Cost implications of HIV retesting for verification in Africa

Abstract

Introduction HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. Methods We evaluated and compared the cost of retesting for verification of HIV seropositivity ( retesting ) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting ( no retesting ), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting , over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. Results and discussion The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. Conclusions Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO’s recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.

Evaluating Point-of-Care Nucleic Acid Tests in Adult Human Immunodeficiency Virus Diagnostic Strategies: A Côte d’Ivoire Modeling Analysis

“…FP diagnoses are costly, increasing HIV-related lifetime costs by $5800. This modeled cost depended on assumptions about the duration of an FP diagnosis (based on Ivoirian loss to follow-up rates) [ 29 ], and was consistent with other published estimates in low-income settings ($3770–$4655) [ 34 , 37 ]. Notably, these estimates do not capture additional individual and societal costs, such as the psychological burden and the erosion of trust in health care systems resulting from misdiagnoses [ 38 ].…”

HIV-1 diagnosis using dried blood spots from patients in Kinshasa, DRC: a tool to detect misdiagnosis and achieve World Health Organization 2030 targets

“…In addition, the utility of DBS for serological and molecular analysis to confirm or rule out HIV infection was evaluated. HIV misdiagnosis can give rise to serious public health and individual consequences not only in low-income countries (LICs) but also in high-income countries (13,18). These errors in diagnosis can decrease the validity of HIV diagnostic techniques, testing programs and strategies and increase the cost in patients who do not need ART.…”

“…These errors in diagnosis can decrease the validity of HIV diagnostic techniques, testing programs and strategies and increase the cost in patients who do not need ART. Currently, the WHO recommends retesting each patient to verify HIV infection previous to an antiretroviral treatment initiation (18,19). Thus, in LICs there is an imperative need to improve correct diagnosis.…”

Accuracy and performance of the WHO 2015 and WHO 2019 HIV testing strategies across epidemic settings

“…However, at low positivity levels, increased HIV-inconclusive results arose primarily due to simplification of testing strategy for persons who are initially discrepant, reducing opportunity for errors, and among individuals who are truly HIV negative but would have been misclassified as HIV-positive under the two-test strategy. Had those HIV-inconclusive individuals received a false-positive misdiagnosis under the two-test testing strategy, the cost of misdiagnosis and life-long treatment would be significant [14,15].…”

“…The alternative, without adopting the strategy requiring three reactive tests to diagnose HIV, is increasing false positive misdiagnoses as a proportion of all those newly diagnosed with HIV. This incurs unnecessary lifelong ART costs for HIV negative persons [14,15], unquantified individual physical, psychosocial and emotional harms of receiving a false positive HIV misdiagnosis [16,17], and undermining confidence in the health system. While the WHO 2019 HIV testing strategy ensures the fidelity of HIV diagnosis and subsequent care and treatment, the main determinant of HIV testing programme cost is the overall scale if HIV testing and the number A1 conducted.…”