Resource Utilization and Cost-Effectiveness of Counselor- vs. Provider-Based Rapid Point-of-Care HIV Screening in the Emergency Department

Abstract

BackgroundRoutine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor.MethodsWe employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs.ResultsEstimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs.ConclusionsThe cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.

Cost-effectiveness of HIV screening in high-income countries: A systematic review

“…Then, relying on full-text reading, we came to the conclusive number of 26 articles (see Fig. 1) [4,9,[20][21][22][23][24][25][26][27][28][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53]. The papers were excluded after a full-text reading because they did not meet the eligibility criteria previously mentioned, they referred to unrelated topics or they presented a quality assessment score below 7.…”

“…We retrieved 12 studies considering exclusively the cost-effectiveness of HIV-screening in specific settings (see Tables 3 and 4) [23,[25][26][27][45][46][47][48][49][50][51][52]. The majority of the authors chose a societal perspective [23,25,26,46,47,48,50,52].…”

“…The majority of the authors chose a societal perspective [23,25,26,46,47,48,50,52]. All studies adopted a long-term perspective [23,[25][26][27][45][46][47][48][49][50][51][52]. For the economic analysis, the reference year ranged from 1999 [52] to 2009 [23,25,26,27,[45][46][47][48]50], adopting a discounting rate ranging from3% [23,[25][26][27][45][46][47][48][49][50]52] to 4% [51].…”

“…In this context, the most commonly studied setting was the emergency department (ED) [27,45,47,48]. Two studies assessed the cost-effectiveness of HIV screening for ED patients compared to the standard diagnostic approach [45,47].…”

A Research Agenda for Emergency Medicine–based Adolescent Sexual and Reproductive Health

“…For research involving aspects of confidentiality and consent, we advise that these topics are investigated together, as they are difficult to separate both clinically and within research. We encourage investigators to consider inclusion of cost‐effectiveness assessment with any intervention, especially those outside of HIV screening where some of this work has been published . Further, we lack research describing the effect of policies on health care provision and best practices for implementation and dissemination once effective ED‐based interventions are identified.…”