Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program?

BACKGROUND: With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program. METHODS: Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services. RESULTS: The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program. CONCLUSIONS: The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.

Development of a Mathematical Model to Estimate the Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program.

BACKGROUND: The Health Resources and Services Administration's Ryan White HIV/AIDS Program provides services to more than half of all people diagnosed with HIV in the United States. We present and validate a mathematical model that can be used to estimate the long-term public health and cost impact of the federal program. METHODS: We developed a stochastic, agent-based model that reflects the current HIV epidemic in the United States. The model simulates everyone's progression along the HIV care continuum, using 2 network-based mechanisms for HIV transmission: injection drug use and sexual contact. To test the validity of the model, we calculated HIV incidence, mortality, life expectancy, and lifetime care costs and compared the results with external benchmarks. RESULTS: The estimated HIV incidence rate for men who have sex with men (502 per 100,000 person years), mortality rate of all people diagnosed with HIV (1663 per 100,000 person years), average life expectancy for individuals with low CD4 counts not on antiretroviral therapy (1.52-3.78 years), and lifetime costs ($362,385) all met our validity criterion of within 15% of external benchmarks. CONCLUSIONS: The model represents a complex HIV care delivery system rather than a single intervention, which required developing solutions to several challenges, such as calculating need for and receipt of multiple services and estimating their impact on care retention and viral suppression. Our strategies to address these methodological challenges produced a valid model for assessing the cost-effectiveness of the Ryan White HIV/AIDS Program.

Factors Associated with State Variation in Mortality Among Persons Living with Diagnosed HIV Infection.

In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

Reducing HIV-Related Health Disparities in the Health Resources and Services Administration's Ryan White HIV/AIDS Program.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) supports direct health care treatment and support services to more than 50% of all people living with diagnosed HIV in the United States. A critical goal of the RWHAP is to reduce HIV-related health disparities to help end the HIV epidemic. From 2010 through 2016, the RWHAP made significant progress reducing viral suppression disparities among client populations, particularly among women, transgender persons, youths, Blacks or African Americans, and unstably housed clients. To assist with the reduction of the remaining disparities in HIV-related health outcomes among clients, the RWHAP continues to support planning and resource allocation for RWHAP Parts A through D and AIDS Drug Assistance Program, as well as through implementing policy and program initiatives, Special Projects of National Significance, evaluation studies, and collaborations to disseminate effective interventions.

Health Center Patients' Insurance Status and Healthcare Use Prior to Implementation of the Affordable Care Act.

INTRODUCTION: U.S. health centers provide primary and preventive care to underserved populations, including low-income and uninsured patients. The purpose of this study is to examine patterns of publicly funded health center use according to patient insurance status (private, public, none), prior to implementation of the Affordable Care Act. METHODS: National data came from the 2009 Health Center Patient Survey, and were analyzed in 2013. Descriptive analysis of health center patient insurance coverage and health center utilization variables was conducted, followed by adjusted multivariate analysis. RESULTS: About 91% of uninsured patients received at least half their annual healthcare visits at a health center, and 86% had at least one usual source of care that included a health center; these rates were not significantly different from those for publicly or privately insured patients. About half of uninsured patients (48%) had long tenures at the health center (≥3 years since first visit), not significantly different from the publicly insured (52%), but lower than the privately insured (63%, p<0.01). Uninsured patients highlighted affordability as the main reason for visiting a health center, whereas insured patients emphasized convenient location and quality of care. CONCLUSIONS: Insured patients used health centers for the majority of their care, and in similar proportions to their uninsured counterparts. The primary motivation for visiting a health center differed based on insurance type. Future studies should be able to examine whether health center demand across insurance categories follows a similar pattern following the Affordable Care Act insurance coverage expansions.

Cost-effectiveness analysis of active surveillance screening for methicillin-resistant Staphylococcus aureus in an academic hospital setting.

OBJECTIVE: To evaluate the cost-effectiveness of 3 alternative active screening strategies for methicillin-resistant Staphylococcus aureus (MRSA): universal surveillance screening for all hospital admissions, targeted surveillance screening for intensive care unit admissions, and no surveillance screening. DESIGN: Cost-effectiveness analysis using decision modeling. METHODS: Cost-effectiveness was evaluated from the perspective of an 800-bed academic hospital with 40,000 annual admissions over the time horizon of a hospitalization. All input probabilities, costs, and outcome data were obtained through a comprehensive literature review. Effectiveness outcome was MRSA healthcare-associated infections (HAIs). One-way and probabilistic sensitivity analyses were conducted. RESULTS: In the base case, targeted surveillance screening was a dominant strategy (ie, was associated with lower costs and resulted in better outcomes) for preventing MRSA HAI. Universal surveillance screening was associated with an incremental cost-effectiveness ratio of $14,955 per MRSA HAI. In one-way sensitivity analysis, targeted surveillance screening was a dominant strategy across most parameter ranges. Probabilistic sensitivity analysis also demonstrated that targeted surveillance screening was the most cost-effective strategy when willingness to pay to prevent a case of MRSA HAI was less than $71,300. CONCLUSION: Targeted active surveillance screening for MRSA is the most cost-effective screening strategy in an academic hospital setting. Additional studies that are based on actual hospital data are needed to validate this model. However, the model supports current recommendations to use active surveillance to detect MRSA.