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

1. Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in Portugal Julian Perelman, Joana Alves Escola Nacional de Saúde Pública Universidade Nova de Lisboa

2. Research team A project commissioned by the Coordenação Nacional para a Infecção VIH/SIDA Harvard Medical School Kenneth Freedberg, MD, MSc Elena Losina, PhD Rochelle Walensky, MD, MPH Madeline Di Lorenzo Ji-Eun Park Yale School of Public Health David Paltiel, PhD University of Lille YazdanYazdanpanah, MD, PhD Escola Nacional de Saúde Pública – UNL Julian Perelman, PhD Joana Alves, MA Céu Mateus, PhD João Pereira, PhD NHS hospitals - Portugal Kamal 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)

3. 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”

4. Contribution of economic analysis COSTA Treatment A CONSEQUENCESA Choice COSTB Treatment B CONSEQUENCESB 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”

5. Contribution of economic analysis

6. 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

7. Source: European Commission - Public Health, 2010

8. Source: Health at a glance, OECD 2010 New cases per million, 2007

9. Rationale for a new HIV testing strategy Source: Health at a glance, OECD 2010

10. Rationale for a new HIV testing strategy

11. Rationale for a new HIV testing strategy 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”)

12. Rationale for a new HIV testing strategy 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

13. Cost-effectiveness of expanded testing Balancing costs and benefits 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

14. Cost-effectiveness of expanded testing 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

15. Cost-effectiveness of expanded testing • Widely published CEPAC* Monte Carlo simulation model of HIV acquisition/detection/care (see egPaltiel 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

16. Cost-effectiveness of expanded testing Primary HIV Infection Chronic HIV Infection Acute Clinical Event Death The CEPAC Int’l Model Freedberg et al. Supported by NIAID

17. Cost-effectiveness of expanded testing 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

18. Treatment cost of HIV/AIDS in Portugal

19. Cost-effectiveness of expanded testing Inputs for the CEPAC Model (1)

20. Cost-effectiveness of expanded testing Inputs for the CEPAC Model (2)

21. Cost-effectiveness of expanded testing Base Case Results (Costs and life expectancy discounted at 5%) All population (undiagnosed prevalence 0.21%) 1. Costs rounded to nearest 10€. 2. ICERs rounded to nearest €/LY or €/QALY.

22. Cost-effectiveness of expanded testing Base Case Results (Costs and life expectancy discounted at 5%) Lisboa (undiagnosed prevalence 0.39%) 1. Costs rounded to nearest 10€. 2. ICERs rounded to nearest €/LY or €/QALY.

23. Cost-effectiveness of expanded testing 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

24. Undiagnosed Prevalence Yearly Incidence

25. Cost-effectiveness of expanded testing Cost-effectiveness of one-time HIV testing at different undiagnosed HIV prevalence values* Base Case *Costs and life expectancy discounted at 5%

26. Cost-effectiveness of screening strategies

27. Cost-effectiveness of expanded testing 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

28. Implicaçõespara 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

29. Implicaçõespara a tomada de decisão • O quepoderiaaindamelhorar o custo-efectividade? • Teremconta a questão da transmissão • Diminuição dos preços da medicação ART e testeconfirmatório • Melhorreferenciação

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

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

32. International: 3-country comparison

33. International: 3-country comparison