Cost-effectiveness of Frequent HIV Screening Among High-risk Young Men Who Have Sex With Men in the United States

Abstract

Background Of new HIV infections in the US, 20% occur among young men who have sex with men (YMSM, ages 13-24), but >50% of YMSM with HIV are unaware of their status. Using Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) data, we projected the clinical benefit and cost-effectiveness of frequent HIV screening among high-risk YMSM from age 15. Methods Using a mathematical simulation, we examined 3 screening strategies: Yearly, 6-monthly, and 3-monthly, each in addition to the Status quo (SQ, 0.7-10.3% screened/year, stratified by age). We used published data (YMSM-specific when available) including: HIV incidences (0.91-6.41/100PY); screen acceptance (80%), linkage-to-care/antiretroviral therapy (ART) initiation (76%), HIV transmission (0.3-86.1/100PY, by HIV RNA), monthly ART costs ($2,290-$3,780), and HIV per-screen costs ($38). Projected outcomes included CD4 count at diagnosis, primary HIV transmissions from ages 15-30, quality-adjusted life expectancy, costs, and incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year saved [QALY]; threshold ≤$100,000/QALY). Results Compared to SQ, all strategies increased projected CD4 at diagnosis (296 to 477-515 cells/µL) and quality-adjusted life expectancy from age 15 (44.4 to 48.3-48.7 years) among YMSM acquiring HIV. Compared to SQ, all strategies increased discounted lifetime cost for the entire population ($170,800 to $178,100-$185,000/person). Screening 3-monthly was cost-effective (ICER: $4,500/QALY) compared to SQ and reduced primary transmissions through age 30 by 40%. Results were most sensitive to transmission rates; excluding the impact of transmissions, screening Yearly was ≤$100,000/QALY (ICER: $70,900/QALY). Conclusions For high-risk YMSM in the US, HIV screening 3-monthly compared to less frequent screening will improve clinical outcomes and be cost-effective.

Modeling Adherence Interventions Among Youth with HIV in the United States: Clinical and Economic Projections

“…Members of the simulated cohort can transmit HIV to others during any month in which they are viremic [20]. The risk of onward HIV transmission is modeled as a function of HIV RNA level in any month; HIV RNA levels and thus transmission rates vary by response to ART.…”

“…While lost to follow-up, YWH experience a 1.5% monthly probability of returning to HIV care, or 50% probability of return if they develop any opportunistic infection [36]. Transmission rates are 0.0-16.5 transmissions/100 person-years, depending on HIV RNA level (Table 1) [20,37,38].…”

Estimating the Cost-Effectiveness of HIV Self-Testing in the United States Using Net Benefit Regression

“…[5][6][7] RCTs of HIV screening strategies have also been reported in studies outside of the United States, including Africa, [8][9][10][11] Australia, United Kingdom, 13 and China. [14][15][16] Cost-effectiveness analyses of HIV screening strategies have used conventional modeling methods, such as decision trees, Markov models, dynamic models, and individual-and population-based models, [17][18][19][20][21][22] while mostly using cohort data as model inputs with a few studies using RCT data to calibrate the model. 22,23 However, net-benefit regression 24 can also be used to conduct cost-effectiveness analyses of HIV screening strategies using person-level data obtained from an RCT.…”

The Value and Challenge of Frequent Human Immunodeficiency Virus (HIV) Testing Among Young Men Who Have Sex With Men in the United States

“…Neilan and colleagues [9] used a wellestablished simulation model (CEPAC [Cost-effectiveness of Preventing AIDS Complications]) to examine the costeffectiveness of alternative HIV screening strategies in YMSM in the United States starting from age 15, taking into account risks of HIV transmission among YMSM reported in the ATN trials. They conducted extensive sensitivity analyses and considered prevention benefits only to the individual tested, which represents the most conservative approach to measuring benefit.…”