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      Economic and health implications from earlier detection of HIV infection in the United Kingdom

      research-article
      1 , 2 , 1
      HIV/AIDS (Auckland, N.Z.)
      Dove Medical Press
      HIV, testing, costs, savings, model

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          Abstract

          Purpose

          To model the budget and survival impact of implementing interventions to increase the proportion of HIV infections detected early in a given UK population.

          Patients and methods

          A Microsoft Excel decision model was designed to generate a set of outcomes for a defined population. Survival was modeled on the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex, and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions, and surviving cases. Three locations in the UK were chosen to model outcomes across a range of HIV prevalence areas: Lambeth, Southwark, and Lewisham (LSL), Greater Manchester Cluster (GMC), and Kent and Medway (K&M).

          Results

          In LSL, the projected cumulative cost savings over 5 years were £3,210,206 or £5,290,206 when including the value of the 104 life-years saved. Savings were insensitive to transmission rates, but sensitive in direct proportion to the percentage shift from late to early detection. In GMC, savings were in a similar proportion to LSL, but the magnitude was smaller, as a consequence of the lower base-case HIV prevalence. In K&M, with a smaller population and lower HIV prevalence than GMC, savings were commensurately smaller (£733,202 cumulatively over 5 years).

          Conclusion

          The results strengthen the rationale for implementing increased testing in high prevalence areas. However, in areas of low prevalence, it is unlikely that costs will be returned over a 5-year period.

          Related collections

          Most cited references21

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          Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals.

          To compare life expectancies between recently diagnosed HIV-infected patients and age and sex-matched uninfected individuals from the general population. : National observational HIV cohort in the Netherlands. Four thousand, six hundred and twelve patients diagnosed with HIV between 1998 and 2007 and still antiretroviral therapy-naive as of 24 weeks after diagnosis were selected. Progression to death compared to the age and sex-matched general population was studied with a multivariate hazards model in 4174 (90.5%) patients without AIDS events at 24 weeks. Life expectancy and number of life years lost were calculated using the predicted survival distribution. During 17 580 person-years of follow-up since 24 weeks after diagnosis [median follow-up 3.3 years, interquartile range (IQR) 1.6-5.8], 118 deaths occurred, yielding a mortality rate of 6.7 [95% confidence interval (CI) 5.5-8.0] per 1000 person-years. Median CD4 cell counts at 24 weeks were 480 cells/microl (IQR 360-650). According to the model, the median number of years lived from age 25 was 52.7 (IQR 44.2-59.3; general population 53.1) for men and 57.8 (49.2-63.7; 58.1) for women without CDC-B event. The number of life years lost varied between 0.4 if diagnosed with HIV at age 25 and 1.4 if diagnosed at age 55; for patients with a CDC-B event this range was 1.8-8.0 years. The life expectancy of asymptomatic HIV-infected patients who are still treatment-naive and have not experienced a CDC-B or C event at 24 weeks after diagnosis approaches that of non-infected individuals. However, follow-up time is short compared to the expected number of years lived.
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            The high cost of medical care for patients who present late (CD4 <200 cells/microL) with HIV infection.

            To compare the direct costs of medical care in the year following HIV diagnosis for patients who present with a CD4 count 200 cells/microL ('early presenters'). Direct costs (i.e. drugs, laboratory tests, outpatient care, in-patient care, and home care) for the 12 months following HIV diagnosis, sociodemographic data and clinical data were collected for all patients presenting for HIV care in Southern Alberta, Canada between April 1996 and April 2001. Mean costs are presented as costs in 2001 Canadian dollars. Thirty-nine per cent of 241 patients presented with a CD4 count <200 cells/microL. The mean costs for late presenters were more than twice as high as those for early presenters (i.e. $18,448 vs. $8455, respectively). Late presenters were more likely to be older, male and black, and to have a risk activity of men having sex with men (MSM) or heterosexual contact (P<0.05). However, the large difference in mean costs cannot be attributed to differences in characteristics. When characteristics were statistically held constant, the estimated excess cost of late presentation was almost unaffected, at $9723 (z=5.6). Repeating the analysis using disaggregated costing categories suggested that the difference in total costs was largely attributable to differences in HIV-related hospital care costs, which were 15 times higher for late presenters. Direct care costs in the year following HIV diagnosis were more than 200% higher for patients who presented late. This difference could not be attributed to differences in patient characteristics. Most costs were attributable to HIV-related hospital care costs and the immediate initiation of antiretroviral therapy. While early diagnosis in those at risk for HIV remains medically important, the short-term economic impact is also substantial.
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              Cost-effectiveness of HIV testing and treatment in the United States.

              In September 2006, the US Centers for Disease Control and Prevention (CDC) released new guidelines calling for routine, voluntary human immunodeficiency virus (HIV) testing for all persons aged 13-64 years in health care settings. These guidelines were motivated, in part, by mounting evidence that the traditional approach of using risk factors to identify candidates for HIV testing is inadequate. Of the 1.0-1.2 million people in the United States thought to be infected with HIV, approximately 25% remain unaware of their infection, and nearly half of all infected patients develop acquired immunodeficiency syndrome < or = 1 year after testing positive for HIV. Also contributing to the change in testing guidelines was recent evidence that routine HIV testing is cost-effective. Cost-effectiveness analysis, a method of assessing health care interventions in terms of the value they confer, reports results in terms of the resources that are required for the intervention to produce an additional unit of change in health effectiveness; more economically efficient programs are those with lower cost-effectiveness ratios. This article reviews the methods and results of cost-effectiveness studies in the United States and articulates why routine, voluntary HIV testing is not only of crucial public health importance but also economically justified.
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                Author and article information

                Journal
                HIV AIDS (Auckl)
                HIV AIDS (Auckl)
                HIV/AIDS - Research and Palliative Care
                HIV/AIDS (Auckland, N.Z.)
                Dove Medical Press
                1179-1373
                2016
                15 March 2016
                : 8
                : 67-74
                Affiliations
                [1 ]Ecole Doctoral Interdisciplinaire Sciences-Santé (EDISS), University of Lyon, Lyon, France
                [2 ]ZRx Outcomes Research Inc., Mississauga, Canada
                Author notes
                Correspondence: Vladimir Zah, ZRx Outcomes Research Inc., 3373 Cawthra Road, Mississauga, ON L5A2X8, Canada, Tel +1 416 953 4427, Fax +1 905 364 5313, Email vzah@ 123456outcomesresearch.ca
                Article
                hiv-8-067
                10.2147/HIV.S96713
                4806762
                27073328
                e753da7c-4dd0-4506-a9fb-090347d34fdb
                © 2016 Zah and Toumi. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Original Research

                Infectious disease & Microbiology
                hiv,testing,costs,savings,model
                Infectious disease & Microbiology
                hiv, testing, costs, savings, model

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