In the Journals

Stronger interventions for HIV patients may prevent up to 752,000 new infections

A computer model developed at Johns Hopkins University estimated that strengthening programs to keep patients with HIV engaged in lifetime care plus enhanced screening would prevent 720,000 new HIV infections and 276,000 AIDS-related deaths over a 20-year duration, according to a recent study.

“Despite having good treatments available, current reports suggest that fewer than half of individuals who need therapy are actually getting appropriate HIV medicine to control their virus, leading to more transmission of disease,” Maunank Shah, MD, PhD, assistant professor of medicine at Johns Hopkins University School of Medicine, said in a press release. “The engagement in care of individuals infected with HIV is not what it could or should be.”

Shah and colleagues developed a transmission model of HIV in U.S. adults aged 15 to 65 years based on current epidemiological data published in scientific literature and national surveillance reports from the CDC, the U.S. Census Bureau and HHS. The model was used to evaluate the cost-effectiveness of enhanced testing and improved retention over a 20-year duration. The HIV population was categorized by disease status and engagement with care, then further stratified by gender and high-risk groups, including men who have sex with men and injection drug users.

The researchers specifically examined the impact of implementing programs that aimed to:

  • increase annual screening in high-risk individuals;
  • increase screening in the general population aged 25 to 65 years every 3 years;
  • increase the proportion of patients who receive care within 3 months of diagnosis from the current level of 70% to 90%; and
  • achieve a 50% reduction in annual rates of care disengagement and increase the annual re-engagement rate to 50%.

The costs of implementing these interventions included resources for expanded testing programs and additional medical staff.

Based on current screening and care engagement efforts, the model predicted that 1.39 million (95% uncertainty range [UR], 0.91-2.2 million) new HIV infections and 435,000 (95% UR, 249,000-774,000) AIDS-related mortalities would occur between 2015 and 2035, despite early ART initiation. An estimated 56% of infections would be transmitted from patients aware of their HIV status. The number of new diagnoses was projected to cost $256 billion (95% UR, 199-298 billion).

The researchers evaluated various combinations of enhanced interventions. The most cost-effective combination included implementation of all the interventions, which reduced new infections by 54% (95% UR, 37-68) and mortality by 64% (95% UR, 46-78), at a cost of $96 billion (95% UR, 67-138 billion), which translates to $45,300 (95% UR, 27,800-72,300) per quality-adjusted life year (QALY) gained over the span of 2 decades.

In contrast, only strengthening programs that aim to reduce disengagement and increase re-engagement reduced new infections by 36% (95% UR, 15-53), costing $33,700 (95% UR, 20,000-60,600) per QALY gained. Increasing linkage to care from 70% to 90% alone would reduce new infections by 21% (95% UR, 13-26), costing $65,700 (95% UR, 44,500-111,000) per QALY. The most modest benefit was observed in increasing screening protocols alone, which would avert between 18% and 21% (95% UR, 10-28) of new infections, costing $84,700 (95% UR, 9-20) per QALY gained in high-risk individuals alone. It would cost an additional $21.9 billion to enhance screening in the general population.

“In an era of constrained resources for HIV prevention in the United States, these findings are relevant for resource allocation decisions,” Shah and colleagues wrote. “Recent emphasis has been placed on increasing screening, particularly among persons at high risk. However, our model suggests that focusing some of these resources toward retention and re-engagement of persons with known HIV — even at an additional cost of several thousand dollars per person-year — might be a more cost-effective use of resources.” – by Stephanie Viguers

Disclosure: Shah reports no relevant financial disclosures.

A computer model developed at Johns Hopkins University estimated that strengthening programs to keep patients with HIV engaged in lifetime care plus enhanced screening would prevent 720,000 new HIV infections and 276,000 AIDS-related deaths over a 20-year duration, according to a recent study.

“Despite having good treatments available, current reports suggest that fewer than half of individuals who need therapy are actually getting appropriate HIV medicine to control their virus, leading to more transmission of disease,” Maunank Shah, MD, PhD, assistant professor of medicine at Johns Hopkins University School of Medicine, said in a press release. “The engagement in care of individuals infected with HIV is not what it could or should be.”

Shah and colleagues developed a transmission model of HIV in U.S. adults aged 15 to 65 years based on current epidemiological data published in scientific literature and national surveillance reports from the CDC, the U.S. Census Bureau and HHS. The model was used to evaluate the cost-effectiveness of enhanced testing and improved retention over a 20-year duration. The HIV population was categorized by disease status and engagement with care, then further stratified by gender and high-risk groups, including men who have sex with men and injection drug users.

The researchers specifically examined the impact of implementing programs that aimed to:

  • increase annual screening in high-risk individuals;
  • increase screening in the general population aged 25 to 65 years every 3 years;
  • increase the proportion of patients who receive care within 3 months of diagnosis from the current level of 70% to 90%; and
  • achieve a 50% reduction in annual rates of care disengagement and increase the annual re-engagement rate to 50%.

The costs of implementing these interventions included resources for expanded testing programs and additional medical staff.

Based on current screening and care engagement efforts, the model predicted that 1.39 million (95% uncertainty range [UR], 0.91-2.2 million) new HIV infections and 435,000 (95% UR, 249,000-774,000) AIDS-related mortalities would occur between 2015 and 2035, despite early ART initiation. An estimated 56% of infections would be transmitted from patients aware of their HIV status. The number of new diagnoses was projected to cost $256 billion (95% UR, 199-298 billion).

The researchers evaluated various combinations of enhanced interventions. The most cost-effective combination included implementation of all the interventions, which reduced new infections by 54% (95% UR, 37-68) and mortality by 64% (95% UR, 46-78), at a cost of $96 billion (95% UR, 67-138 billion), which translates to $45,300 (95% UR, 27,800-72,300) per quality-adjusted life year (QALY) gained over the span of 2 decades.

In contrast, only strengthening programs that aim to reduce disengagement and increase re-engagement reduced new infections by 36% (95% UR, 15-53), costing $33,700 (95% UR, 20,000-60,600) per QALY gained. Increasing linkage to care from 70% to 90% alone would reduce new infections by 21% (95% UR, 13-26), costing $65,700 (95% UR, 44,500-111,000) per QALY. The most modest benefit was observed in increasing screening protocols alone, which would avert between 18% and 21% (95% UR, 10-28) of new infections, costing $84,700 (95% UR, 9-20) per QALY gained in high-risk individuals alone. It would cost an additional $21.9 billion to enhance screening in the general population.

“In an era of constrained resources for HIV prevention in the United States, these findings are relevant for resource allocation decisions,” Shah and colleagues wrote. “Recent emphasis has been placed on increasing screening, particularly among persons at high risk. However, our model suggests that focusing some of these resources toward retention and re-engagement of persons with known HIV — even at an additional cost of several thousand dollars per person-year — might be a more cost-effective use of resources.” – by Stephanie Viguers

Disclosure: Shah reports no relevant financial disclosures.