Comparison of effectiveness and cost for different HIV screening strategies implemented at large urban medical centre in the United States

Abstract

Introduction Incident HIV infections persist in the United States (U.S.) among marginalized populations. Targeted and cost‐efficient testing strategies can help in reaching HIV elimination. This analysis compares the effectiveness and cost of three HIV testing strategies in a high HIV burden area in the U.S. in identifying new HIV infections. Methods We performed a cost analysis comparing three HIV testing strategies in Chicago: (1) routine screening (RS) in an inpatient and outpatient setting, (2) modified partner services (MPS) among networks of the recently HIV infected and diagnosed, and (3) a respondent drive sampling (RDS)‐based social network (SN) approach targeting young African‐American men who have sex with men. All occurred at the same academic medical centre during the following times: routine testing, 2011 to 2016; MPS, 2013 to 2016; SN: 2013 to 2014. Costs were in 2016 dollars and included personnel, HIV testing, training, materials, overhead. Outcomes included cost per test, HIV‐positive test and new diagnosis. Sensitivity analyses were performed to assess the impact of population demographics. Results The RS programme completed 57,308 HIV tests resulting in 360 (0.6%) HIV‐positive tests and 165 new HIV diagnoses (0.28%). The MPS completed 146 HIV tests, resulting in 79 (54%) HIV‐positive tests and eight new HIV diagnoses (5%). The SN strategy completed 508 HIV tests, resulting in 210 (41%) HIV‐positive tests and 37 new HIV diagnoses (7.2%). Labour accounted for the majority of costs in all strategies. The estimated cost per new HIV diagnosis was $16,773 for the RS programme, $61,418 for the MPS programme and $15,683 for the SN testing programme. These costs were reduced for the RS and MPS strategies in sensitivity analyses limiting testing efficacy to the highest prevalence patient populations ($2,841 and $33,233 respectively). Conclusions The SN strategy yielded the highest proportion of new diagnoses, followed closely by the MPS programme. Both the SN strategy and RS programme were comparable in the cost per new diagnosis. A simultaneous approach that consists of RS in combination with SN testing may be most effective for identifying new HIV infections in settings with heterogeneous epidemics with both high rates of HIV prevalence and HIV testing.

Do partner services linked to molecular clusters yield people with viremia or new HIV?

“…The project, named ‘Project Conéctate’ by CDC, was initiated in 2017 with project close-out and results expected in 2021. Notably, Houston utilized a social network strategy which may have several strengths as a network approach when compared with traditional partner services that were utilized in this analysis [23]. Despite lack of evidence of impact highlighted by our findings, cluster detection and response has shown promising results in identifying prevention and care service gaps and needs of specific populations.…”

Leveraging social networks for identification of people with HIV who are virally unsuppressed

“…Previous research has found that strategies that elicit social rather than sexual contacts are effective at identifying individuals' OoC and unaware of their HIV infection [19,20,23,[39][40][41][42][43]. Moreover, a recent systematic study concluded that SNS is an effective way of reaching urban BSMM who are at high risk but not engaged with the healthcare system [44].…”

“…In addition, naming a friend, or family member rather than a sex partner also decreases stigma [18][19][20]. This 'social network strategy' (SNS) is promoted by the CDC, with studies showing that up to 6% of people tested using SNS are unaware of their HIV infection [5,[21][22][23].…”

HIV testing in a high prevalence urban area in the US: Identifying missed opportunities two ways

“…Employing complementary HIV screening approaches is likely to be most effective at identifying new diagnoses. 35 To supplement routine screening in a systemic way, we need better sexual history-taking and structured EMR documentation to identify those patients with reasons to test more frequently, as well as coupling HIV testing with other bacterial STI testing, all while leveraging automated processes within the EMR as much as possible. 36,37 Expanding the reach of HIV testing can improve earlier diagnosis of HIV and increase the number of PLWH who are aware of their diagnosis.…”