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Analysis of the Cost of an HIV Rapid Testing Initiative

The benefits of identifying and treating asymptomatic Human Immunodeficiency Virus (HIV)-infected individuals substantially exceed those of early recognition of most medical conditions. Routine HIV testing is of particular importance to the VA, the largest provider of HIV services in the United States. Nevertheless, in the VA, as in many other health care systems, 50 percent of HIV-infected patients are diagnosed after they have developed severe immunological damage.

Among the deterrents to promoting early routine HIV testing is that reliance on standard blood tests requires that patients receive their test results at a later date; this can present a considerable barrier for homeless and transient patients. To address this barrier, QUERI-HIV/Hepatitis has undertaken a series of studies to evaluate the utility of same-day, oral fluid-based HIV rapid testing programs. One such study, which was conducted in a primary care clinic setting, demonstrated increased patient satisfaction and receipt of test results with nurse-based offer and performance of HIV rapid tests as opposed to traditional physician-ordered, blood-based HIV testing.

Economic Impact of HIV Rapid Testing

To assess the economic impacts of rapid testing, we conducted two separate complementary Cost-Effectiveness and Business Case Model (BCM, also referred to as Budget Impact Analysis) analyses. Whereas cost-effectiveness analyses consider the long-term (i.e., over a patient's lifetime) financial and health impacts of an intervention from a health care system or societal perspective, BCM analyses evaluate the near-term financial costs of program implementation. ¹

Even for programs that reduce costs (i.e., are cost saving), the savings are usually over a period of many years and the immediate implementation costs may overshadow short-term savings. This temporal financial mismatch is magnified for programs that are cost-effective rather than cost saving. Consequently, both Cost-Effectiveness and Business Case Models are necessary to appropriately estimate short-term and long-term financial impact.

Following this paradigm, we first conducted a cost-effectiveness analysis of the long-term financial and health impacts of nurse-based HIV rapid testing as opposed to physician-ordered traditional blood-based HIV testing. This evaluation built upon previous analyses that demonstrated that routine blood-based HIV testing is costeffective on a societal basis at the $50,000/ QALY threshold for populations where the prevalence of undiagnosed HIV infection is greater than 0.05 percent. In analyses that considered the time spent for pre-test counseling, test performance and post-test counseling, laboratory supplies, and the care of persons found to be HIV-infected, we found that compared with the blood-based testing, the incremental cost of nurse-based rapid testing was $10,689/QALY when societal benefits were considered.²

More recently, we developed a BCM to compare the financial impact of routinely offering rapid HIV tests during non-peak hours in a VA Emergency Department (ED) versus offering diagnostic testing only for patients presenting with symptoms suggestive of HIV infection (as is usual ED practice). We estimated the number of people who would be identified as HIV-infected through routine rapid testing, the start-up and maintenance costs of the rapid test program, and diagnostic and treatment costs for HIV-infected patients identified by rapid testing. We then compared these costs to the expenses incurred by patients identified as being HIV-infected at later stages of disease through routine practice.

Using base case data from a single VA ED, we found that a rapid test program that makes use of ED capacity during non-peak hours was not more costly than usual ED practice. This result is likely due to the high costs of care of patients who present with late stage disease when current practice is followed. Given that early detection of HIV and linkage to treatment is associated with better health outcomes, and that the rapid test program does not cost more than current practice, this budget impact analysis provides support for the implementation of HIV rapid testing programs in VA EDs.³

Conclusion

Often, long-term cost-effectiveness assessments are used to establish the value of an initiative such as routine HIV testing. However, even when the long-term value of a program is clear, the realities of implementation in the near-term can create significant barriers for acceptance. Effective BCM assesses the short-term costs and benefits to evaluate the consequences of implementing new initiatives.

References

1. Mauskopf JA, Sullivan SD, Annemans L, et al. Principles of Good Practice for Budget Impact Analysis: Report of the ISPOR Task Force on Good Research Practices - Budget Impact Analysis. Value Health 2007; 10:336-47.
2. Sanders GD, Anaya H, Asch S, et al. Cost Effectiveness of Rapid HIV Testing with Streamlined Counseling 2007; Sydney, Australia; July 22-25, 2007.
3. Gidwani R, Goetz MB, Needleman J, et al. Development of Business Case Methodology Using VA Data: Implications for QUERI Research Projects. VA HSR&D Annual Meeting 2009; Baltimore, MD.