Optimizing PMTCT efforts by repeat HIV testing during antenatal and perinatal care in resource-limited settings: A longitudinal assessment of HIV seroconversion.

BACKGROUND: Mother to child transmission (MTCT) of HIV remains a challenge in resource-limited settings. Central to elimination of MTCT is effective Provider Initiated HIV Counseling and Testing (PICT). Research has shown that conducting PICT only at the initial antenatal care (ANC) visit fails to benefit pregnant women who seroconvert later in their pregnancy. This study aimed to determine the most cost effective time to perform repeat HIV testing during ANC and perinatal care (PNC). METHODS: We studied the repeat HIV testing results of pregnant women ≥ 18 and adolescent girls aged 15-17 in the Sauri, Kenya Millennium Villages Project (MVP) site. Nurses provided HIV screening to 1,403 expectant women and 256 adolescent girls following the 1st, 2nd, 3rd and 4th ANC visits, at birth and 6 and 14 weeks postpartum. RESULTS: Five women seroconverted during the study period (incidence proportion 0.41%). One woman seroconverted at the 2nd ANC visit, another one at the 3rd, two at the 4th and one at 6 weeks post-partum. Of all the women who seroconverted, four reported an HIV negative primary partner, while one reported an unknown partner status. None of the participants reported condom use during pregnancy. Two of the seroconverters vertically transmitted HIV to their babies. The results did not suggest a clear pattern of seroconversion during ANC and PNC. CONCLUSIONS: The low rates of seroconversion suggest that testing pregnant women multiple times during ANC and PNC may not be cost effective, but a follow-up test during birth may be protective of the newborn.

Organization of funding for community-based HIV testing in Côte d'Ivoire: potentially counterproductive search for efficiency?

Since the early 2010s, the President's Emergency Plan for AIDS Relief (Pepfar) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have stiffened their result-based management strategies. Disbursement conditions are increasingly demanding for funded NGOs (achievement of quantified objectives, frequent reporting, and monitoring of activities), and their remuneration depends on the results achieved. This article aims to analyze the effects of this strengthening of policies based on New Public Management on local implementation of activities, based on the example of community-based HIV testing. In three health districts of Côte d'Ivoire, in 2015 and 2016, we mapped the actors involved in community-based HIV testing and conducted semi-directive interviews with members of the community-based NGOs (n = 18). The funding of local HIV testing organizations is channeled through intermediary organizations according to a complex pyramid system. This, combined with cumbersome activity reporting and data validation, results in delays in the disbursement of funds and significantly reduces the actual time available to implement activities, i.e., to less than half the time planned for this purpose. This managerialization -of both Pepfar and the Global Fund - produces the counterproductive effects against which it was supposed to fight.

Cost implications of HIV retesting for verification in Africa.

INTRODUCTION: HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. METHODS: We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. RESULTS AND DISCUSSION: The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. CONCLUSIONS: Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO's recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.

HIV Prevention Practices and Non-Federal Funding Among U.S. States and Non-State Regions: A Survey of HIV/AIDS Directors.

We surveyed U.S. HIV/AIDS directors or designees in states and non-state regions, regarding factors influencing HIV viral suppression: (1) non-federal prevention funding; (2) contacting newly reported patients and providers, for care linkage and partner services; (3) follow-up of non-received viral load reports, to identify untreated patients; and (4) genotype/phenotype surveillance, to monitor drug resistance. The survey was conducted April-July 2015; 50 (87.7%) participated. Eighty percent of jurisdictions contacted all newly reported patients; 60% contacted all providers. HIV resistance tests were reportable in 38%; 66% contacted providers and/or patients about missed viral loads. Non-federal funding was significantly associated with annual diagnoses (p = .0001) and population (p = .0002), but not with other factors studied. Many jurisdictions lacked non-federal funding (28%), or experienced unrestored reductions since 2008 (33%). Jurisdictions' funding and preventive practices varied greatly. HIV viral suppression could be enhanced by restoring (or establishing) non-federal prevention funding, and by more standardized surveillance/outreach practices.

Assessing Differences in CDC-Funded HIV Testing by Urbanicity, United States, 2016.

HIV prevention efforts have contributed to a decline in annual HIV infections in the United States. However, progress has been uneven and certain groups and geographic areas continue to be disproportionately affected. Subsequent to implementation of CDC's high-impact HIV prevention approach to reducing new infections, we analyzed national-level CDC-funded HIV test data from 2016 to describe the population being reached in three urbanicity settings (metropolitan: ≥ 1,000,000 population; urban: 50,000-999,999; rural: < 50,000). Over 70% of CDC-funded HIV tests and almost 80% of persons newly diagnosed with HIV as a result of CDC-funded testing occurred in metropolitan areas. Nonetheless, CDC-funded testing efforts are reaching urban and rural areas, especially in the South, providing opportunities to identify persons unaware of their HIV status and link those with newly diagnosed HIV to medical care and prevention services. While CDC-funded testing efforts have continued to focus on population subgroups and geographic areas at greatest risk, efforts should also continue in rural areas and among groups in need with a low national burden.

Social franchising of community-based HIV testing and linkage to HIV care and treatment services: an evaluation of a pilot study in Tshwane, South Africa.

INTRODUCTION: Although HIV testing services (HTS) have been successfully task-shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small-scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS-managed pilot project compared to the Foundation for Professional Development (FPD) employee-managed HTS programme in testing and linking clients to care. METHODS: Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV-prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per-HIV test and received larger payments per-HIV-positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per-counsellor cost of HIV test and linkage to care in the two HTS groups. RESULTS: The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first-time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV-positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). CONCLUSIONS: SF HTS was effective in identifying more clients, first-time HIV testers and more HIV-positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD-employee model. We recommend strengthening SFs particularly their linkage to care activities.

Cost-Effectiveness of Voluntary HIV Testing Strategies in a Very Low-Prevalence Country, the Republic of Korea.

BACKGROUND: The Republic of Korea has a very low prevalence of human immunodeficiency virus (HIV) infection, but the number of new HIV diagnoses has steadily risen, strongly indicating a large number of undetected HIV infections. Thus, it is important for Korean public health authorities to adopt and encourage cost-effective HIV detection tools, such as rapid HIV screening tests. In this study, we aimed to evaluate the cost-effectiveness of enzyme-linked immunosorbent assays (ELISA) and rapid tests in a public health center (PHC) setting. METHODS: We developed a decision analytic model to assess the per-examinee cost and the cost-effectiveness of identifying HIV patients in a PHC setting using two HIV testing strategies: conventional HIV screening by ELISA versus rapid HIV testing. Analysis was performed in two scenarios: HIV testing in an average-risk population and in a high-risk population. RESULTS: Compared to the ELISA, the rapid test was cost-saving and cost-effective. The per-examinee cost was USD 1.61 with rapid testing versus USD 3.38 with ELISA in an average-risk population, and USD 4.77 with rapid testing versus USD 7.62 with ELISA in a high-risk population. The cost of identifying a previously undiagnosed HIV case was USD 26,974 with rapid testing versus USD 42,237 with ELISA in an average-risk population, and USD 153 with rapid testing versus USD 183 with ELISA in a high-risk population. CONCLUSION: Rapid testing would be more cost-effective than using conventional ELISA testing for identifying previously undiagnosed HIV-infected cases in Korea, a country with extremely low HIV prevalence.

The Cost and Cost-utility of Three Public Health HIV Case-finding Strategies: Evidence from Rhode Island, 2012-2014.

To evaluate three testing strategies to identify new HIV diagnoses in Rhode Island (RI). RI deployed three testing strategies, by using rapid HIV tests at clinical settings, community-based organization (CBO) settings, and the Partner Notification Services (PNS) program from 2012 to 2014. We reviewed the rapid HIV test results and confirmatory test results to identify new diagnoses, and conducted a cost-utility analysis. The average cost per new diagnosis was $33,015 at CBO settings, $5446 at clinical settings, and $33,818 at the PNS program. The cost-utility analysis showed the state-wide program was cost-saving; testing was cost-saving at clinical settings, and cost-effective at CBO settings and the PNS program. Further analyses showed that cost-effectiveness varied widely across CBOs. The HIV testing expansion program in RI was cost-saving overall. The heterogeneity of cost-effectiveness across settings should provide guidance to officials for allocation of future resources to HIV testing.

Comparison of turnaround time and total cost of HIV testing before and after implementation of the 2014 CDC/APHL Laboratory Testing Algorithm for diagnosis of HIV infection.

BACKGROUND: Updated recommendations for HIV diagnostic laboratory testing published by the Centers for Disease Control and Prevention and the Association of Public Health Laboratories incorporate 4th generation HIV immunoassays, which are capable of identifying HIV infection prior to seroconversion. OBJECTIVES: The purpose of this study was to compare turnaround time and cost between 3rd and 4th generation HIV immunoassay-based testing algorithms for initially reactive results. STUDY DESIGN: The clinical microbiology laboratory database at Mayo Clinic, Rochester, MN was queried for 3rd generation (from November 2012 to May 2014) and 4th generation (from May 2014 to November 2015) HIV immunoassay results. All results from downstream supplemental testing were recorded. Turnaround time (defined as the time of initial sample receipt in the laboratory to the time the final supplemental test in the algorithm was resulted) and cost (based on 2016 Medicare reimbursement rates) were assessed. RESULTS: A total of 76,454 and 78,998 initial tests were performed during the study period using the 3rd generation and 4th generation HIV immunoassays, respectively. There were 516 (0.7%) and 581 (0.7%) total initially reactive results, respectively. Of these, 304 (58.9%) and 457 (78.7%) were positive by supplemental testing. There were 10 (0.01%) cases of acute HIV infection identified with the 4th generation algorithm. The most frequent tests performed to confirm an HIV-positive case using the 3rd generation algorithm, which were reactive initial immunoassay and positive HIV-1 Western blot, took a median time of 1.1 days to complete at a cost of $45.00. In contrast, the most frequent tests performed to confirm an HIV-positive case using the 4th generation algorithm, which included a reactive initial immunoassay and positive HIV-1/-2 antibody differentiation immunoassay for HIV-1, took a median time of 0.4 days and cost $63.25. Overall median turnaround time was 2.2 and 1.5 days, and overall median cost was $63.90 and $72.50 for 3rd and 4th generation algorithms, respectively. CONCLUSIONS: Both 3rd and 4th generation HIV immunoassays had similar total numbers of tests performed and positivity rates during the study period. A greater proportion of reactive 4th generation immunoassays were confirmed to be positive, and the 4th generation algorithm identified several cases of acute HIV infection that would have been missed by the 3rd generation algorithm. The 4th generation algorithm had a more rapid turnaround time but higher cost for confirmed positive HIV infections and overall, compared to the 3rd generation algorithm.

Latent class analysis of acceptability and willingness to pay for self-HIV testing in a United States urban neighbourhood with high rates of HIV infection.

INTRODUCTION: Acceptability and willingness to both take and pay for HIV self-tests (HIVSTs) in US neighbourhoods with high rates of HIV infection are not well understood. METHODS: We surveyed 1,535 individuals about acceptability and willingness to take and pay for an HIVST in a predominately African American neighbourhood with 3% HIV seroprevalence. We recruited individuals presenting for HIV screening services in a community-based programme. Latent class analysis (LCA) grouped individuals with similar patterns of HIV-risk behaviours and determined which groups would be most willing to use and buy HIVSTs. RESULTS: Nearly 90% of respondents were willing to use an HIVST; 55% were willing to buy HIVSTs, but only 23% were willing to pay the market price of US $40. Four distinct groups emerged and were characterized by risk behaviours: (1) low risk (N = 324); (2) concurrent partnerships (N = 346); (3) incarceration and substance use (N = 293); and (4) condomless sex/multiple partners (N = 538). Individuals in the low-risk class were less willing to self-test compared to concurrent sexual partners (OR = 0.39, p = .003) and incarceration and substance use (OR = 0.46, p = .011) classes. There were no significant differences across classes in the amount individuals were willing to pay for an HIVST. CONCLUSION: HIVSTs were overwhelmingly acceptable but cost prohibitive; most participants were unwilling to pay the market rate of US $40. Subsidizing and implementing HIVST programmes in communities with high rates of infection present a public health opportunity, particularly among individuals reporting condomless sex with multiple partners, concurrent sexual partnerships and those with incarceration and substance use histories.

Investing for Impact: The Global Fund Approach to Measurement of AIDS Response.

The Global Fund raises and invests nearly US$4 billion a year to support programs run in more than 140 countries. The Global Fund strategy 2012-2016 is focused on "Investing for Impact". In order to accomplish this, timely and accurate data are needed to inform strategies and prioritize activities to achieve greater coverage with quality services. Monitoring and evaluation is intrinsic to the Global Fund's system of performance-based funding. The Global Fund invests in strengthening measurement and reporting of results at all stages of the grant cycle. The Global Fund approach to measurement is based on three key principles-(1) simplified reporting: the Global Fund has updated its measurement guidance to focus on impact, coverage and quality with the use of a harmonized set of indicators. (2) Supporting data systems-based on a common framework developed and supported by partners, it promotes investment in five common data systems: routine reporting including HMIS; Surveys-population based and risk group surveys; Analysis, reviews and transparency; Administrative and financial data sources; and, Vital registration systems. (3) Strengthen data use: the Global Fund funding encourages use of data at all levels-national, subnational and site level. Countries do not automatically prioritize M&E but when guidance, tools and investments are available, there is high level utilization of M&E systems in program design, planning, implementation, and results reporting. An in-depth analysis of the available data helps the Global Fund and countries to direct investments towards interventions where impact could be achieved and focus on target population groups and geographic areas that are most affected.

Cost-utility of HIV Testing Programs Among Men Who Have Sex with Men in the United States.

Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.

Patients' Willingness to Participate in Rapid HIV Testing: A pilot study in three New York City dental hygiene clinics.

Purpose: One in eight people living with an HIV infection in the United States is unaware of their status. Rapid HIV testing (RHT) is an easily used and accepted screening tool that has been introduced in a limited number of clinical settings. The purpose of this study was to investigate patient acceptability, certainty of their decision, and willingness to pay for screening if RHT was offered in university-based dental hygiene clinics.Methods: A cross-sectional survey was administered to 426 patients at three dental hygiene clinics in New York City over a period of four months. The survey questionnaire was based on the decisional conflict scale measuring personal perceptions; with zero indicating extremely high conflict to four indicating no conflict. Patients were assessed for their acceptance of RHT, provider preference for administration of the test and their willingness to pay for RHT.Results: Over half (72.2%) indicated acceptance of HIV testing in a dental hygiene clinic setting; with 85.3% choosing oral RHT, 4.9% fingerstick RHT, and 8.8% venipuncture. Respondents were amenable to testing when offered by dental hygienists (71.7%) and dentists (72.4%). Over 30% indicated their willingness to receive HIV testing in the dental setting when offered at no additional cost. The mean decisional conflict score was 3.42/4.0 indicating no decisional conflict.Conclusions: Patients are willing to undergo oral RHT when offered as a service and provided by dental hygienists in the dental setting. Patients appear to be aware of the benefits and risks associated with RHT. Further research is needed to evaluate the public health benefits and logistical challenges facing the delivery of RHT within in the dental setting.

Centers for Disease Control and Prevention-Funded Human Immunodeficiency Virus Testing, Positivity, and Service Delivery among Newly Diagnosed Women in 61 Health Department Jurisdictions, United States, 2014.

BACKGROUND: More than 1.2 million persons are living with human immunodeficiency virus (HIV) in the United States; at the end of 2011, 23% of them were women. Minority women are disproportionately affected by HIV, and new infections are higher among older women. HIV testing and service delivery among women funded by the U.S. Centers for Disease Control and Prevention (CDC) is examined. METHODS: Data were submitted by 61 health department jurisdictions. HIV testing, HIV-positive tests, new HIV diagnoses among women, and linkage and referral services among newly diagnosed women are described. Differences across demographic characteristics for HIV diagnoses, linkage, and referral services were assessed. Diagnoses were identified as new when women who tested HIV positive were not found to be reported previously in the jurisdiction's HIV surveillance system; when jurisdictions could not verify prior test results in their surveillance systems, new diagnoses were identified by self-report. RESULTS: Of CDC-funded testing events in 2014, 1,484,902 (48.7%) were among women, and they accounted for 19.5% of all HIV-positive testing events. Among women tested, 0.4% were HIV positive, and 0.1% had new HIV diagnoses. Women aged 40 and older and Black women were more likely to test HIV positive (0.7% and 0.5%, respectively). Among newly diagnosed women, 62.8% were linked within any timeframe, 57.1% were linked within 90 days, 74.1% were referred to partner services, 57.5% were interviewed for partner services, and 55.5% were referred to HIV risk reduction services. CONCLUSIONS: Among all women receiving CDC-funded HIV testing, Black women and older women were more likely to have HIV-positive tests and new diagnoses. Although women overall may not be at the highest risk for HIV, Black women in this sample are disproportionately affected. Additionally, linkage, referral, and interview services for women need improvement. Targeted testing approaches may ensure effective test-and-treat strategies for women.

Modeling the Cost-Effectiveness of Home-Based HIV Testing and Education (HOPE) for Pregnant Women and Their Male Partners in Nyanza Province, Kenya.

INTRODUCTION: Women in sub-Saharan Africa face a 2-fold higher risk of HIV acquisition during pregnancy and postpartum and the majority do not know the HIV status of their male partner. Home-based couple HIV testing for pregnant women can reduce HIV transmission to women and infants while increasing antiretroviral therapy (ART) coverage in men. However, the cost-effectiveness of this program has not been evaluated. METHODS: We modeled the health and economic impact of implementing a home-based partner education and HIV testing (HOPE) intervention for pregnant women and their male partners in a region of Western Kenya (formally Nyanza Province). We used data from the HOPE randomized clinical trial conducted in Kisumu, Kenya, to parameterize a mathematical model of HIV transmission. We conducted an in-country microcosting of the HOPE intervention (payer perspective) to estimate program costs as well as a lower cost scenario of task-shifting to community health workers. RESULTS: The incremental cost of adding the HOPE intervention to standard antenatal care was $31-37 and $14-16 USD per couple tested with program and task-shifting costs, respectively. At 60% coverage of male partners, HOPE was projected to avert 6987 HIV infections and 2603 deaths in Nyanza province over 10 years with an incremental cost-effectiveness ratio (ICER) of $886 and $615 per disability-adjusted life year averted for the program and task-shifting scenario, respectively. ICERs were robust to changes in intervention coverage, effectiveness, and ART initiation and dropout rates. CONCLUSIONS: The HOPE intervention can moderately decrease HIV-associated morbidity and mortality by increasing ART coverage in male partners of pregnant women. ICERs fall below Kenya's per capita gross domestic product ($1358) and are therefore considered cost-effective. Task-shifting to community health workers can increase intervention affordability and feasibility.

Unmet HIV Service Needs Among Hispanic Men who Have Sex with Men in the United States.

The National HIV/AIDS Strategy (NHAS) originally issued in 2010 targets the reduction of HIV-related health disparities. Hispanic men who have sex with men (MSM) have the third highest burden of incident HIV in the US, but there are no estimates of the unmet HIV service needs for Hispanic MSM. We estimate that of approximately 204,800 Hispanic MSM living with HIV, roughly 46,900 were undiagnosed. 157,900 were diagnosed, and of those, 75,700 were not linked to care and 82,200 were linked. Among diagnosed individuals, 48,800 had undetectable viral loads, and 109,100 had detectable viral loads. An estimated 30,000 of diagnosed Hispanic MSM engage in unprotected, serodiscordant risk behaviors. Total cost to meet service needs and achieve NHAS goals is ~$2.511 billion in 2011 US dollars. Transmission rate modeling suggests this investment would avert 3656 new HIV infections at an economically favorable cost of $61,202 per quality-adjusted life year saved.