Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in Portugal Julian...
Transcript of Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in Portugal Julian...
Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in
Portugal
Julian Perelman, Joana AlvesEscola Nacional de Saúde Pública
Universidade Nova de Lisboa
Research team
Harvard Medical SchoolKenneth Freedberg, MD, MScElena Losina, PhDRochelle Walensky, MD, MPHMadeline Di LorenzoJi-Eun Park
Yale School of Public HealthDavid Paltiel, PhD
University of LilleYazdan Yazdanpanah, MD, PhD
Escola Nacional de Saúde Pública – UNLJulian Perelman, PhDJoana Alves, MACéu Mateus, PhDJoão Pereira, PhD
NHS hospitals - PortugalKamal Mansinho, MD, and Ana Cláudia Miranda, MD (CH Lisboa Ocidental)Francisco Antunes, MD, PhD, and Manuela Doroana, MD (CH Lisboa Norte)Rui Marques, MD (H São João)José Saraiva da Cunha, MD, PhD, and Joaquim Oliveira, MD (HUC)José Poças, MD (CH Setubal)Eugénio Teófilo, MD (CH Lisboa Central)
A project commissioned by the Coordenação Nacional para a Infecção VIH/SIDA
Contribution of economic analysis
Resources are scarce• Choices must be made concerning their deployment• Using resources in one setting: opportunity costs• Economic evaluation of health care programs
Economic analysis makes explicit the efficiency criteria• Systematic comparison of costs and consequences• “Value for money”
Contribution of economic analysis
Choice
Treatment A
Treatment B
COSTA
COSTB
CONSEQUENCESB
CONSEQUENCESA
Cost-effectiveness analysis links costs to a medical outcome: cost of achieving one additional unit of medical outcome, “cost per life-year
gained”, “cost per QALY”
Contribution of economic analysis
Some examples for HIV/AIDS Cost/QALY
ZDV+3TC vs ZDV (Chancellor et al., 1997) £6,276
ZDV+3TC+ABC vs ZDV+3TC (Trueman et al., 2000) £10,254
HAART (2 NRTI + 1 PI) vs no treatment (Freedberg et al., 2001) $23,000
Personal risk assessment, counselling and education – gay and bissexual male adolescents (Tao et al., 1998)
$6,180
Condom distribution – national US population (Pinkerton et al., 1999)
Cost-saving
Antenatal HIV screening (Ades et al., 1999) <£10,000
Expansion methadone maintenance program - IV drug users(Zaric et al., 2000)
$10,900
Needle exchange program – IV drug users (Laufer et al., 2001)
$20,947/case avoided
Rationale for a new HIV testing strategy
Portugal
Situation 31/12/2010: 39,347 diagnosed cases
Diagnosed prevalence 18-69 yo: 0.48%
Estimated undiagnosed prevalence 18-69 yo: 0.21%
Europe
740,000 people living with HIV or AIDS
No decrease in HIV incidence in the recent past
Estimation: 30% undiagnosed cases
Source: European Commission - Public Health, 2010
Source: Health at a glance, OECD 2010
New cases per million, 2007
Source: Health at a glance, OECD 2010
Rationale for a new HIV testing strategy
Rationale for a new HIV testing strategy
Portugal France
Mean CD4 at care initiation
292 372
Viral load at care initiation
> 100,00042.10% 18.75%
30,0001 - 100,00023.71% 21.15%
10,001 - 30,00014.03% 15.19%
3,001 - 10,0008.22% 13.88%
501 - 3,0004.76% 11.19%
20-5004.76% 19.84%
< 202.41% 0.00%
Rationale for a new HIV testing strategy
Proposal of a new HIV testing strategy in Portugal
Testing at all health care settings as part of routine care
All population
Provider-initiated test (rapid test)
Counselling of positive cases and linkage to care
Voluntary (opting-out approach)
Confidentiality and anonymity
Voluntary provider-initiated HIV testing, counselling and referral(here-below “expanded testing”)
Rationale for a new HIV testing strategy
Proposal of a new HIV testing strategy in Portugal
Necessity to evaluate different strategies
All population versus high-risk groups
Whole country versus high-prevalence areas
Screen once versus every year versus every 3, 5 or 10 years
Screen at primary care centres versus emergency units
Research project: evaluate the cost-effectiveness of different expanded testing strategies in Portugal
Cost-effectiveness of expanded testing
Expanded testing
Higher cost of testing, counselling and referral
Earlier detection: Earlier treatment:
Lower viral replication Less drug-related AE Lower costs (?)
Higher life expectancy Better quality of life Lower rate of transmission
Background strategy
Lower cost of testing, counselling and referral
Later detection: Later treatment:
Higher costs (?) Lower efficacy
Lower life expectancy Lower quality of life Higher rate of transmission
Balancing costs and benefits
Cost-effectiveness of expanded testing
Other less documented and measurable issues:
• HIV as “normal” disease
• Costs of waiting and costs of knowing
• How the test is performed (versus opportunity of testing)
– Confidentiality and anonymity
– Counselling and referral
– Anti-discrimination laws
Cost-effectiveness of expanded testing
Widely published CEPAC* Monte Carlo simulation model of HIV acquisition/detection/care (see eg Paltiel et al., N Engl J
Med 2005) Examine the impact of expanded screening in Portugal,
compared to current risk-factor-based screening The model captures data on
HIV screening: HIV prevalence and incidence, test offer/acceptance rates, returns for test results, linkage to care, and HIV counseling and testing costs
HIV disease: incidence of opportunistic diseases, HIV treatment, mortality rates, and all associated costs and quality of life effects
*Cost-effectiveness of Preventing AIDS Complications
Acute Clinical Event
Death
Chronic HIVInfection
Primary HIVInfection
The CEPAC Int’l ModelFreedberg et al.Supported by NIAID
Cost-effectiveness of expanded testing
Cost-effectiveness of expanded testing
Inputs required to estimate the CE of HIV expanded testing in Portugal
Epidemiology of HIV: incidence/prevalence, undiagnosed prevalence,
CD4 and viral load at detection
Progression of disease and efficacy of treatments: international
literature
Treatment costs of HIV (by stage of disease), cost of testing and
counselling, prices of anti-retroviral and prophylaxis drugs
Behaviours: test acceptance and return rate, linkage to care, attitude
towards risk and transmission of disease
Treatment cost of HIV/AIDS in Portugal
Cost-effectiveness of expanded testing
Inputs for the CEPAC Model (1)
Cost-effectiveness of expanded testing
Inputs for the CEPAC Model (2)
Cost-effectiveness of expanded testing
Scenario Life months
Quality-adjusted life
months
Costs (€) 1
ICER (€/LY) 2
ICER (€/QALY) 2
Current practice 193.11 192,98 980 - -
Screen once 193.14 193.01 1,070 33,865 38,601
Screen every 5 years 193.16 193.02 1,150 46,531 51,818
Screen annually 193.19 193.05 1,320 62,769 80,632
Base Case Results (Costs and life expectancy discounted at 5%)
1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.
All population (undiagnosed prevalence 0.21%)
Cost-effectiveness of expanded testing
Scenario Life months
Quality-adjusted life
months
Costs (€) 1
ICER (€/LY) 2
ICER (€/QALY) 2
Current practice 192.86 192.63 1,820 - -
Screen once 192.92 192.68 1,990 32,937 37,309
Screen every 5 years 192.96 192.71 2,120 43,120 46,627
Screen annually 193.02 192.77 2,390 52,357 61,002
Base Case Results (Costs and life expectancy discounted at 5%)
1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.1. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.
Lisboa (undiagnosed prevalence 0.39%)
Cost-effectiveness of expanded testing
Cost-effectiveness of one-time expanded testing improves with higher
estimated undiagnosed prevalence
Lisboa 0.39%, Setúbal 0.33%, Porto 0.26%, Faro 0.26%
Highly cost-effective among high-risk groups (undiagnosed
prevalence >1%): MSM, IDUs
Additional preliminary results for IDUs: testing cost-effective every 5
years
Undiagnosed Prevalence Yearly Incidence
Cost-effectiveness of expanded testing
Cost-effectiveness of one-time HIV testing at different undiagnosed HIV prevalence values*
*Costs and life expectancy discounted at 5%
Test Acceptance (25%:75%)
Discount Rate (0%;5%)
Linkage to Care (25%;100%)
0 10,000 20,000 30,000 40,000 50,000 60,000
Incremental cost-effectiveness ratio (€/QALY)
Base CaseBase Case
Cost-effectiveness of screening strategies
Cost/QALY
Screening hypertension, asymptomatic men 20+ (Littenberg, Ann Intern Med 90)
$80,400
Colon cancer, FOBT + SIG q5y, adults 50-85 (Frazier, JAMA 2000)
$57,700
Biennal breast cancer screening, women 50-69Biennal breast cancer screening, women 40-49 (Salzmann, Ann
Intern Med 1997) (Salzmann, Ann Intern Med 1997)
$21,400/LYG$105,000/LYG
HPV vaccine at 12 and cytologic screening every 3y after 25 (Goldie, Journal Nacional Cancer Institute, 2004)
$58,500
Cost-effectiveness of expanded testing
Main limitations
Disease transmission not accounted for. US results:
37,100$/QALY without transmission effect
30,800$/QALY with transmission effect
Uncertainty for undiagnosed prevalence & incidence
Use international published literature for quality of life
Use data for specific settings: emergency rooms
Implicações para a tomada de decisão
Valores razoáveis para um rastreio único e alargado, proposto pelo
médico, acompanhado de aconselhamento e referenciação
Valores aceitáveis para populações e regiões alvo
IDUs de 5 em 5 anos
MSM
Regiões de alta prevalência: Lisboa, Setúbal, Porto, Faro
Características do teste alargado
Teste único e teste rápido
‘Opting-out’ e aconselhamento limitado a seropositivos
Centros de saúde, internamentos e urgências
Estimativas para o grupo 18-69 anos
Implicações para a tomada de decisão
O que poderia ainda melhorar o custo-efectividade?
Ter em conta a questão da transmissão
Diminuição dos preços da medicação ART e teste
confirmatório
Melhor referenciação
International: US recommendations
Source: CDC Recommendations 2006, Morbidity and Mortality Weekly Report, 22/9/2006, vol. 55, RR-14
International: French recommendations
Source: Dépistage de l’infection VIH en France, Recommendations en Santé Publique, Haute Autorité de Santé, October 2009.
International: 3-country comparison
Portugal France USA
Undiagnosed prevalence
0.00210 0.00098 0.000768
Cost comparison
CD4 test 36.20€ 21.60€ 48.57€
Viral load test 51.00€ 59.40€ 87.97€
Confirmation test 99.50€ 53.10€ 23.68€
Counselling 31.00€ 22.00€ 8.14€
International: 3-country comparison
Line Portugal France USA
1. EFV + TDF/FTC 732.05 € 745.85 € 1,058.32 €
2. ATV/r + TDF/FTC 1,025.04 € 927.99 € 1,518.05 €
3. LPV/r + TDF/FTC + AZT 1,191.04 € 1,118.93 € 1,507.29 €
4a. RAL + OBR (2 NRTIs) + DRV/r - with truvada 2,086.11 €1,999.79 €
1,946.92 €
4b. RAL + OBR (2 NRTIs) + DRV/r - with kivexa 1,942.40 €
5a.i. ENF + OBR (DRV/r + 2NRTIs) - with truvada 2,758.03 €2,496.54 €
2,963.13 €
5a.ii. ENF + OBR (DRV/r + 2NRTIs) - with kivexa 2,614.32 €
5b. MVC + OBR (1 PI/r + 2NRTIs) +/- ENF - with trivuda 2,865.50 €2,384.02 €
5b. MVC + OBR (1 PI/r + 2NRTIs) +/- ENF- with kivexa 2,721.79 €
6a. OBR (1 PI/r + 2NRTIs) - with trivuda 1,933.61 €1,191.47 €
1,288.53 €
6b. OBR (1 PI/r + 2NRTIs) - with kivexa 1,789.90 €