Costs of Expanded Rapid HIV Testing in Four Emergency Departments

Abstract

Objective. The HIV Prevention Trials Network (HPTN) 065 trial sought to expand HIV screening of emergency department (ED) patients in Bronx, New York, and Washington, D.C. This study assessed the testing costs associated with different expansion processes and compared them with costs of a hypothetical optimized process.Methods. Micro-costing studies were conducted in two participating EDs in each city that switched from point-of-care (POC) to rapid-result laboratory testing. In three EDs, laboratory HIV testing was only conducted for patients having blood drawn for clinical reasons; in the other ED, all HIV testing was conducted with laboratory testing. Costs were estimated through direct observation and interviews to document process flows, time estimates, and labor and materials costs. A hypothetical optimized process flow used minimum time estimates for each process step. National wage and fringe rates and local reagent costs were used to determine the average cost (excluding overhead) per completed nonreactive and reactive test in 2013 U.S. dollars.Results. Laboratory HIV testing costs in the EDs ranged from $17.00 to $23.83 per completed nonreactive test, and POC testing costs ranged from $17.64 to $37.60; cost per completed reactive test ranged from $89.29 to $123.17. Costs of hypothetical optimized HIV testing with automated process steps were approximately 45% lower for nonreactive tests and 20% lower for reactive tests. The cost per ED visit to conduct expanded HIV testing in each hospital ranged from $1.21 to $3.96.Conclusion. An optimized process could achieve additional cost savings but would require an investment in electronic system interfaces to further automate testing processes.

The Potential Epidemiological Impact of Coronavirus Disease 2019 (COVID-19) on the Human Immunodeficiency Virus (HIV) Epidemic and the Cost-effectiveness of Linked, Opt-out HIV Testing: A Modeling Study in 6 US Cities

“…39 Assembling and organizing the labor force to address COVID-19 has taken an all-encompassing effort in the six participating cities, but limited additional training is required to include an offer for an HIV test. 34 Offering linked HIV testing may add relatively little time to each contact, but implementation of HIV testing in practice may depend on local public health initiatives. For instance, sample collection with a self-administered oral swab would allow physical distancing, similar to how SARS-CoV-2 viral testing is currently being conducted, and point-of-care HIV testing would provide immediate results (albeit with slightly lower sensitivity) that may better facilitate subsequent linkage to care.…”

“…33 These costs were adapted from the estimated costs for HIV testing in emergency department settings. 34 We assumed reactive results would be reported to public health authorities for follow-up, and we did not include the cost of these follow-up activities.…”

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents

“…An ED call-back risks accidental early disclosure, breach of adolescent confidentiality, loss of adolescent trust in the medical system, and loss to follow-up at a critical time. Point-of-care testing, which is preferred by adolescents and is associated with increased receipt of results, 40,48,49 may mitigate these risks with earlier time to test results; however, in addition to higher costs 50 and decreased sensitivity in pragmatic settings, 41,42 this strategy would require the development of new workflow processes in a setting without established methods for point-of-care test collection. 51 Our primary limitation in approaching adolescents and offering true universal screening as recommended by the CDC was staff availability: 60% of adolescent ED visits occurred when a screening investigator was not present and, as a result, only 11% of all adolescents seen in the ED during the pilot period received routine HIV screening.…”

The Optimal Age for Screening Adolescents and Young Adults Without Identified Risk Factors for HIV

“…In addition to current practice , a one-time HIV screen was offered to both infected and uninfected patients (Table 1). In the base case analysis, for all one-time screening strategies, we assumed an 80.0% combined probability of being offered and accepting screening, 97.0% result return, 75.6% linkage to care and ART provision after a positive screen (based on data for AYA aged 13–24 when available), as well as screening costs of $35.92 per screen plus an additional $72.23 per completed reactive screen [13–15, 25, 26]. HIV screening was modeled as a fourth generation HIV immunoassay per CDC recommendations.…”

“…) c HIV screen cost was derived from an average of reported costs with and without counseling at sexually transmitted infection clinics [14]. The cost of completing a positive screen was based on average reported costs at hospitals [15]. Costs include costs of reagents and controls, laboratory equipment costs, specimen collection, transport and process, quality control, counseling and personnel time at national wage and fringe labor rates. d Antiretroviral efficacy is defined as the rate of suppression of HIV RNA <400 copies/mL at 48 weeks. Additional references for inputs are noted in the appendix (Table A1). PY: person-years; USD: US dollars …”