Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in Portugal Julian...

Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in

Portugal

Julian Perelman, Joana AlvesEscola Nacional de Saúde Pública

Universidade Nova de Lisboa

Research team

Harvard Medical SchoolKenneth Freedberg, MD, MScElena Losina, PhDRochelle Walensky, MD, MPHMadeline Di LorenzoJi-Eun Park

Yale School of Public HealthDavid Paltiel, PhD

University of LilleYazdan Yazdanpanah, MD, PhD

Escola Nacional de Saúde Pública – UNLJulian Perelman, PhDJoana Alves, MACéu Mateus, PhDJoão Pereira, PhD

NHS hospitals - PortugalKamal Mansinho, MD, and Ana Cláudia Miranda, MD (CH Lisboa Ocidental)Francisco Antunes, MD, PhD, and Manuela Doroana, MD (CH Lisboa Norte)Rui Marques, MD (H São João)José Saraiva da Cunha, MD, PhD, and Joaquim Oliveira, MD (HUC)José Poças, MD (CH Setubal)Eugénio Teófilo, MD (CH Lisboa Central)

A project commissioned by the Coordenação Nacional para a Infecção VIH/SIDA

Contribution of economic analysis

Resources are scarce• Choices must be made concerning their deployment• Using resources in one setting: opportunity costs• Economic evaluation of health care programs

Economic analysis makes explicit the efficiency criteria• Systematic comparison of costs and consequences• “Value for money”


Choice

Treatment A

Treatment B

COSTA

COSTB

CONSEQUENCESB

CONSEQUENCESA

Cost-effectiveness analysis links costs to a medical outcome: cost of achieving one additional unit of medical outcome, “cost per life-year

gained”, “cost per QALY”


Some examples for HIV/AIDS Cost/QALY

ZDV+3TC vs ZDV (Chancellor et al., 1997) £6,276

ZDV+3TC+ABC vs ZDV+3TC (Trueman et al., 2000) £10,254

HAART (2 NRTI + 1 PI) vs no treatment (Freedberg et al., 2001) $23,000

Personal risk assessment, counselling and education – gay and bissexual male adolescents (Tao et al., 1998)

$6,180

Condom distribution – national US population (Pinkerton et al., 1999)

Cost-saving

Antenatal HIV screening (Ades et al., 1999) <£10,000

Expansion methadone maintenance program - IV drug users(Zaric et al., 2000)

$10,900

Needle exchange program – IV drug users (Laufer et al., 2001)

$20,947/case avoided

Rationale for a new HIV testing strategy

Portugal

Situation 31/12/2010: 39,347 diagnosed cases

Diagnosed prevalence 18-69 yo: 0.48%

Estimated undiagnosed prevalence 18-69 yo: 0.21%

Europe

740,000 people living with HIV or AIDS

No decrease in HIV incidence in the recent past

Estimation: 30% undiagnosed cases

Source: European Commission - Public Health, 2010

Source: Health at a glance, OECD 2010

New cases per million, 2007

Source: Health at a glance, OECD 2010



Portugal France

Mean CD4 at care initiation

292 372

Viral load at care initiation

> 100,00042.10% 18.75%

30,0001 - 100,00023.71% 21.15%

10,001 - 30,00014.03% 15.19%

3,001 - 10,0008.22% 13.88%

501 - 3,0004.76% 11.19%

20-5004.76% 19.84%

< 202.41% 0.00%


Proposal of a new HIV testing strategy in Portugal

Testing at all health care settings as part of routine care

All population

Provider-initiated test (rapid test)

Counselling of positive cases and linkage to care

Voluntary (opting-out approach)

Confidentiality and anonymity

Voluntary provider-initiated HIV testing, counselling and referral(here-below “expanded testing”)


Proposal of a new HIV testing strategy in Portugal

Necessity to evaluate different strategies

All population versus high-risk groups

Whole country versus high-prevalence areas

Screen once versus every year versus every 3, 5 or 10 years

Screen at primary care centres versus emergency units

Research project: evaluate the cost-effectiveness of different expanded testing strategies in Portugal

Cost-effectiveness of expanded testing

Expanded testing

Higher cost of testing, counselling and referral

Earlier detection: Earlier treatment:

Lower viral replication Less drug-related AE Lower costs (?)

Higher life expectancy Better quality of life Lower rate of transmission

Background strategy

Lower cost of testing, counselling and referral

Later detection: Later treatment:

Higher costs (?) Lower efficacy

Lower life expectancy Lower quality of life Higher rate of transmission

Balancing costs and benefits


Other less documented and measurable issues:

• HIV as “normal” disease

• Costs of waiting and costs of knowing

• How the test is performed (versus opportunity of testing)

– Confidentiality and anonymity

– Counselling and referral

– Anti-discrimination laws


Widely published CEPAC* Monte Carlo simulation model of HIV acquisition/detection/care (see eg Paltiel et al., N Engl J

Med 2005) Examine the impact of expanded screening in Portugal,

compared to current risk-factor-based screening The model captures data on

HIV screening: HIV prevalence and incidence, test offer/acceptance rates, returns for test results, linkage to care, and HIV counseling and testing costs

HIV disease: incidence of opportunistic diseases, HIV treatment, mortality rates, and all associated costs and quality of life effects

*Cost-effectiveness of Preventing AIDS Complications

Acute Clinical Event

Death

Chronic HIVInfection

Primary HIVInfection

The CEPAC Int’l ModelFreedberg et al.Supported by NIAID



Inputs required to estimate the CE of HIV expanded testing in Portugal

Epidemiology of HIV: incidence/prevalence, undiagnosed prevalence,

CD4 and viral load at detection

Progression of disease and efficacy of treatments: international

literature

Treatment costs of HIV (by stage of disease), cost of testing and

counselling, prices of anti-retroviral and prophylaxis drugs

Behaviours: test acceptance and return rate, linkage to care, attitude

towards risk and transmission of disease

Treatment cost of HIV/AIDS in Portugal


Inputs for the CEPAC Model (1)


Inputs for the CEPAC Model (2)


Scenario Life months

Quality-adjusted life

months

Costs (€) 1

ICER (€/LY) 2

ICER (€/QALY) 2

Current practice 193.11 192,98 980 - -

Screen once 193.14 193.01 1,070 33,865 38,601

Screen every 5 years 193.16 193.02 1,150 46,531 51,818

Screen annually 193.19 193.05 1,320 62,769 80,632

Base Case Results (Costs and life expectancy discounted at 5%)

1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.

All population (undiagnosed prevalence 0.21%)


Scenario Life months

Quality-adjusted life

months

Costs (€) 1

ICER (€/LY) 2

ICER (€/QALY) 2

Current practice 192.86 192.63 1,820 - -

Screen once 192.92 192.68 1,990 32,937 37,309

Screen every 5 years 192.96 192.71 2,120 43,120 46,627

Screen annually 193.02 192.77 2,390 52,357 61,002

Base Case Results (Costs and life expectancy discounted at 5%)

1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.

Lisboa (undiagnosed prevalence 0.39%)


Cost-effectiveness of one-time expanded testing improves with higher

estimated undiagnosed prevalence

Lisboa 0.39%, Setúbal 0.33%, Porto 0.26%, Faro 0.26%

Highly cost-effective among high-risk groups (undiagnosed

prevalence >1%): MSM, IDUs

Additional preliminary results for IDUs: testing cost-effective every 5

years

Undiagnosed Prevalence Yearly Incidence


Cost-effectiveness of one-time HIV testing at different undiagnosed HIV prevalence values*

*Costs and life expectancy discounted at 5%

Test Acceptance (25%:75%)

Discount Rate (0%;5%)

Linkage to Care (25%;100%)

0 10,000 20,000 30,000 40,000 50,000 60,000

Incremental cost-effectiveness ratio (€/QALY)

Base CaseBase Case

Cost-effectiveness of screening strategies

Cost/QALY

Screening hypertension, asymptomatic men 20+ (Littenberg, Ann Intern Med 90)

$80,400

Colon cancer, FOBT + SIG q5y, adults 50-85 (Frazier, JAMA 2000)

$57,700

Biennal breast cancer screening, women 50-69Biennal breast cancer screening, women 40-49 (Salzmann, Ann

Intern Med 1997) (Salzmann, Ann Intern Med 1997)

$21,400/LYG$105,000/LYG

HPV vaccine at 12 and cytologic screening every 3y after 25 (Goldie, Journal Nacional Cancer Institute, 2004)

$58,500


Main limitations

Disease transmission not accounted for. US results:

37,100$/QALY without transmission effect

30,800$/QALY with transmission effect

Uncertainty for undiagnosed prevalence & incidence

Use international published literature for quality of life

Use data for specific settings: emergency rooms

Implicações para a tomada de decisão

Valores razoáveis para um rastreio único e alargado, proposto pelo

médico, acompanhado de aconselhamento e referenciação

Valores aceitáveis para populações e regiões alvo

IDUs de 5 em 5 anos

MSM

Regiões de alta prevalência: Lisboa, Setúbal, Porto, Faro

Características do teste alargado

Teste único e teste rápido

‘Opting-out’ e aconselhamento limitado a seropositivos

Centros de saúde, internamentos e urgências

Estimativas para o grupo 18-69 anos

Implicações para a tomada de decisão

O que poderia ainda melhorar o custo-efectividade?

Ter em conta a questão da transmissão

Diminuição dos preços da medicação ART e teste

confirmatório

Melhor referenciação

International: US recommendations

Source: CDC Recommendations 2006, Morbidity and Mortality Weekly Report, 22/9/2006, vol. 55, RR-14

International: French recommendations

Source: Dépistage de l’infection VIH en France, Recommendations en Santé Publique, Haute Autorité de Santé, October 2009.

International: 3-country comparison

Portugal France USA

Undiagnosed prevalence

0.00210 0.00098 0.000768

Cost comparison

CD4 test 36.20€ 21.60€ 48.57€

Viral load test 51.00€ 59.40€ 87.97€

Confirmation test 99.50€ 53.10€ 23.68€

Counselling 31.00€ 22.00€ 8.14€

International: 3-country comparison

Line Portugal France USA

1. EFV + TDF/FTC 732.05 € 745.85 € 1,058.32 €

2. ATV/r + TDF/FTC 1,025.04 € 927.99 € 1,518.05 €

3. LPV/r + TDF/FTC + AZT 1,191.04 € 1,118.93 € 1,507.29 €

4a. RAL + OBR (2 NRTIs) + DRV/r - with truvada 2,086.11 €1,999.79 €

1,946.92 €

4b. RAL + OBR (2 NRTIs) + DRV/r - with kivexa 1,942.40 €

5a.i. ENF + OBR (DRV/r + 2NRTIs) - with truvada 2,758.03 €2,496.54 €

2,963.13 €

5a.ii. ENF + OBR (DRV/r + 2NRTIs) - with kivexa 2,614.32 €

5b. MVC + OBR (1 PI/r + 2NRTIs) +/- ENF - with trivuda 2,865.50 €2,384.02 €

5b. MVC + OBR (1 PI/r + 2NRTIs) +/- ENF- with kivexa 2,721.79 €

6a. OBR (1 PI/r + 2NRTIs) - with trivuda 1,933.61 €1,191.47 €

1,288.53 €

6b. OBR (1 PI/r + 2NRTIs) - with kivexa 1,789.90 €

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