Using cost-effectiveness league tables to compare interventions to prevent sexual transmission of HIV.

Cost-effectiveness information is needed to help public health decision makers choose between competing HIV prevention programs. One way to organize this information is in a 'league table' that lists cost-effectiveness ratios for different interventions and which facilitates comparisons across interventions. Herein we propose a common outcome measure for use in HIV prevention league tables and present a preliminary league table of interventions to reduce sexual transmission of HIV in the US. Fifteen studies encompassing 29 intervention for different population groups are included in the table. Approximately half of the interventions are cost-saving (i.e. save society money, in the long run), and three-quarters are cost-effective by conventional standards. We discuss the utility of such a table for informing the HIV prevention resource allocation process and delineate some of the difficulties associated with the league table approach, especially as applied to HIV prevention cost-effectiveness analysis.

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention.

OBJECTIVE: To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections. METHOD: The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost. RESULTS: Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million. CONCLUSION: Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

Counseling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests.

New rapid human immunodeficiency virus (HIV) antibody tests permit many individuals to receive test results and appropriate counseling at one clinic visit. Because currently used tests require significant time for processing, all individuals must return for a second visit for test results and counseling. Since return rates for the second visit are low, the more rapid tests present an opportunity to improve the efficiency of HIV counseling and testing. The authors compared the costs and effectiveness of the currently used counseling and testing procedure and a streamlined procedure made possible by the new, more rapid screening tests. When test-positive clients are given preliminary screening test results, the rapid procedure is more cost-effective than the current procedure. Since over 90% of the clients in most clinics will test negative, the rapid counseling and testing procedure allows the vast majority of clients to be counseled and tested and to receive their results and posttest counseling in one visit. However, in the case where the goal of HIV counseling and testing is to focus only on infected individuals, if information regarding a positive result from the rapid screening test is not given to clients at the initial visit before a confirmatory test is performed, then the rapid counseling and testing procedure is not more cost-effective than the current procedure.

Hours at work and employment status among HIV-infected patients.

OBJECTIVE: To study differences in employment and work hours among three groups of HIV-infected and non-infected individuals. METHODS: Data on 1263 patients seen in five different sites in California were drawn from the AIDS Time-Oriented Health Outcome Study. Three groups of patients were examined: AIDS patients, HIV-positives without diagnosed AIDS, and HIV-negatives. The HIV-negative patients were used as a comparison group in comparing hours worked by all patients, whether they worked or not; the probability of working, regardless of the number of hours; and work hours only for those patients who worked. RESULTS: Adjustment for covariates in a 2-equation econometric model reduced the difference in employment rates between the AIDS patients and the other two groups, suggesting that characteristics other than AIDS status account, in part, for their low employment rates. After adjustment, we did not find any statistically significant differences in employment probabilities or work hours between the HIV-positive patients without diagnosed AIDS and the comparison group. However, AIDS patients reported approximately 14 work hours fewer (P < 0.0001) and lower probabilities of employment (P < 0.0001) than the HIV-negative comparison group among all patients with and without jobs. Moreover, among those with jobs, patients with AIDS reported approximately 3 work hours fewer per week (P = 0.0385). No statistically significant differences in work hours were found between HIV-positives without diagnosed AIDS and comparison patients. CONCLUSION: AIDS patients were less likely to be employed than either of the other groups, but crude, unadjusted unemployment rates exaggerate the effect of AIDS. For those employed, AIDS patients work only 3 h less per week than either of the other groups.

Defining and measuring the costs of the HIV epidemic to business firms.

Most published estimates of the costs of the epidemic of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) have been developed from the societal perspective, attempting to measure the burden of the epidemic to society in this country. Although societal cost analysis is well-developed, relatively little is known about many of the factors influencing the costs of the epidemic to business firms. The business community may bear a substantial portion of those costs in the form of health-related benefits provided to workers. Other effects of the epidemic in the workplace are related to fears and stigma associated with the illness. The author compares frameworks for analyzing the costs of the epidemic to the business community and to society. Societal costs include direct costs, the resources used in providing health care, and indirect costs, the resources lost to society as a result of the epidemic. Costs to business include illness-based employment costs, legal or administrative costs, prevention costs, perception-based employment costs, care giver costs, and nonmonetary costs. Not all societal costs are borne by business, and businesses may incur costs that are not traditionally measured from the societal perspective.

Estimating the value of preventing a human immunodeficiency virus infection.

We estimated the medical cost savings for a case of human immunodeficiency virus (HIV) infection prevented. Using medical care cost estimates, assumptions concerning knowledge of serostatus, time spent in various stages of HIV disease, and a discount factor, we estimated the present value of future cost savings for a case of HIV prevented, which ranged from $56,000 to $80,000. Since this method excludes both indirect costs and direct costs other than medical care, these figures underestimate the true cost savings for a case of HIV prevented. However, the method may prove useful in assigning a systematic economic value to an HIV infection averted that can be used in cost-benefit analyses of HIV prevention interventions.

Costs to business for an HIV-infected worker.

We use a Markov model to calculate the expected medical, disability, employee replacement, life insurance, and pension costs to a business firm for an HIV-infected employee. This analysis differs from previous HIV/AIDS cost analyses because we take the perspective of a business firm rather than of society, and we focus on the expected costs over a time frame relevant for business decision making. The maximum expected five-year cost to a business firm for an HIV-infected employee is estimated at $32,000, with an average expected cost of $17,000. These expected employment-based costs are less than the lifetime medical AIDS costs to society for an individual, which are estimated at more than $85,000. Employment-based costs are most influenced by the type of benefits provided under employer-based health insurance plans.

Knowledge, attitudes, beliefs, and behaviors of the business community relative to HIV-AIDS.

One of the goals of the Centers for Disease Control's (CDC) policy on the prevention of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) is to support business organizations in implementing HIV and AIDS information, education, and prevention activities. However, the response of the American business community to HIV infection and AIDS has been varied. Although company executives consider AIDS to be one of the leading problems in the country, surveys typically indicate that less than one-third of businesses have or are developing some type of AIDS policy. The workplace appears to be a valid site for AIDS information and education programs, given the weight employees attach to information received there. However, workplace education and information programs are undertaken primarily by large companies. Many small companies do not devote much time and effort to these activities, even though extensive, indepth educational programs are likely to have positive impacts on worker attitudes and behavior, whereas short programs or literature distribution may only increase workers' fears. The question of what is an effective workplace program still needs additional research. Very little is known about the magnitude of the costs of HIV infection and AIDS to business. These costs, which are affected by the changing roles of employer-based health insurance, cost shifting, and public programs, will influence how employers react to the epidemic and how they respond to CDC's prevention initiatives.