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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 - PowerPoint PPT Presentation
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Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness
Yazdan Yazdanpanah, MDJulian Perelman, PhD
Joana AlvesKamal Mansinho, MDMadeline A. DiLorenzo
Ji-Eun ParkElena Losina, PhD
Rochelle P. Walensky, MD, MPHFarzad Noubary, PhDHenrique Barros, MD
Kenneth A. Freedberg, MD, MScA. David Paltiel, PhD, MBA
-0.4 -0.3 -0.2 -0.1 0 0 10 20 30 40
HIV Epidemiological Burden in Portugal
0 10 20 30 400.4% 0.3% 0.2% 0.1% 0%
2009 HIV Prevalence 2009 Incidence Per Million Population
Luxembourg
Italy
Ireland
Belgium
Switzerland
PortugalIceland
Spain
France
Austria
UKNetherlands
DenmarkSweden
Greece
GermanyFinland
Norway
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.
2010 GDP
Challenge: Economic / Fiscal Crisis
Source: Eurostat, ACSS
<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%
Regional Disparities
2010 Annual HIV Incidence (%)
< 0.0050.005 - 0.0090.010 - 0.020
> 0.020
2010 Undiagnosed HIV Prevalence (%)
< 0.050.05 - 0.090.10 - 0.20
> 0.20
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
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
Methods Overview
Variable Value Reference
Undiagnosed HIV prevalence
0.16% Portuguese National Institute of Health 2010;
Hammers & Philips, HIV Med, 2008
Annual incidence 0.02% INSA 2010
Test offer/acceptance rate 63.2% Assumption +Jauffret-Roustide, BEH, 2006
Linkage to care rate 78.4% Portuguese CAD Report, 2010
Mean CD4 at care initiation
292 cells/μL 2010 Survey at 3 Portuguese Hospitals
HIV rapid test cost 5.40€ Ordinance 839-A/2009
Cost of 1st Line ART (EFV + TDF/FTC)
732.05€ Portuguese Central Administration of the Health System, 2010
Selected Input Parameters
Variable Value Reference
Undiagnosed HIV prevalence
0.16% Portuguese National Institute of Health 2010;
Hammers & Philips, HIV Med, 2008
Annual incidence 0.02% INSA 2010
Test offer/acceptance rate 63.2% Assumption +Jauffret-Roustide, BEH, 2006
Linkage to care rate 78.4% Portuguese CAD Report, 2010
Mean CD4 at care initiation
292 cells/μL 2010 Survey at 3 Portuguese Hospitals
HIV rapid test cost 5.40€ Ordinance 839-A/2009
Cost of 1st Line ART (EFV + TDF/FTC)
732.05€ Portuguese Central Administration of the Health System, 2010
Selected Input Parameters
Model Outcomes
Clinical (quality adjusted life years, or QALY)
Economic (per-person lifetime costs, 2010 €)
Incremental Cost-effectiveness (€/QALY)
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
Benchmarks for Cost-Effectiveness in Portugal
Testing strategy
Quality-adjusted life months
HIV-infected1
Quality-adjusted life months
total population1Costs (€)1,2 ICER
(€/QALY) 3
Current practice 174.62 193.21 720 ---
Screen once 177.03 193.23 780 36,000
Screen every three years 179.28 193.26 870 53,000
Screen annually 181.07 193.27 980 75,000
Base Case Results For National Program(Undiagnosed Prevalence = 0.16%, Annual Incidence = 0.02%)
1. Costs and quality-adjusted life months discounted at 5% per annum.2. Costs rounded to nearest 10€.3. ICERs are for the general population and are rounded to nearest 1000€/QALY.
Cost-Effectiveness of One-Time HIV Screening in Different Regions
2010 Annual Incidence (%)
CE of National One-Time Screening
Infarmed Threshold
>WHO ThresholdWHO CE Threshold
0.005-0.009
>0.0200.010-0.020
<0.005
CE of Regional One-Time Screening
Cost-Effectiveness of HIV Screening Every Three Years in Different Regions
2010 Annual Incidence (%)
CE of National Screening Every 3 Years
Infarmed Threshold
>WHO ThresholdWHO CE Threshold
0.005-0.009
>0.0200.010-0.020
<0.005
CE of Regional Screening Every Three Years
One-Way Sensitivity Analyses on CE of National, One-Time, Routine Screening
25,000 30,000 35,000 40,000 45,000 50,000 55,000 60,000
Cost-effectiveness ratio (€/QALY)
HIV test cost (5.4€-42.7€)
Mean CD4 at care initiation(255 cells/µL-350 cells/µL)
Linkage to care rate(100%-15%)
Test acceptance rate(100%-25%)
Mean population age (37.6y-42.6y)
Infarmed Threshold
Base Case
WHO Threshold
Cost-effectiveness Ratio (€/QALY)
First-line ART Costs(512€-732€)
Testing strategy
Quality-adjusted life months
HIV-infected1
Quality-adjusted life months
total population1Costs (€)1,2 ICER
(€/QALY) 3
Current practice 132.85 185.74 6,720 ---
Screen once 138.96 186.03 7,500 33,000
Screen every three years 139.60 186.05 7,620 dominated*
Screen annually 141.10 186.12 7,880 48,000
Risk Group Results - MSM(Undiagnosed Prevalence = 3.34%, Annual Incidence = 0.04%)
1. Costs and quality-adjusted life months discounted at 5% per annum.2. Costs rounded to nearest 10€.3. ICERs are for the general population and are rounded to nearest 1000€/QALY.4. “dominated”: costs more and confers fewer QALYs than an alternative strategy.
Testing strategy
Quality-adjusted life months
HIV-infected1
Quality-adjusted life months
total population1Costs (€)1,2 ICER
(€/QALY) 3
Current practice 109.88 164.67 9,740 ---
Screen once 119.87 165.60 12,210 32,000
Screen every three years 122.98 165.88 13,070 36,000
Screen annually 126.58 166.21 14,080 36,000
1. Costs and quality-adjusted life months discounted at 5% per annum.2. Costs rounded to nearest 10€.3. ICERs are for the general population and are rounded to nearest 1000€/QALY.4. “dominated”: costs more and confers fewer QALYs than an alternative strategy.
Risk Group Results - IDU(Undiagnosed Prevalence = 6.69%, Annual Incidence = 0.09%)
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.
Limitations
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.
Escola Nacional de Saúde Pública – UNLJulian PerelmanJoana AlvesCéu MateusJoão Pereira
Instituto de Saúde Pública – U. do PortoHenrique Barros
NHS hospitals - PortugalKamal 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)
AcknowledgmentsHarvard Medical SchoolKenneth A. FreedbergElena LosinaRochelle P. WalenskyFarzad NoubaryMadeline A. DiLorenzoJi-Eun Park
Yale School of MedicineA. David Paltiel
Hôpital Bichat – U. Paris DiderotYazdan 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.
