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Research ArticleOriginal Research

The Cost-Effectiveness of Expanded Testing for Primary HIV Infection

Andrew Coco
The Annals of Family Medicine September 2005, 3 (5) 391-399; DOI: https://doi.org/10.1370/afm.375
Andrew Coco
MD, MS
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  • Figure 1.
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    Figure 1.

    Decision tree for cost-effectiveness of expanded testing for primary human immunodeficiency virus (HIV) infection showing outcomes for patients and partners.

  • Figure 2.
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    Figure 2.

    Probabilistic sensitivity analysis, p24 antigen EIA compared with no testing.

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    Figure 3.

    Probabilistic sensitivity analysis, HIV-1 RNA assay compared with p24 antigen EIA.

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    Table 1.

    Summary of Variables

    VariableBaseline EstimateRange Used in Sensitivity AnalysisSource
    EIA = enzyme immunosorbent assay; HIV = human immunodeficiency virus; PHI = primary HIV infection; CBC = complete blood count; G6PD = glucose-6-phosphate dehydrogenase; CMV = cytomegalovirus; RPR = rapid plasma reagin; PPD = purified protein derivative (tuberculin); NAAT = nucleic acid amplification test.
    * Initial battery of laboratory tests includes: CBC, chemistry panel, G6PD assay, toxoplasmosis titer, CMV titer, RPR, PPD skin test, viral hepatitis panel, lipid panel, urinalysis, chest radiograph, urine NAAT for gonorrhea and chlamydia.
    Costs ($)
        p24 antigen EIA24.6512.33–49.30Medicare fee schedule
        HIV-1 RNA assay118.8959.45–237.78Medicare fee schedule
        Third-generation HIV-1 EIA19.179.59–38.34Medicare fee schedule
        Western blot assay27.0513.53–54.10Medicare fee schedule
        CD4 cell count per microliter9045–180Medicare fee schedule
        Initial battery of laboratorys tests (new diagnosis)*254200–614Medicare fee schedule
        Expanded testing program costs101.4751–203MMWR20
        Discounted lifetime medical costs (diagnosed with PHI and antiretroviral therapy started at CD4 cell count of 350/μL)95,80047,900–191,600Freedberg et al23
        Discounted lifetime medical costs (PHI not diagnosed and antiretroviral therapy started when HIV diagnosed)88,10044,050–176,200Freedberg et al23
        Return visit52.5340–67.86Kaplan & Anderson24
    Test characteristics
        p24 antigen EIA, sensitivity0.8870.770–0.957Hecht et al,8 Daar et al9
        Specificity0.99960.9950–0.9999Hecht et al,8 Daar et al9
        HIV-1 RNA, sensitivity1.000—Hecht et al,8 Daar et al9
        Specificity0.9800.950–0.999Hecht et al,8 Daar et al9
        Third-generation HIV-1 EIA, sensitivity0.7900.600–0.920Hecht et al8
        Specificity0.9700.930–0.990Hecht et al8
        Probability of indeterminate Western blot0.000004—Kleinman et al22
    Prevalence factors (%)
        Patients lost to follow-up3116–62MMWR21
        Prevalence in screened population0.660.53–0.92Coco & Kleinhans16
        Sexual transmission factors
        Patients who change behavior to avoid infecting sexual partner500–96MMWR6
        Patients that are sexually active5025–85MMWR6
        Infectivity (probability of sexual transmission during PHI period)150–30Yerly et al,25 Pilcher et al26
    Utilities
        Asymptomatic HIV infection0.9370.926–0.949Schackman et al27
        Anxiety while waiting for confirmatory test results for patients with a positive screen0.6820.400–0.800Kaplan & Anderson24
    Quality-adjusted life-expectancy (discounted), years
        No PHI24—NCHS15
        Positive screening result, no PHI23.973523.950–23.983NCHS,15 Kaplan & Anderson24
        PHI diagnosed at screening with follow-up care and antiretroviral treatment started at CD4 cell count of 350/μL11.911.832–11.952Freedberg et al23
        PHI not diagnosed at screening or lost to care with antiretroviral treatment started when HIV diagnosed11—Freedberg et al23
    • View popup
    Table 2.

    Cost, Effectiveness, and Incremental Cost-Effectiveness of Expanded Testing for Primary HIV Infection of 3,030,303 Hypothetical Patients at a Prevalence of 0.66% With Third-Generation HIV-1 EIA, p24 Antigen EIA, and HIV-1 RNA Assay

    VariableNo TestingThird-Generation HIV-1 EIAp24 Antigen EIAHIV-1 RNA Assay
    Note: each column is compared with the one to the left.
    HIV = human immunodeficiency virus; EIA = enzyme immunosorbent assay; QALYs = quality-adjusted life-years.
    * Dominated means this option cost more and was less effective than other options.
    Cost (millions), $1,762.12,233.62,258.22,561.8
    Incremental cost (millions), $—471.524.6303.6
    Effectiveness (thousands) QALYs69,710.069,720.869,726.169,725.8
    Incremental effectiveness, QALYs—10,8005,300(300)
    Effectiveness, No.
        Primary HIV infection cases diagnosed—15,80317,05420,000
        Primary HIV infection cases lost to care (31% of those diagnosed)20,0004,8995,2876,200
        False-positive diagnoses—90,2571,12759,169
        False-negative diagnoses—2,9243,0120
        Cases avoided per behavior change403435501
    Cost-effectiveness, $
        Testing cost per case identified—29,83629,09039.985
        Incremental cost per quality-adjusted year of life gained—Dominated*30,800Dominated*
    • View popup
    Table 3.

    Changes in Incremental Cost per Quality-Adjusted Life-Year in Key 1-Way Sensitivity Analyses

    EIA = enzyme immunosorbent assay; HIV = human immunodeficiency virus; PHI = primary HIV infection.
    1. Doubling the cost of lifetime medical care for patients being observed to CD4 cell counts of 350/μL or seeking care at later stages of infection ($88,100/$95,800 to $176,050/$191,600) increased the cost of expanded testing with the p24 antigen EIA from $30,800 to $34,100 compared with no testing

    2. Doubling the expanded testing and counseling enrollment program costs ($101.47 to $203), increased the cost of the p24 antigen EIA testing option to $49,800 compared with no testing

    3. Increasing the specificity of the HIV-1 RNA assay (0.98 to 0.999) decreased the cost of the HIV-1 RNA assay option to $142,000 compared with the p24 antigen EIA option

    4. Assuming no benefit to sexual partners of patients with PHI, ie, no cases avoided through changes in behavior, increased the cost of the p24 antigen EIA to $50,600 when compared with no testing

Additional Files

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  • The Article in Brief

    The Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients

    By Andrew Coco, M.D., and colleague
    Background: Approximately 40,000 new cases of HIV infection are identified each year in the United States. Primary HIV infection refers to the early, flu-like symptoms associated with HIV disease. Diagnosis of Primary HIV is an opportunity to help prevent the disease from being transmitted. This study set out to estimate how many patients visiting the doctor�s office, emergency department, or hospital clinic for fever, rash, or sore throat have primary HIV infection.
    What this study found: Based on data from a large national survey, the study estimates that primary HIV infection would be found in 0.66 percent of patients complaining of fever, 0.56 percent of patients with rash, and 0.13 percent of patients with sore throat.
    Implications
    � This is the first study to estimate the rate of primary HIV infection.
    � The study results can help policy makers develop national guidelines for HIV testing.
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The Annals of Family Medicine: 3 (5)
The Annals of Family Medicine: 3 (5)
Vol. 3, Issue 5
1 Sep 2005
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The Cost-Effectiveness of Expanded Testing for Primary HIV Infection
Andrew Coco
The Annals of Family Medicine Sep 2005, 3 (5) 391-399; DOI: 10.1370/afm.375

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The Cost-Effectiveness of Expanded Testing for Primary HIV Infection
Andrew Coco
The Annals of Family Medicine Sep 2005, 3 (5) 391-399; DOI: 10.1370/afm.375
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