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Cost-Effectiveness of HIV Screening in Patients Older than 55 Years of Age

Gillian D. Sanders, PhD; Ahmed M. Bayoumi, MD, MSc; Mark Holodniy, MD; and Douglas K. Owens, MD, MS
[+] Article and Author Information

Disclaimer: The views expressed in this publication are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care.

Grant Support: This research is supported in part by the Department of Veterans Affairs, the National Institute on Drug Abuse (R01 DA15612-01); the National Institute of Aging through the Stanford Center on the Demography and Economics of Health and Aging (P30-AG017253); the Ontario HIV Treatment Network; and the Ontario Ministry of Health and Long-Term Care.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol: Available from Dr. Sanders (e-mail, mailto:gillian.sanders@duke.edu). Statistical code: Not available. Data set: Available from Dr. Sanders (e-mail, mailto:gillian.sanders@duke.edu).

Requests for Single Reprints: Gillian D. Sanders, PhD, Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715; e-mail, mailto:gillian.sanders@duke.edu.

Current Author Addresses: Dr. Sanders: Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715.

Dr. Bayoumi: Centre for Research on Inner City Health, St. Michael's Hospital, 30 Bond Street, Toronto, M5B 1W8 Ontario, Canada.

Dr. Holodniy: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304.

Dr. Owens: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.

Author Contributions: Conception and design: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Analysis and interpretation of the data: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Drafting of the article: G.D. Sanders, D.K. Owens.

Critical revision of the article for important intellectual content: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Final approval of the article: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Statistical expertise: G.D. Sanders, A.M. Bayoumi.

Obtaining of funding: D.K. Owens.

Collection and assembly of data: G.D. Sanders, A.M. Bayoumi, M. Holodniy.


From Duke Clinical Research Institute, Durham, North Carolina; St. Michael's Hospital, Toronto, Ontario, Canada; Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Stanford University School of Medicine, Stanford, California.


Ann Intern Med. 2008;148(12):889-903. doi:10.7326/0003-4819-148-12-200806170-00002
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Background: Although HIV infection is more prevalent in people younger than age 45 years, a substantial number of infections occur in older persons. Recent guidelines recommend HIV screening in patients age 13 to 64 years. The cost-effectiveness of HIV screening in patients age 55 to 75 years is uncertain.

Objective: To examine the costs and benefits of HIV screening in patients age 55 to 75 years.

Design: Markov model.

Data Sources: Derived from the literature.

Target Population: Patients age 55 to 75 years with unknown HIV status.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: HIV screening program for patients age 55 to 75 years compared with current practice.

Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.

Results of Base-Case Analysis: For a 65-year-old patient, HIV screening using traditional counseling costs $55 440 per QALY compared with current practice when the prevalence of HIV was 0.5% and the patient did not have a sexual partner at risk. In sexually active patients, the incremental cost-effectiveness ratio was $30 020 per QALY. At a prevalence of 0.1%, HIV screening cost less than $60 000 per QALY for patients younger than age 75 years with a partner at risk if less costly streamlined counseling is used.

Results of Sensitivity Analysis: Cost-effectiveness of HIV screening depended on HIV prevalence, age of the patient, counseling costs, and whether the patient was sexually active. Sensitivity analyses with other variables did not change the results substantially.

Limitations: The effects of age on the toxicity and efficacy of highly active antiretroviral therapy and death from AIDS were uncertain. Sensitivity analyses exploring these variables did not qualitatively affect the results.

Conclusion: If the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 years reaches conventional levels of cost-effectiveness when counseling is streamlined and if the screened patient has a partner at risk. Screening patients with advanced age for HIV is economically attractive in many circumstances.

Figures

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Figure 1.
The Markov model.

The square node at the left represents the decision to screen or not to screen for HIV. The patient's health thereafter is simulated by a Markov model shown on the right. Patients may enter the model with prevalent HIV infection (asymptomatic or symptomatic HIV or AIDS) or they may not be infected. Each month, patients who are not infected are at risk for HIV infection. Patients who have asymptomatic disease may progress to symptomatic HIV or remain in the asymptomatic health state. Patients who have symptomatic HIV infection may progress to an AIDS-defining condition or remain with symptomatic HIV. Patients with AIDS may either die of infection or remain with AIDS. Each month, all patients may be identified either through a voluntary screening program in the HIV screening group or through symptom-based case findings in the symptomatic HIV and AIDS health states in both the HIV screening group and the no-screening group. Throughout the patients' lifetime, all patients are at risk for non–HIV-related death. Health states are further characterized by viral load level, CD4 count, and antiretroviral treatment history (not shown). HAART = highly active antiretroviral therapy.

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Figure 2.
Effect of early identification of HIV infection on life expectancy.

The solid line represents the effect on undiscounted life expectancy and the dotted line represents the effect on undiscounted quality-adjusted life expectancy of identifying asymptomatic HIV infection compared with symptom-based case findings.

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Figure 3.
Incremental cost-effectiveness of HIV screening in patients older than age 55 years who receive traditional counseling.

QALY = quality-adjusted life-year. Top. Patients with a sexual partner at risk. Bottom. Patients without a partner at risk. Each part represents the incremental cost-effectiveness of HIV screening (assuming implementation of traditional counseling) compared with current practice for patients of varying ages with differing underlying prevalence of unidentified HIV. The dashed-and-dotted line indicates a cost-effectiveness threshold of $50 000 and $100 000 per QALY.

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Figure 4.
Incremental cost-effectiveness of HIV screening in patients older than age 55 years who receive streamlined counseling.

QALY = quality-adjusted life-year. Top. Patients with a sexual partner at risk. Bottom. Patients without a partner at risk. Each part represents the incremental cost-effectiveness of HIV screening (assuming implementation of streamlined counseling) compared with current practice for patients of varying ages with differing underlying prevalence of unidentified HIV. The dashed-and-dotted line indicates a cost-effectiveness threshold of $50 000 and $100 000 per QALY.

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Appendix Figure 1.
Effect of screening frequency on the incremental cost-effectiveness of screening at various HIV incidence rates.

The solid line marked with solid circles represents the baseline incidence, the dotted line marked with solid squares represents the cost-effectiveness of recurrent screening when the incidence of HIV is twice the baseline rate, and the dashed line marked with solid triangles represents the cost-effectiveness of recurrent screening when the incidence of HIV is 3 times the baseline rate.

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Appendix Figure 2.
Cost-effectiveness acceptability curve of HIV screening, assuming traditional counseling.
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Appendix Figure 3.
Cost-effectiveness acceptability curve of HIV screening, assuming streamlined counseling.
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