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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

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

slide2

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

hiv care in portugal
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.
challenge economic fiscal crisis
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

regional disparities
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 (%)

slide6

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
slide7

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
slide10

Model Outcomes

  • Clinical (quality adjusted life years, or QALY)
  • Economic (per-person lifetime costs, 2010 €)
  • Incremental Cost-effectiveness (€/QALY)
slide11

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

slide12

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.
cost effectiveness of one time hiv screening in different regions
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

cost effectiveness of hiv screening every three years in different regions
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

one way sensitivity analyses on ce of national one time routine screening
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)

slide16

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.
slide17

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.
slide18

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.
slide19

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.
slide20

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)