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      Comparing Cost-Effectiveness of HIV Testing Strategies: Targeted and Routine Testing in Washington, DC

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          Abstract

          Background

          Routine HIV testing is an essential approach to identifying undiagnosed infections, linking people to care and treatment, and preventing new infections. In Washington, DC, where HIV prevalence is 2.4%, a combination of routine and targeted testing approaches has been implemented since 2006.

          Methods

          We sought to evaluate the cost effectiveness of the District of Columbia (DC) Department of Health’s routine and targeted HIV testing implementation strategies. We collected HIV testing data from 3 types of DC Department of Health-funded testing sites (clinics, hospitals, and community-based organizations); collected testing and labor costs; and calculated effectiveness measures including cost per new diagnosis and cost per averted transmission.

          Results

          Compared to routine testing, targeted testing resulted in higher positivity rates (1.33% vs. 0.44%). Routine testing averted 34.30 transmissions per year compared to targeted testing at 17.78. The cost per new diagnosis was lower for targeted testing ($2,467 vs. $7,753 per new diagnosis) as was the cost per transmission averted ($33,160 vs. $104,205). When stratified by testing site, both testing approaches were most cost effective in averting new transmissions when conducted by community based organizations ($25,037 routine; $33,123 targeted) compared to hospitals or clinics.

          Conclusions

          While routine testing identified more newly diagnosed infections and averted more infections than targeted testing, targeted testing is more cost effective per diagnosis and per transmission averted overall. Given the high HIV prevalence in DC, the DC Department of Health’s implementation strategy should continue to encourage routine testing implementation with emphasis on a combined testing strategy among community-based organizations.

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          Most cited references15

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          Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.

          These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1-10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1-62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63-85). Major revisions from previously published guidelines are as follows: For patients in all health-care settings HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.
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            Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement.

            V Moyer (2013)
            Update of the 2005 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for HIV. The USPSTF reviewed new evidence on the effectiveness of treatments in HIV-infected persons with CD4 counts greater than 0.200 × 109 cells/L; effects of screening, counseling, and antiretroviral therapy (ART) use on risky behaviors and HIV transmission risk; and long-term cardiovascular harms of ART. These recommendations apply to adolescents, adults, and pregnant women. The USPSTF recommends that clinicians screen adolescents and adults aged 15 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A recommendation)The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (Grade A recommendation).
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              The lifetime cost of current human immunodeficiency virus care in the United States.

              We sought to project the lifetime cost of medical care for human immunodefiency virus (HIV)-infected adults using current antiretroviral therapy (ART) standards. Medical visits and hospitalizations for any reason were from the HIV Research Network, a consortium of high-volume HIV primary care sites. HIV treatment drug regimen efficacies were from clinical guidelines and published sources; data on other drugs used were not available. In a computer simulation model, we projected HIV medical care costs in 2004 U.S. dollars. From the time of entering HIV care, per person projected life expectancy is 24.2 years, discounted lifetime cost is Dollars 385,200, and undiscounted cost is Dollars 618,900 for adults who initiate ART with CD4 cell count < 350/microL. Seventy-three percent of the cost is antiretroviral medications, 13% inpatient care, 9% outpatient care, and 5% other HIV-related medications and laboratory costs. For patients who initiate ART with CD4 cell count < 200/microL, projected life expectancy is 22.5 years, discounted lifetime cost is Dollars 354,100 and undiscounted cost is Dollars 567,000. Results are sensitive to drug manufacturers' discounts, ART efficacy, and use of enfuvirtide for salvage. If costs are discounted to the time of infection, the discounted lifetime cost is Dollars 303,100. Effective ART regimens have substantially improved survival and have increased the lifetime cost of HIV-related medical care in the U.S.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 October 2015
                2015
                : 10
                : 10
                : e0139605
                Affiliations
                [1 ]The Milken Institute School of Public Health at the George Washington University, Washington, DC, United States of America
                [2 ]The George Washington University School of Public Policy and Public Administration, Washington, DC, United States of America
                [3 ]District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD, TB Administration, Washington, DC, United States of America
                Emory University Rollins School of Public Health, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: ADC AD SC JS JP. Performed the experiments: AD SC. Analyzed the data: AD SC. Contributed reagents/materials/analysis tools: AD ADC SC JS NR MK JP. Wrote the paper: ADC AD SC JS.

                Article
                PONE-D-15-14586
                10.1371/journal.pone.0139605
                4605630
                26465771
                b05f1e44-96c1-42ef-9c34-e0967923baae
                Copyright @ 2015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                : 3 April 2015
                : 14 September 2015
                Page count
                Figures: 0, Tables: 4, Pages: 11
                Funding
                This study was funded through the District of Columbia Developmental Center for AIDS Research, an NIH-funded Program (P30AI087714). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Custom metadata
                Data are only available upon request as they were obtained from a third party, i.e. the District of Columbia (DC) Department of Health HIV/AIDS Hepatitis, STD, TB Administration (HAHSTA) HIV testing grantee agencies and cannot be shared as per our IRB approval through the George Washington University and the DC Department of Health Institutional Review Boards. Readers who are interested in requesting the data may contact Mr. Michael Kharfen, Senior Deputy Director of HAHSTA at the DC Department of Health at Michael.kharfen@ 123456dc.gov to arrange access.

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                Uncategorized

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