Routine HIV Screening in Portugal: Clinical Impact and Cost-Effectiveness Yazdan Yazdanpanah, MD Julian Perelman, PhD Joana Alves Kamal Mansinho, MD Madeline.

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

-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

Portugal

Iceland

Spain

France

Austria

UK

Netherlands

Denmark

Sweden

Greece

Germany

Finland

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 population1

Costs (€)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 population1

Costs (€)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 population1

Costs (€)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.