Expanded HIV Testing in Low-Prevalence, High-Income Countries: A Cost-Effectiveness Analysis for the United Kingdom

Abstract

ObjectiveIn many high-income countries with low HIV prevalence, significant numbers of persons living with HIV (PLHIV) remain undiagnosed. Identification of PLHIV via HIV testing offers timely access to lifesaving antiretroviral therapy (ART) and decreases HIV transmission. We estimated the effectiveness and cost-effectiveness of HIV testing in the United Kingdom (UK), where 25% of PLHIV are estimated to be undiagnosed.DesignWe developed a dynamic compartmental model to analyze strategies to expand HIV testing and treatment in the UK, with particular focus on men who have sex with men (MSM), people who inject drugs (PWID), and individuals from HIV-endemic countries.MethodsWe estimated HIV prevalence, incidence, quality-adjusted life years (QALYs), and health care costs over 10 years, and cost-effectiveness.ResultsAnnual HIV testing of all adults could avert 5% of new infections, even with no behavior change following HIV diagnosis because of earlier ART initiation, or up to 18% if risky behavior is halved. This strategy costs £67,000–£106,000/QALY gained. Providing annual testing only to MSM, PWID, and people from HIV-endemic countries, and one-time testing for all other adults, prevents 4–15% of infections, requires one-fourth as many tests to diagnose each PLHIV, and costs £17,500/QALY gained. Augmenting this program with increased ART access could add 145,000 QALYs to the population over 10 years, at £26,800/QALY gained.ConclusionsAnnual HIV testing of key populations in the UK is very cost-effective. Additional one-time testing of all other adults could identify the majority of undiagnosed PLHIV. These findings are potentially relevant to other low-prevalence, high-income countries.

Modeling and Cost-Effectiveness in HIV Prevention

“…In high-income countries such as the United Kingdom, annual targeted testing to MSM, IDUs, and people from HIV-endemic countries has been reported to prevent 4%-15% of infections and require testing 2,500 people per HIV diagnosis, with an ICER of £17,500/QALY gained (~$26,700, 2012 USD) [23]. Testing MSM more frequently (at 3 or 6 month intervals) is reported to be cost-effective and even cost-saving in some scenarios over a one-year period in the United States [24].…”

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities

“…In the past, when local HIV budgets have contracted (e.g. California’s budget shortfall in 2009) (79), detailed surveillance data was instrumental in targeting resources to high risk communities and stemming additional infections in the short term (79, 81). Although state funds may be able to compensate for short term losses in federal support, the sustainability of programs may be challenged.…”

Creating impact with operations research in health: making room for practice in academia

“…Recently I took a sabbatical in Geneva, Switzerland, working for the Joint United Nations Programme on HIV/AIDS (UNAIDS). This had led to several fruitful collaborations [23-25]. …”