Clinical Impact and Cost-Effectiveness of Expanded Voluntary HIV Testing in India

Abstract

BackgroundDespite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.MethodsWe used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population (“national population”), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for “cost-effective” was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for “very cost-effective” was <1x the annual per capita GDP ($1,300/YLS).ResultsCompared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.ConclusionsIn India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.

Epidemiological impact of achieving UNAIDS 90-90-90 targets for HIV care in India: a modelling study

“… 19 20 We found that with annual HIV screening for high-risk groups and testing every 5 years for the general population (a strategy shown to be cost-effective in India even as an isolated intervention), 9 out of 10 PLWH could achieve and maintain awareness of HIV status by 2020 and beyond. 34 In the context of achieving 90-90-90 targets, improved screening would likely yield even greater epidemiological benefits and improved cost-effectiveness, as newly diagnosed individuals would rapidly integrate into care and achieve viral suppression. However, even after initiation of ART, many Indians face delays in detection of viral failure and subsequent treatment modification to alternative ART regimens, as only nine laboratories are qualified to cover viral load testing requests for all of India.…”

The impact of antiretroviral therapy in resource‐limited settings and current HIV therapeutics

“…Lancet 364: 3-4. Kumarasamy N (2013). Cell-the lancet translational medicine conf, San Francisco-Nov 3-5, 2013.…”

“…A recently presented cohort study in India had shown that significant number of persons were on ART for more than 10 years (Kumarasamy, 2013). The major reason for inpatient care in this cohort is due to the non-AIDS complications including diabetes, cardiac, renal, liver, malignancy, and neurocognitive impairment.…”

Factors associated with HIV testing among male injecting drug users: findings from a cross-sectional behavioural and biological survey in Manipur and Nagaland, India

“…HIV testing is a cost-effective strategy for the reduction of HIV risk and transmission [ 5 ] and provides an entry point for prevention, treatment and care. Early HIV diagnosis can lead to timely initiation of treatment [ 6 – 8 ] and knowledge of sero-positive status through testing can lead to the adoption of safer injection and sexual behaviours [ 2 , 9 – 13 ].…”

“…In India, the majority of IDUs are from the states of Manipur and Nagaland, two high HIV prevalence states where the HIV epidemic is primarily driven by injection drug use [ 6 ] [ 5 ]. The vast majority of IDUs in Manipur and Nagaland are male [ 16 ], and approximately 2 % of the adult population in these states engage in injecting drugs, mainly heroin and spasmo-proxyvon (a synthetic opioid analgesic) [ 17 ].…”