Feedback from HIV Europe France: The new recommendation from the French National Authority for Health D Costagliola U943 INSERM and Universite Pierre et.

Feedback from HIV Europe France:

The new recommendation fromthe French National Authority for

Health

D Costagliola

U943 INSERM and Universite Pierre et Marie Curie

Objective

• To assess whether change in strategies and organization of screening was necessary

Method• Systematic literature search and critical review on

– Screening and counselling benefit– Targeted screening– Clinical benefit – Acceptability of screening– Efficiency of general population screening

• Modelling the cost-effectiveness and clinical impact of routine HIV screening in France – Done by Yazdan Yazdanpanah, with InVS, CRESGE, HAS

associated with INSERM U943, Partners AIDS Research Center from Harvard Medical School and the Yale School of Public Health)

• Discussion within a working group including 22 health professionals, researchers and NGO and critical review of the recommendation by an independent group including the different categories of people (n=47)

Background 1

• In France, roughly 40,000 of the estimated 113,000 – 141,000 people currently infected with HIV remain unaware of their infection (2007 estimates)

Background 2: Access to care with advanced HIV disease in France

FHDH ANRS CO4, 2009

Background 3: Excess death risk in patients with advanced HIV disease when

accessing care

Lanoy, AVT 2007

Background 4

• In the era of lifesaving antiretroviral therapy (ART), effective prevention counselling and early detection can reduce the burden of HIV at the individual and population levels

ROUTINE HIV SCREENING IN FRANCE: CLINICAL IMPACT AND COST-EFFECTIVENESS

Yazdan Yazdanpanah, Caroline E. Sloan, Cécile Charlois-Ou, Stéphane Le Vu, Caroline Semaille, Dominique Costagliola,

Anne-Isabelle Poullié, Olivier Scémama, Sylvie Deuffic-Burban, Elena Losina, Rochelle P. Walensky, Kenneth A.

Freedberg, A. David PaltielCentre Hospitalier de Tourcoing, EA 2694, Institut de Veille Sanitaire, U943 INSERM, Université Pierre et Marie Curie, Haute Autorité de Santé, and INSERM U795, France; Massachusetts General Hospital, Boston University School of Public Health,

and Brigham and Women’s Hospital, Boston, MA; Yale University School of Medicine, New Haven, CTSupported by the Haute Autorité de Santé, the Institut de Veille Sanitaire, Sidaction, the National Institute of Allergy and

Infectious Diseases (R37 AI042006, P30 AI42851, and K24 AI062476), the National Institute of Mental Health (R01 MH65869) and the Doris Duke Charitable Foundation Clinical Scientist Development Award.

Presented at ICAAC, 2009

Objective

• To estimate the life-expectancy, costs and cost-effectiveness associated with routine, voluntary HIV counseling, testing and referral (CTR)

– in the French general population

– and certain sub-populations, including

• MSMs, IDUs and the population of French Guyana

Analytic framework 1

• We used a widely published Monte Carlo simulation of HIV acquisition, detection and care to examine the impact of routine HIV CTR in France, compared to current risk-factor-based screening practices

• 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

Analytic framework 2• We evaluated routine HIV CTR once, every five

years, and annually in adults ages 18-69 years• We evaluated outcomes (life-expectancy, quality-

adjusted life expectancy, cost and cost-effectiveness) from the societal perspective, using a 3% annual discount rate. Cost-effectiveness was defined as value in 2007 € per quality-adjusted life-year (QALY) gained

• We assumed ART had a moderately favorable effect on transmission

• We used sensitivity analysis to examine the stability of results to changes in input parameters

Input data

Base casePerformance of routine screening in the general French population

Variable Current practice

Current practice and screen once

Current practice and screen every 5 years

Current practice and screen annually

Time from HIV infection to diagnosis, months 24 22 18 9 Mean CD4 count at detection, cells/ μl 370 379 400 444 HIV infections detected at presentation with AI , %DS 25 23 17 9 HIV cases Mean discou nted quality-adjusted surviva ,l QALM 242.81 244.12 245.13 246.35

MeanΔ in numbe r of 2º HI V cases (10 y ) earscompared to current practic ,e % -- -7.7 -10.5 -17.9

Population † Mean undiscounted survival, months 479.56 479.57 479.59 479.61 Mean discou nted quality-adjusted surviva ,l QALM 268.77 268.78 268.78 268.76 Mean discou nted lifetime co sts per person, 2007 € 1,360 1,420 1,570 2,220 Incremental cost-effectiveness -- 95,100 934,800 Dominat *ed QAL : M quality-adju sted life-month; QALY: quality-adjusted life-year * A dominated strategy has a higher cost and an equal or lo wer quality-adjusted lif e expectancy than s ome combination of other strategi .es † Population results include added costs and life expectancy losses assoc iatedw ith sec .ondary HIV cases

Sensitivity analysis 1

5.0%

Base case

Effect of prevalence on the cost effectiveness one-time voluntary HIV CTR vs. current practice with base case incidence

Sensitivity analysis 2

• Among – IDUs (prevalence 6.2%; incidence 0.17/PY), – MSM (prevalence 1.7%; incidence 0.99/PY) – in French Guyana (prevalence 0.38%; incidence 0.30/PY),

• annual screening led to ICERs of – €53,300,– €73,400 and – €38,900/QALY compared to current practice

Limitations

• A simulation model of HIV screening and disease that combines input data from several sources and relies on multiple assumptions

• The prevalence of undiagnosed HIV is from a back calculation performed in 2000

• The estimated rate of background testing outside of the routine screening program is low. Higher estimates have an impact on results, but the rate of background testing is likely to decrease as routine HIV tests become increasingly available

Conclusions

• One-time universal routine HIV CTR reduces the delay between HIV infection and diagnosis, decreases the number of secondary infections, and has a cost-effectiveness ratio consistent with common screening interventions recommended in France. This strategy should be implemented throughout France

• In specific sub-populations with higher prevalence and incidence, annual routine HIV CTR is economically justifiable

• These strategies will only be successful if efforts to increase the acceptability of HIV screening and linkage to care are implemented

Main HAS recommendations 1• Systematic HIV screening proposal to all

people 15 to 70 years of age, in the absence of signs or symptoms and whatever the characteristics

• Based on the mobilization of GP and all Health professionals including community initiatives

• To evaluate this new strategy and the proportion of late diagnosis after 5 years

• To promote the benefit of the knowledge of the personal HIV status both at the individual and the population level and to change the opinion on the HIV diagnosis

Main HAS recommendations 2

• Targeted HIV screening every year for MSM, IDUs, heterosexual people from sub-Saharan Africa and Carribean region with multiple partners

• In addition to the actual screening strategy in people at risk

Main HAS recommendations 3

• Given the fact that in French Guyana the epidemic is generalized,– specific programs should be organized to

insure the test offer to all inhabitants once a year

Main HAS recommendations 4

• The screening proposal in the general population should be associated with the appropriate information in order– to get an informed consent and – To evaluate the capacity of the person to

understand the test result

• Outside this case, a targeted counselling should be offered dependent of the various contexts

Full recommendations

• Can be found (in French) at– www.has-sante.fr