Health Economic Evaluation On Provider Initiated HIV Testing And Counseling Strategies

Objective:To explore whether non-targeted HIV screening strategy in healthcare settings is cost effective in concentrated HIV epidemic areas in China, and to provide health economic evidence for proposal of appropriate provider initiated HIV testing and counseling(PITC) strategy accordingly.Methods:There were two parts in this study, ie, field trial and modeling study. Semi-experiment design was applied for the field study. Two similar hospitals were selected to carry out different PITC strategies (symptom screening PITC vs non-targeted screening PITC) prospectively. Cost and effectiveness indicators were collected for either strategy, based on which cost effective analysis and incremental cost effective analysis were conducted. Furthermore, previous cost and testing data were collected retrospectively to compare the pre- and post- effectiveness. In the second part, the field data were combined with literature data to establish the economic evaluation model of PITC using decision tree software. The long term effect of PITC in terms of healthy life years was predicted by the model and cost utility analysis and incremental cost utility analysis were conducted, to identify the most cost effective PITC strategy in different HIV prevalence scenarios for different parameters.Results:Under symptom screening PITC strategy,10 new HIV cases were identified, accounting for 0.016% of the total person times of outpatients during study period, slightly higher than 0.009%(6/65801) in the same period before the study, with no statistically significance (p=0.180). Under non-targeted screening PITC strategy,19 new HIV cases were identified, accounting for 0.033% of the total person times of outpatients during study period, statistically significant higher than 0.008% before the study (OR=4.133, CI:1.543-11.069, p=0.002). Compared to symptom screening PITC strategy, non-targeted screening strategy identified more new HIV cases, with 19 vs 10(p=0.047); had more cases receiving HIV testing results and referral service, with 16 vs 9 (p=0.085); and found more cases in early disease stage, with 7 vs 3 (p=0.146)When adopting ELISA method for the screening, the total cost for symptom screening PITC was ￥9089.29, and the unit cost for one test was ￥10.58. On the other hand, the total cost for non-targeted screening PITC was ￥39156.46, and the unit cost for one test was ￥6.96.In the study area, the cost of identifying a new HIV case was ￥908.9, ￥1413.3 and ￥2060.9 for symptom screening strategy, male non-targeted screening strategy, and non-targeted screening strategy, respectively. The incremental cost was ￥844.5, ￥2674.3 and ￥3874.0. Moreover, the incremental cost per quality adjusted life year(QALY) was ￥37456.41, ￥35974.89 and ￥41526.69, which suggested that each strategy was cost-effective according to GDP level in China. If expanding the PITC program from one year to every year, the corresponding incremental cost effectiveness was ￥46,267.78/QALY, ￥56,050.49/QALY and ￥56,336.67/QALY, which still met the standard of cost-effectiveness.By combining all the six above PITC strategies together to explore appropriate minimum HIV prevalence for each PITC strategy, the model showed that the required HIV prevalence in low to high order was 0.0254%、 0.0492%、 0.088%、 0.1134%、 0.247%和2.76%, for one year male non-targeted screening strategy, yearly symptom screening strategy, yearly male non-targeted screening strategy,1 year symptom screening strategy, yearly non-targeted screening strategy, yearly male non-targeted screening strategy, and 1 year symptom screening strategy respectively.Conclusion:Compared to symptom screening strategy, non-targeted screening strategy in healthcare settings could detect more HIV cases. It was cost-effective to carry out one year non-targeted screening strategy in areas with HIV prevalence over 0.088%, and yearly non-targeted screening strategy in areas with HIV prevalence over 0.12%.