervention • Linkage to other medical and social services • STD screening Limitation There is wide variation in methods. This review did not include any review of the quality of methods
FUTURE RESEARCH/ NEXT STEPS Fill in the gaps in the cost-effectiveness of HIV prevention literature Incorporate measures to assess the strength of the evidence that informs costs and effectiveness underlying each cost-effectiveness evaluation.
Thank You!For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: email@example.com Web: http://www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of theCenters for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
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