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Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness

Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness. Yazdan Yazdanpanah, MD Julian Perelman, PhD Joana Alves Kamal Mansinho, MD Madeline A. DiLorenzo Ji-Eun Park Elena Losina, PhD Rochelle P. Walensky, MD, MPH Farzad Noubary, PhD Henrique Barros, MD

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Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness

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  1. Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness Yazdan Yazdanpanah, MD Julian Perelman, PhD Joana Alves Kamal Mansinho, MD Madeline A. DiLorenzo Ji-Eun Park Elena Losina, PhD Rochelle P. Walensky, MD, MPH Farzad Noubary, PhD Henrique Barros, MD Kenneth A. Freedberg, MD, MSc A. David Paltiel, PhD, MBA

  2. HIV Epidemiological Burden in Portugal Portugal Iceland Spain Italy France Switzerland Luxembourg Austria Ireland UK Netherlands Belgium Denmark Sweden Greece Norway Germany Finland 40 0% 0 10 0.4% 20 0.3% 30 0.2% 0.1% 2009 HIV Prevalence 2009 Incidence Per Million Population

  3. HIV Care in Portugal • The Portuguese National Health Service provides universal coverage for HIV care (including free access to HIV testing and ART) via a national network of public primary care centers and hospitals. • In 2011, the Portuguese Parliament adopted a resolution calling for voluntary, routine population-based HIV testing, counseling and referral (HIV-TCR). • Portugal faces numerous challenges in implementing this resolution.

  4. Challenge: Economic / Fiscal Crisis 2010 GDP <7,600€ 7,600-12,900€ 12,900-20,500€ >20,500€ • 2010 Portuguese GDP/capita: 16,300€ • Mean 2010 EU GDP/capita: 24,000€ • 2011 GDP growth rate: -1.5% Source: Eurostat, ACSS

  5. Regional Disparities < 0.005 < 0.05 0.005 - 0.009 0.05 - 0.09 0.010 - 0.020 0.10 - 0.20 > 0.020 > 0.20 2010 Undiagnosed HIV Prevalence (%) 2010 Annual HIV Incidence (%)

  6. Objective • To evaluate the clinical impact and cost-effectiveness of routine HIV screening in Portuguese adults (vs. current practice), focusing on the regional heterogeneity in burden of disease. • We examined three different strategies: • One-time screening • Screening every 3 years • Annual screening

  7. Methods Overview • Cost-Effectiveness of Preventing AIDS Complications (CEPAC), a widely published Monte Carlo simulation model of the detection, natural history and treatment of HIV disease. • Assembly of Portuguese national/regional input data on • Epidemiology of HIV infection • HIV clinical care • Economic resource use

  8. Selected Input Parameters

  9. Selected Input Parameters

  10. Model Outcomes • Clinical (quality adjusted life years, or QALY) • Economic (per-person lifetime costs, 2010 €) • Incremental Cost-effectiveness (€/QALY)

  11. Benchmarks for Cost-Effectiveness in Portugal • World Health Organization Commission on Macroeconomics and Health guidance: • “Cost-effective” if the CE ratio is less than three times the per capita GDP for a given country. • Portuguese GDP per capita is 16,300€, implying a threshold = 48,900 €/QALY. • Portuguese Infarmed “informal threshold” for cost-effectiveness of innovative drugs: ICER < 30,000 €/QALY. Source: Pordata, 2011

  12. Base Case Results For National Program (Undiagnosed Prevalence = 0.16%, Annual Incidence = 0.02%) • Costs and quality-adjusted life months discounted at 5% per annum. • Costs rounded to nearest 10€. • ICERs are for the general population and are rounded to nearest 1000€/QALY.

  13. Cost-Effectiveness of One-Time HIV Screening in Different Regions <0.005 Infarmed Threshold 0.005-0.009 WHO CE Threshold 0.010-0.020 >WHO Threshold >0.020 CE of Regional One-Time Screening 2010 Annual Incidence (%) CE of National One-Time Screening

  14. Cost-Effectiveness of HIV Screening Every Three Years in Different Regions <0.005 Infarmed Threshold 0.005-0.009 WHO CE Threshold 0.010-0.020 >WHO Threshold >0.020 CE of Regional Screening Every Three Years 2010 Annual Incidence (%) CE of National Screening Every 3 Years

  15. One-Way Sensitivity Analyses on CE of National, One-Time, Routine Screening WHO Threshold Base Case Infarmed Threshold HIV test cost (5.4€-42.7€) Linkage to care rate (100%-15%) Mean CD4 at care initiation (255 cells/µL-350 cells/µL) First-line ART Costs (512€-732€) Mean population age (37.6y-42.6y) Test acceptance rate (100%-25%) Cost-effectiveness Ratio (€/QALY)

  16. Risk Group Results - MSM (Undiagnosed Prevalence = 3.34%, Annual Incidence = 0.04%) • Costs and quality-adjusted life months discounted at 5% per annum. • Costs rounded to nearest 10€. • ICERs are for the general population and are rounded to nearest 1000€/QALY. • “dominated”: costs more and confers fewer QALYs than an alternative strategy.

  17. Risk Group Results - IDU (Undiagnosed Prevalence = 6.69%, Annual Incidence = 0.09%) • Costs and quality-adjusted life months discounted at 5% per annum. • Costs rounded to nearest 10€. • ICERs are for the general population and are rounded to nearest 1000€/QALY. • “dominated”: costs more and confers fewer QALYs than an alternative strategy.

  18. Limitations • A simulation model of HIV screening and disease that combines input data from disparate sources and relies on multiple assumptions. • Impact of expended HIV screening on disease transmission was not considered. • “Cost-effective” ≠ “Affordable”. Budget impact analysis will be a useful next step to understand effects on individual stakeholders.

  19. Summary and Conclusion • Overall, one-time screening of the national Portuguese population: • is “borderline cost-effective” by informal Portuguese national standards • is cost-effective by WHO standards. • Given the economic crisis as well as the higher disease burden in certain regions, we recommend initiating routine screening in high-prevalence regions first. • More frequent HIV screening may be considered in both high-risk populations (IDUs, MSM) and high-prevalence regions.

  20. Acknowledgments Harvard Medical School Kenneth A. Freedberg Elena Losina Rochelle P. Walensky Farzad Noubary Madeline A. DiLorenzo Ji-Eun Park Yale School of Medicine A. David Paltiel Hôpital Bichat – U. Paris Diderot Yazdan Yazdanpanah Funding sources: Coordenação Nacional para a Infecção VIH/SIDA, Agence nationale de recherche sur le SIDA et les hépatites virales, National Institute of Allergy and Infectious Diseases, National Institute of Mental Health, National Institute on Drug Abuse. Escola Nacional de Saúde Pública – UNL Julian Perelman Joana Alves Céu Mateus João Pereira Instituto de Saúde Pública – U. do Porto Henrique Barros NHS hospitals - Portugal Kamal Mansinho, Ana Cláudia Miranda (CH Lisboa Ocidental) Francisco Antunes, Manuela Doroana (CH Lisboa Norte) Rui Marques (H São João) José Saraiva da Cunha, Joaquim Oliveira (HUC) José Poças (CH Setubal) Eugénio Teófilo (CH Lisboa Central)

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