Original Article

Cost-Effectiveness Analysis of Early vs Late Diagnosis of HIV-Infected Patients in South Carolina

Authors: Marlon Rampaul, MBBS, Babatunde Edun, MD, Monetha Gaskin, MPH, Helmut Albrecht, MD, Sharon Weissman, MD

Abstract

Objectives: It is anticipated that early diagnosis, linkage to care, initiation of antiretroviral therapy (ART), and retention in care would lead to reduced opportunistic infections, reduction in human immunodeficiency virus–related morbidity and mortality and reduced rates of HIV transmission. This would be expected to lead to a reduction in the lifetime cost of care (LCC). This study analyzed existing data to determine to what extent early-versus-late HIV diagnosis affects LCC.

Methods: The South Carolina Department of Health and Environmental Control electronic HIV/acquired immunodeficiency syndrome reporting system data were used for this study. The first CD4 and viral load reported to the Enhanced HIV/AIDS Reporting System of the Centers for Disease Control and Prevention are considered the initial CD4 and viral load. Late HIV diagnosis was based on a CD4 count ≤200 at diagnosis. A previously validated simulation model developed by the John Snow Institute for the South Carolina Department of Health and Environmental Control was used to determine the discounted LCC. Comparisons were made between late and early HIV diagnosis.

Results: From 2013 through 2015, 2138 individuals were diagnosed as having HIV in South Carolina; 180 individuals were excluded from further analysis because an initial CD4 count was missing. Final analysis was based on 1958 individuals. Late HIV diagnosis occurred in 509 individuals (26%). When stratified based on CD4 count at diagnosis, the discounted LCC per person in those with an initial CD4 count ≤200 was $262,374 and in those with an initial CD4 count >500 was $416,766. Those with lower CD4 counts at diagnosis had more lost quality-adjusted life-years (QALYs; 7.95 QALYs lost per person with an initial CD4 count ≤200 compared with 4.45 QALYs lost per person with an initial CD4 count >500), more lifetime HIV transmissions (1.4 per person with an initial CD4 count ≤200 compared with 0.72 per person with an initial CD4 count >500), and lower additional life expectancy (30.73 additional years with an initial CD4 count ≤200 compared with 38.08 additional years with an initial CD4 count >500).

Conclusions: Although individuals with lower CD4 counts at diagnosis had a lower discounted LCC, they had more lost QALYs, more lifetime HIV transmissions, and lower additional life expectancy.

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References

1. Centers for Disease Control and Prevention. Missed opportunities for earlier diagnosis of HIV infection-South Carolina, 1997-2005. MMWR Morb Mortal Wkly Rep 2006;55:1269-1272.
 
2. Weissman S, Duffus WA, Iyer M, et al. Rural-urban differences in HIV viral loads and progression to AIDS among new HIV cases. South Med J 2015;108:180-188.
 
3. Centers for Disease Control and Prevention. State HIV prevention progress report, 2014. http://www.cdc.gov/hiv/pdf/policies/StateProgressReport2014.pdf. Accessed December 9, 2016.
 
4. Shah M, Risher K, Berry SA, et al. The epidemiologic and economic impact of improving HIV testing, linkage, and retention in care in the United States. Clin Infect Dis 2016;62:220-229.
 
5. Farnham PG, Gopalappa C, Sansom SL, et al. Updates of lifetime costs of care and quality-of-life estimates for HIV-infected persons in the United States: late versus early diagnosis and entry into care. J Acquir Immune Defic Syndr 2013;64:183-189.
 
6. Buchacz K, Armon C, Palella FJ, et al. CD4 cell counts at HIV diagnosis among HIV outpatient study participants, 2000-2009. AIDS Res Treat 2012;2012:86984.
 
7. Tripathi A, Gardner LI, Ogbuanu I, et al. Predictors of time to enter medical care after a new HIV diagnosis: a statewide population-based study. AIDS Care 2011;23:1366-1373.
 
8. Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care 2006;44:990-997.
 
9. Krentz HB, Gill MJ. The direct medical costs of late presentation (<350/mm) of HIV infection over a 15-year period. AIDS Res Treat 2012;2012:757135.
 
10. Edun B, Iyer M, Albrecht H, et al. The South Carolina HIV cascade of care. South Med J 2015;108:670-674.