The cost-effectiveness of on-site rapid HIV testing in substance abuse treatment: results of the CTN 0032 randomized trial

Schackman BR, Metsch LR, Colfax GN, Leff JA, Wong A,

Scott CA, Feaster DJ, Gooden L, Matheson T, Mandler RN,

Haynes LF, Paltiel AD, Walensky RP

6th IAS Conference on HIV Pathogenesis, Treatment, and

PreventionJuly 18, 2011

US National HIV/AIDS Strategy

• Target: increase proportion of people living with HIV who know their status from 79% to 90% by 2015

• Implementation: Federally-funded substance abuse and mental health treatment clinics to offer voluntary, routine HIV testing

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HIV testing in substance abuse treatment centers

• Less than one-third of US drug treatment programs offer HIV testing and counseling

• Less than one-half of community treatment programs in the National Drug Abuse Clinical Trials Network (CTN) make HIV testing available, either in the program or through referral

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Objective

• To project the life expectancy gains, costs and cost-effectiveness of 3 HIV testing strategies in substance abuse treatment centers evaluated in the CTN Rapid Testing and Counseling Study randomized controlled trial (CTN 0032)

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Analytic overview

• We used data on short-term outcomes from CTN 0032 (Abstract TUPE402)

• To project long-term clinical and economic outcomes, we used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, a computer simulation state-transition model of HIV disease natural history, detection and treatment

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Model outcomes

• For HIV-infected individuals:– Life expectancy, undiscounted– Quality-adjusted life years (QALYs) gained

and cost of additional care due to early detection, discounted at 3% annually

• For HIV-uninfected individuals:– Cost of HIV testing offer

• All costs are in 2009 US dollars

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Cost-effectiveness is about value for money

• Incremental cost-effectiveness ratio:

• US cost-effectiveness threshold: <$100,000/QALY

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Additional Resource Use ($)Additional Health Benefits (QALYS)

Strategies examined

1) No HIV testing

2) Offer of referral to off-site HIV testing only

3) Offer of on-site rapid HIV testing with verbal information about testing only

4) Offer of on-site rapid HIV testing with risk reduction counseling

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Cohort description

Male 61%

White 65%

Injection drug use history 49%

Prevalence of undetected HIV 0.4%

Mean CD4 cells at time of detection with intervention* 551/ul

Time between HIV tests elsewhere* 5.3 years

Eligibility for HIV test offer:Not known to be HIV+ Did not receive results of an HIV test performed in the last 12 months

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*estimated

Input parameters by strategy

Accepted & received HIV

test result

Cost per offer

Mean number of unprotected sex acts after 6

months

Off-site referral 18.4% $10 20.5

On-site testing + information

84.8% $42 21.3

On-site testing + counseling

79.7% $78 21.3

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Base case cost-effectiveness results

Life expectancy

HIV+ (years)

Population avg total

cost

Population avg total

HIV+ QALM

CE ratio($/QALY)

No intervention 17.1 $1,100 0.49

Off-site referral 17.9 $1,200 0.51 dominated (inefficient)

On-site testing + information

20.8 $1,560 0.59 $60,300

On-site testing + counseling

20.5 $1,570 0.58 Dominated(higher

cost, lower QALY)

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Sensitivity analysis: cost-effectiveness of on-site testing + information vs. no intervention

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Limitations

• Assume HIV+ individuals who receive test results will be linked to care, and consistently receive guideline-concordant care

• Potential benefit of reduced HIV transmission due to earlier detection is not included

• Additional start-up costs will be required to implement on-site HIV testing

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Conclusions

• In substance abuse treatment centers:– Referral for off-site testing is less costly but

also less efficient than on-site testing– On-site risk reduction counseling adds cost

without either reducing sexual risk behavior or increasing acceptance of HIV testing, and is not cost-effective

• Offering rapid HIV testing on-site in substance abuse treatment programs is cost-effective using the current US threshold of <$100,000/QALY 14

Funding

• National Drug Abuse Treatment Clinical Trials Network (CTN): U10 DA013720, U10DA13720-09S, U10 DA020036, U10DA15815, U10DA13034, U10DA013038, U10 DA013732, U10 DA13036, U10 DA13727, U10DA015833, HHSN271200522081C, HHSN271200522071C

• National Institute on Drug Abuse: R01 DA027379, K23 DA019809

• National Institute of Mental Health: R01 MH063869

• National Institute of Allergy and Infectious Diseases: R37 A1042006

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Special thanks to site coordinators, staff, and participants

CPCDS: Antoine Douiah, Dorothy Sandstrom, Carrie Baron-Myak

La Frontera: Pat Penn, Roger Owen, and Sue McDavitt

Daymark: Robert Werstlein, Jessica Sides

Chesterfield: Dace Svikas, Ned Snead, Laurie Safford

Glenwood: Robert Schwartz, Lil Donnard, Lynn Calvin

MCCA: Steve Martino, David Avila, Stacy Botex

Wheeler: Steve Martino, Ray Muszynksi, Brandi Welles

CODA: Todd Korthuis, Katharina Weist, Diane Lape

Lifelink: Sarah Erickson, Michael DeBernardi, Meredith Davis

LRADAC: Louise Haynes, Beverly Holmes

Morris Village: Louise Haynes, Kim Pressley

Gibson: Angela Case-Williams, Kevin Steward, Andrew Johnson

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