Potential Impact of Routinely Offering

HIV Screening at Auckland DHB

Chris Hopkins, Judy Gilmour, Suzanne Werder,

Murray Reid, Simon Briggs

Auckland District Health Board

Tonya

• 48yo caterer, partner & mother

• Months/years of various health problems.

• 7 attendances in the last 18mths to Auckland

DHB services, plus numerous GP visits.

• Worsening breathlessness for weeks.

• Admitted to Auckland City Hospital:

• Diagnosed with Pneumocystis Pneumonia

• HIV test POSITIVE

• Deteriorated despite treatment on ICU

• Passed away

Introduction

n 50% of new HIV diagnoses in NZ are late, and 32% have

advanced HIV disease.

n CDC recommends routine offer of HIV screening to all

adults ≤65 at all healthcare interactions.

n Earlier diagnosis leads to better outcomes

& reduced

transmission.

1. Dickson NP et al. HIV Med 2012;13:182-189

2. Branson BM et al. MMWR Recomm Rep 2006;22;55(RR-14):1-17

3. Nakagawa F, May M & Phillips A. Curr Opin Infect Dis 2013;26:17

4. Cohen MS, Chen YQ & McCauley M et al. N Engl J Med 2011;365:493-505

Aim

n Screen all ADHB-resident adults (15-65y) diagnosed with

HIV between Jan 2007 – Dec 2013.

n Identify those who could have been diagnosed earlier if

screening had been offered at a previous ADHB attendance.

n Estimate costs associated with screening all patients

attending ADHB services.

n Model cost savings from earlier diagnosis:

n HIV-related complications

n Reduction in transmissions

n Hypothesis:- A routine offer of HIV screening will be

cost neutral to implement.

Transmissions

(potentially

avoidable)

DIAGNOSIS

Undiagnosed infection

From prior negative test, or estimated

from CD4 at diagnosis*:

≤199



7 years

200-349



5 years

350-499



3 years

≥500



1 year

Any ADHB attendances?

(missed opportunities for

earlier diagnosis)

6 months

ADHB attendances due to HIV

-related complications

(potentially avoidable costs)

Method

* Lodi S et al (for the CASCADE investigators). Clin Infect Dis 2011;53:817-25.

Results

New

Diagnosis

= 201

Missed Opportunity

= 68 (34%)

No Opportunity

= 133 (66%)

Baseline

Characteristics

Missed

Opportunity

(n=68)

No Opportunity

(n = 133)

Number % Number %

Age

Median 38 36 0.32

Range 18-67 18-64

Gender

Male 62 91% 122 92% 1

Transmission risk factor

MSM 46 68% 109 82%

0.01

Hetero M 14 21% 13 10%

Hetero F 5 7% 11 8%

IVDU 3 4% 0 0%

Ethnicity

NZE 30 44% 55 42%

0.40

Asian 14 21% 24 18%

Maori 8 12% 10 8%

African 6 9% 19 14%

European 5 7% 11 8%

Pacific 5 7% 7 5%

Other / NA 0 0% 7 5%

CD4 at diagnosis

≤199 24 35% 16 12%

<0.001

200-349 13 19% 28 21%

350-499 14 21% 33 25%

≥500 17 25% 56 42%

Estimated time since infection (years)

5 3

<0.001

2007 2008 2009 2010 2011 2012 2013

Year of diagnosis

New Diagnosis

Missed Opportunity

Missed Opportunities

ADHB Attendances

CADS

100

120

Transmission

Risk Factor

Number of

patients

Months of potential

earlier diagnosis

MSM 46 1166

Hetero M 14 311

Hetero F 5 53

IVDU 3 38

TOTAL 68 1568

(median 12;

range 1-84)

Departments (OP & IP):

Anaes, Cardio, Diab, Gastro, Gen Med, Gen Surg, Gynae, ID,

Obstetrics, Ophth, Oral Health, ORL, Ortho, Resp, Rheum, Urol

Transmissions

n Problems with modelling:

n Assumptions

n Estimates from other studies

n Wide range of estimates

n Conservative

n Only for MSM

Potentially

avoidable

transmissions:

Australian data USA data

19.9 6

Cost/Benefit analysis

Costs of Screening for 7 years

HIV tests (EIAs)

(210 239 @ $17.71 each)

$ 3,723,000

HIV viral loads for false positives

(124 @ $362.97 each)

$ 45,000

Cost of ART for patients who are diagnosed earlier

(130 years of treatment @ $11,500 per year)

$ 1,495,000

Total cost (over 7 years) $ 5,263,000

Costs Saved by Screening

Cost of HIV-related illnesses avoided:

• Inpatient admissions

• Outpatient clinic visits

$ 279,000

$ 7,900

Total cost of ART avoided (↓transmission)

$11,526 per year x (708 or 214) years

+ $ 8,165,000

(Australian data)

$ 2,416,000

(USA data)

Total cost saved =

$ 8,452,000 $ 2,748,000

Potential Grand Total Cost

(conservative estimate)

- $ 3,189,000

OR + $ 2,515,000

Additional Benefits

n Normalisation of testing

n Reducing stigma

n Raise awareness of testing

n Personal/social/productivity benefits of earlier diagnosis and

reduced transmissions

n One part of the overall strategy to end HIV transmission

Discussion

n Conservative estimates at all

stages of modelling.

n Most of the underlying patient

& cost data is robust.

n This is the only method to

estimate cost-effectiveness.

n First study of its kind in NZ.

n Modelling relies on numerous

assumptions & estimates.

n Transmission modelling was only

for MSM.

n Assumes everyone will be offered

& accept a single test.

n Undiagnosed people are not

included in the study.

n Costs & savings are not

experienced by the same

stakeholder at the same time.

n Costs are likely to change.

n Only applies to ADHB population.

n Does not account for long-term

effects on HIV incidence.

Strengths Limitations

Conclusions

n A universal offer of HIV screening to ADHB residents

attending all ADHB services could result in…

n Earlier diagnosis in 30% of new diagnoses, at a median of 12

months earlier.

n Approx 1 - 3 transmissions avoided per year of screening.

n Many additional non-financial benefits.

n Screening 70% of the total adult ADHB population.

n Uncertain cost-benefit due to uncertainty in transmissions.

Our modelling study supports introducing a trial of a

universal offer of HIV screening to ADHB residents

attending adult ADHB services.

Acknowledgements

n The Earlier Diagnosis team:

n Simon Briggs

n Murray Reid

n Judy Gilmour

n Suzanne Werder

n Finance department & Data

Analysts:

n Marissa Gordon

n Rochelle Jarvis

n Patrick Firkin

n Raksha Kumar

n Daniel Gurrung-Diaz

n Martin Thomas.