The Cost-Effectiveness of Early Access to HIV Services and Starting cART in the UK 1996–2008

To calculate use, cost and cost-effectiveness of people living with HIV (PLHIV) starting routine treatment and care before starting combination antiretroviral therapy (cART) and PLHIV starting first-line 2NRTIs+NNRTI or 2NRTIs+PI(boosted), comparing PLHIV with CD4≤200 cells/mm3 and CD4>200 cells/mm3. Few studies have calculated the use, cost and cost-effectiveness of routine treatment and care before starting cART and starting cART above and below CD4 200 cells/mm3.Use, costs and cost-effectiveness were calculated for PLHIV in routine pre-cART and starting first-line cART, comparing CD4≤200 cells/mm3 with CD4>200 cells/mm3 (2008 UK prices).cART naïve patients CD4≤200 cells/mm3 had an annual cost of £6,407 (95%CI £6,382 to £6,425) PPY compared with £2,758 (95%CI £2,752 to £2,761) PPY for those with CD4>200 cells/mm3; cost per life year gained of pre-cART treatment and care for those with CD4>200 cells/mm3 was £1,776 (cost-saving to £2,752). Annual cost for starting 2NRTIs+NNRTI or 2NRTIs+PI(boosted) with CD4≤200 cells/mm3 was £12,812 (95%CI £12,685-£12,937) compared with £10,478 (95%CI £10,376-£10,581) for PLHIV with CD4>200 cells/mm3. Cost per additional life-year gained on first-line therapy for those with CD4>200 cells/mm3 was £4639 (£3,967 to £2,960).PLHIV starting to use HIV services before CD4≤200 cells/mm3 is cost-effective and enables them to be monitored so they start cART with a CD4>200 cells/mm3, which results in better outcomes and is cost-effective. However, 25% of PLHIV accessing services continue to present with CD4≤200 cells/mm3. This highlights the need to investigate the cost-effectiveness of testing and early treatment programs for key populations in the UK

Rising Population Cost for Treating People Living with HIV in the UK, 1997-2013

Background The number of people living with HIV (PLHIV) is increasing in the UK. This study estimated the annual population cost of providing HIV services in the UK, 1997–2006 and projected them 2007–2013. Methods Annual cost of HIV treatment for PLHIV by stage of HIV infection and type of ART was calculated (UK pounds, 2006 prices). Population costs were derived by multiplying the number of PLHIV by their annual cost for 1997–2006 and projected 2007–2013. Results Average annual treatment costs across all stages of HIV infection ranged from £17,034 in 1997 to £18,087 in 2006 for PLHIV on mono-therapy and from £27,649 in 1997 to £32,322 in 2006 for those on quadruple-or-more ART. The number of PLHIV using NHS services rose from 16,075 to 52,083 in 2006 and was projected to increase to 78,370 by 2013. Annual population cost rose from £104 million in 1997 to £483 million in 2006, with a projected annual cost between £721 and £758 million by 2013. When including community care costs, costs increased from £164 million in 1997, to £683 million in 2006 and between £1,019 and £1,065 million in 2013. Conclusions Increased number of PLHIV using NHS services resulted in rising UK population costs. Population costs are expected to continue to increase, partly due to PLHIV's longer survival on ART and the relative lack of success of HIV preventing programs. Where possible, the cost of HIV treatment and care needs to be reduced without reducing the quality of services, and prevention programs need to become more effective. While high income countries are struggling to meet these increasing costs, middle- and lower-income countries with larger epidemics are likely to find it even more difficult to meet these increasing demands, given that they have fewer resources

Expanded HIV testing in low-prevalence, high-income countries: a cost-effectiveness analysis for the United Kingdom.

ObjectiveIn many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed.DesignWe developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries.MethodsWe estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness.ResultsAnnual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000-£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4-15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained.ConclusionsAnnual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries

Expanded HIV Testing in Low-Prevalence, High-Income Countries: A Cost-Effectiveness Analysis for the United Kingdom

<div><p>Objective</p><p>In many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed.</p><p>Design</p><p>We developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries.</p><p>Methods</p><p>We estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness.</p><p>Results</p><p>Annual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000–£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4–15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained.</p><p>Conclusions</p><p>Annual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries.</p></div

Summary of key model parameters.

<p>ART = antiretroviral therapy; MSM = men who have sex with men; PWID = people who inject drugs.</p><p>* Quality of life for all PWID is multiplied by this factor, across all health states.</p><p>** Under current UK guidelines <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095735#pone.0095735-British2" target="_blank">[24]</a>, individuals who are screened for HIV are given a pre-test counseling session and a post-test counseling session.</p><p>The length of the post-test counseling session depends on the outcome of the HIV test.</p

Projected annual HIV incidence over time in the UK under different testing strategies.

<p>The six graphs correspond to six different risk groups in the UK, with projected annual HIV incidence per 100,000 people shown under current testing and treatment levels (black solid line), universal annual testing of all adults (blue dashed), or universal annual testing coupled with antiretroviral therapy (ART) initiation of 75% at CD4 <350 cells/mm³ (red dotted). The cumulative number of new HIV infections over 10 years is given in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095735#pone-0095735-t003" target="_blank">Table 3</a>.</p

Projected outcomes under different testing strategies.

<p>* Model-projected new HIV infections in the UK between 2013 and 2022 under status quo testing and treatment levels, and projected number of averted infections with increased testing and treatment in parentheses. Three scenarios for the reduction in risky sexual behavior following HIV diagnosis are given.</p><p>** Incremental costs and quality-adjusted life years (QALYs) discounted to the present, are relative to the status quo, assuming a 25% reduction in risky sexual behavior following HIV diagnosis.</p>†<p>Strategies that are dominated, i.e., have higher costs but generate fewer health benefits than a combination of other strategies.</p

Cost-effectiveness of alternative HIV testing and treatment strategies in the UK.

<p>The incremental costs (x-axis) and QALYs (y-axis) of different HIV testing and treatment scenarios are shown, relative to status quo levels. The blue points correspond to universal HIV testing strategies for all adults, with testing every one, two, or three years. The green points correspond to targeted strategies, with annual testing for high-risk persons and testing every two years or one-time for all other persons. The red points correspond to an expanded HIV testing program coupled with 75% antiretroviral therapy initiation of at CD4 <350 cells/mm³. The solid black line marks the cost-effectiveness frontier, or the set of strategies that is most economically efficient, and the corresponding incremental cost-effectiveness ratios are given. Costs and QALYs are discounted at 3% annually, and include the direct costs of the programs over 10 years, as well as the lifetime costs and QALYs of all individuals in the population. HR = high-risk, and includes men who have sex with men (MSM), people who inject drugs (PWID), and men and women from HIV-endemic countries. LR = low-risk, and includes men and women who do not belong to the identified key populations. ART = antiretroviral therapy. QALY = quality-adjusted life year.</p

Model validation results under status quo scenario.

<p>* Source: Health Protection Agency. HIV in the United Kingdom: 2012 Report <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0095735#pone.0095735-Health6" target="_blank">[45]</a>.</p