1. Economic evaluation of the HIV counseling and testing program at Hampden County Correction Center (HCCC) Beena Varghese, PhD Division of HIV/AIDS Prevention, CDC CDC: TA Peterman, C Mugalla, K Irwin, T Gift HCCC: T Lincoln, T Conklin, A Miller, J Vivian, and HIV VCT staff

2. Background Limited resources and competing priorities Economic evaluation tools can: • Quantify the costs and benefits of a program, especially prevention programs • Guide resource allocation HIV counseling and testing (CT) program at HCCC is one of the many health care programs for inmates

3. BackgroundHIV CT program • Well established and functional • Standard testing (EIA & WB) • Most of the eligible inmates (sentenced & who stay > 2 weeks) get tested • Drug use or sexual exposure was main risk

4. Objective • Estimate the cost of CT program to detect a newly identified HIV case • Model the cost-effectiveness of CT program compared to no program in preventing HIV

5. Methods – Data Sources From January 1 – December 31, 2000 Annual cost data (HCCC) • Labor (wages adjusted for % time on CT) • Material (phlebotomy related) • Laboratory (charges for HIV tests) • Other costs (biohazard waste disposal) Test data (Massachusetts Dept. of Public health, MDPH) • Inmate demographics & risk behavior • Test results

6. Methods – Data Sources Effectiveness data (literature) Decision model (Varghese 2001) • Adjusted for prior knowledge of serostatus (41%) • Reduction in annual risk for HIV due to CT • 25% for infected inmates (from 7% to 5.2%) • 10% for uninfected inmates (from 0.3% to 0.27%)

7. Decision Tree: Effectiveness of HIV CT Program

8. HIV CT Program:Test data(Calendar year 2000) • Number of HIV tests: 1192 • Number positive: 16 • previously negative or unknown: 14

9. HIV CT program: Direct Annual Costs* * Fixed costs of facility and overhead costs are not included

10. Effectiveness of HIV CT program at HCCC Newly identified HIV positive cases: 14 Annual risk of HIV infection: 7% Reduction in risk due to CT: 25% Cases prevented:14 x 7% x 25% = 0.25

11. Effectiveness of HIV CT program at HCCC Inmates tested negative: 1176 Risk of HIV acquisition: 0.3% (Kamb 1998) Reduction in risk due to CT: 10% Cases prevented: Benefits for only those previously untested (59%) 1176 x 59% x 0.3% x 10% = 0.21 Benefits for all with Project RESPECT style counseling 1176 x 0.3% x 20% = 0.71

12. Cost-effectiveness of HIV CT program for 1192 inmates at HCCC -Summary

13. HIV CT program Summary • Offered only to ~ 50% of inmates (sentenced and who stay > 2 weeks) • Costs $6071 per new HIV infection identified • May avert 0.46 cases and would save societal dollars

14. Limitations • CE tools are best suited for comparisons of different programs • Fixed and overhead costs not included • Secondary cases from uninfected inmates not included

15. Discussion • Despite frequent testing, new positives identified • Increased focus on prevention? • Risk-specific prevention? • Client centered counseling of HIV negatives? • Rapid testing (Increase testing)? • Prevention for positives ?

16. ConclusionsHIV CT program at HCCC • Is effective in identifying new HIV cases • Saves money for society in averted treatment costs • Increased focus on prevention may be beneficial for both HIV positive and negative inmates • Potential to increase testing with existing personnel