Reducing infection transmission in solid organ transplantation through donor nucleic acid testing: a cost-effectiveness analysis.

For solid organ transplant (SOT) donors, nucleic acid-amplification testing (NAT) may reduce human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission over antibody (Ab) testing given its shorter detection window period. We compared SOT donor NAT + Ab versus Ab alone using decision models to estimate incremental cost-effectiveness ratios (ICERs; cost per quality-adjusted life year [QALY] gained) from the societal perspective across a range of HIV/HCV prevalence values and NAT costs. The cost per QALY gained was calculated for two scenarios: (1) favorable: low cost ($150/donor)/high prevalence (HIV: 1.5%; HCV: 18.2%) and (2) unfavorable: high cost ($500/donor)/low prevalence (HIV: 0.1%; HCV: 1.5%). In the favorable scenario, adding NAT screening cost $161 013 per QALY gained for HIV was less costly) for HCV, and cost $86 653 per QALY gained for HIV/HCV combined. For the unfavorable scenario, the costs were $15 568 484, $221 006 and $10 077 599 per QALY gained, respectively. Universal HCV NAT + Ab for donors appears cost-effective to reduce infection transmission from SOT donors, while HIV NAT + Ab is not, except where HIV NAT is ≤$150/donor and prevalence is ≥1.5%. Our analyses provide important data to facilitate the decision to implement HIV and HCV NAT for deceased SOT donors and shape national policy regarding how to reduce infection transmission in SOT.

Targeted screening and treatment for latent tuberculosis infection using QuantiFERON-TB Gold is cost-effective in Mexico.

OBJECTIVE: To assess the cost-effectiveness of screening for latent tuberculosis infection (LTBI) using a commercially available detection test and treating individuals at high risk for human immunodeficiency virus (HIV) infection in a middle-income country. DESIGN: We developed a Markov model to evaluate the cost per LTBI case detected, TB case averted and quality-adjusted life year (QALY) gained for a cohort of 1000 individuals at high risk for HIV infection over 20 years. Baseline model inputs for LTBI prevalence were obtained from published literature and cross-sectional data from tuberculosis (TB) screening using QuantiFERON-TB Gold In-Tube (QFT-GIT) testing among sex workers and illicit drug users at high risk for HIV recruited through street outreach in Tijuana, Mexico. Costs are reported in 2007 US dollars. Future costs and QALYs were discounted at 3% per year. Sensitivity analyses were performed to evaluate model robustness. RESULTS: Over 20 years, we estimate the program would prevent 78 cases of active TB and 55 TB-related deaths. The incremental cost per case of LTBI detected was US$730, cost per active TB averted was US$529 and cost per QALY gained was US$108. CONCLUSIONS: In settings of endemic TB and escalating HIV incidence, targeting LTBI screening and treatment among high-risk groups may be highly cost-effective.

Education status among orphans and non-orphans in communities affected by AIDS in Tanzania and Burkina Faso.

The AIDS pandemic has created an estimated 15 million orphans who may face elevated risk of poor health and social outcomes. This paper compares orphans and non-orphans regarding educational status and delay using data collected in three low-income communities affected by AIDS in Tanzania and Burkina Faso. Orphans were significantly more likely not to attend school than were non-orphans and also to be delayed when in school, though, after controlling for confounders, the risk was borderline and non-significant. Multivariate analysis indicates that variables such as age, religion, family of origin, the relation between the child and the head of household and the dependency ratio of the household better explain differences in education than does orphan status. This study suggests, therefore, that orphans' educational status is relatively equivalent to non-orphans perhaps as a result of family based or community program safety nets.

Cost and efficiency of HIV voluntary counselling and testing centres in Andhra Pradesh, India.

BACKGROUND: [corrected] As part of the effort to control HIV/AIDS, the number of HlV voluntarycounselling and testingcentres (VCTCs) is increasing rapidly in the public health system of the Indian state of Andhra Pradesh, which is estimated to have one of the highest rates of HIV infection in India. However, systematic data on the cost and efficiency of providing VCT services in India are not available to help guide efficient use of resources for these services. METHODS: We used standardized methods to obtain detailed cost and output data for the 2002-03 fiscal year from written records and interviews in 17 VCTCs in the public health system in Andhra Pradesh. We calculated the economic cost per client receiving VCT services, and analysed the variation and determinants of total and unit costs across VCTCs. We used multivariate regression techniques to estimate incremental unit costs. We assessed hurdles towards serving an optimal number of clients by VCTCs. RESULTS: In the 2002-03 fiscal year, 32 413 clients received the complete sequence of services at the 17 VCTCs, including post-HIV test counselling. The number of clients served by each VCTC ranged from 334 to 7802 (median 979). The overall HIV-positive rate in post-test counselled clients was 20.5% (range 5.4%-52.6%). The cost per client for the complete VCT sequence varied 6-fold between VCTCs (range Rs 141.5-829.6 [US 2.92-17.14 dollars], median Rs 363.5 [US 7.51 dollars]). The cost per client was significantly lower at VCTCs with more clients (p < 0.001, R2 = 0.83; power function) due to substantial fixed costs. Personnel made up the largest component of cost (53.7%). The cost per client had a significant direct relation with percent personnel cost for VCTCs (p < 0.001, R2 = 0.58; exponential function). A multiple regression model revealed that the incremental cost of providing complete VCT services to each HIV-positive and -negative client was Rs 123.5 (US 2.54 dollars) and Rs 59.2 (US 1.22 dollars), respectively. Fourteen VCTCs (82.4%) reported that they could serve more clients with the available personnel and infrastructure, and that inadequate demand for their services was the main hurdle towards achieving this. CONCLUSION: These data suggest that the efforts of the National AIDS Control Organisation of India and the Andhra Pradesh State AIDS Control Society in increasing VCTCs could yield even higher benefit if the demand for these services was enhanced, as this would increase the number of clients served and reduce the cost per client. Ongoing systematic cost-efficiency analysis is necessary to help guide efficient use of HIV-control resources in India.

Cost-effectiveness of prevention referrals for high-risk HIV-negatives in San Francisco.

We retrospectively assessed the cost-effectiveness of providing prevention referrals to high-risk seronegatives at HIV test sites in San Francisco. We examined the costs and effects from the perspectives of society and the San Francisco Department of Public Health (SFDPH). Cost categories assessed included referral materials, counsellor training and time required to make referrals, prevention services and the value of client time. Effect data are drawn from a study of 289 high-risk seronegatives and the published literature, and are applied to a city-wide caseload of 6,626 high-risk seronegatives. We estimate that a city-wide programme in San Francisco averts two HIV infections per year and yields net savings to society of $43,765, with a cost to the SFDPH of $20,738 per HIV infection averted. We conclude that providing HIV prevention referrals to high-risk seronegatives receiving antibody testing imposes significant costs, but has attractive cost-effectiveness when applied to a large high-risk population.

Cost-effectiveness of the Mpowerment Project, a community-level intervention for young gay men.

OBJECTIVES: Previous evaluation demonstrated that the Mpowerment Project community-level intervention for young gay men reduces HIV risk behaviors. The current analysis was undertaken to estimate the intervention's health and economic outcomes. DESIGN/METHODS: We conducted a retrospective cost-effectiveness analysis. We estimated HIV infections averted, the gain in quality-adjusted life years (QALYs), cost per infection averted, and net cost. Using a population-level model, we portrayed two epidemic scenarios: the first with stable HIV prevalence and the other with rising HIV prevalence. Inputs included behavior change resulting from the intervention and program cost data. Cost was calculated from three perspectives: societal; societal excluding volunteer time; and that of a community-based organization (CBO). Outcomes were calculated for 1, 5 (baseline), and 20 years. RESULTS: The Mpowerment Project averted an estimated 2.0 to 2.3 HIV infections in the first year (according to the epidemic scenario), 5.0 to 6.2 over 5 years, and 9.2 to 13.1 over 20 years. The societal cost per HIV infection averted was estimated at between $14,600 and $18,300 over 5 years. Costs per infection averted were 28% lower when excluding volunteer time and 35% lower from the CBO perspective. Net savings were $700,000 to $900,000 over 5 years from the societal perspective. CONCLUSIONS: The Mpowerment Project is cost-effective compared with many other HIV prevention strategies. The cost per HIV infection prevented is far less than the lifetime medical costs of HIV disease.

Health and federal budgetary effects of increasing access to antiretroviral medications for HIV by expanding Medicaid.

UNLABELLED: OBJECTIVES. This study modeled the health and federal fiscal effects of expanding Medicaid for HIV-infected people to improve access to highly active antiretroviral therapy. METHODS: A disease state model of the US HIV epidemic, with and without Medicaid expansion, was used. Eligibility required a CD4 cell count less than 500/mm3 or viral load greater than 10,000, absent or inadequate medication insurance, and annual income less than $10,000. Two benefits were modeled, "full" and "limited" (medications, outpatient care). Federal spending for Medicaid, Medicare, AIDS Drug Assistance Program, Supplemental Security Income, and Social Security Disability Insurance were assessed. RESULTS: An estimated 38,000 individuals would enroll in a Medicaid HIV expansion. Over 5 years, expansion would prevent an estimated 13,000 AIDS diagnoses and 2600 deaths and add 5,816 years of life. Net federal costs for all programs are $739 million (full benefits) and $480 million (limited benefits); for Medicaid alone, the costs are $1.43 and $1.17 billion, respectively. Results were sensitive to awareness of serostatus, highly active antiretroviral therapy cost, and participation rate. Strategies for federal cost neutrality include Medicaid HIV drug price reductions as low as 9% and private insurance buy-ins. CONCLUSIONS: Expansion of the Medicaid eligibility to increase access to antiretroviral therapy would have substantial health benefits at affordable costs.

Cost-effectiveness of the female condom in preventing HIV and STDs in commercial sex workers in rural South Africa.

We assessed the cost-effectiveness of the female condom (FC) in preventing HIV infection and other STDs among commercial sex workers (CSWs) and their clients in the Mpumulanga Province of South Africa. The health and economic outcomes of current levels of male condom (MC) use in 1000 CSWs who average 25 partners per year and have an HIV prevalence of 50.3% was compared with the expected outcomes resulting from the additional provision of FCs to these CSWs. A simulation model calculated health and public sector cost outcomes assuming 5 years of HIV infectivity, 1 month of syphilis and gonorrhea infectivity, and FC use in 12% of episodes of vaginal intercourse. Delayed infections and interactions between STDs and HIV were modeled. The simulation was extended to non-CSWs with as few as one casual partner per year. We conducted multiple sensitivity analyses. The program would distribute 6000 FCs annually at a cost of $4002 and would avert 5.9 HIV, 38 syphilis, and 33 gonorrhea cases. This would save the public sector health payer $12,090 in averted HIV/AIDS treatment costs, and $1,074 in averted syphilis and gonorrhea treatment costs for a net saving of $9163. Sensitivity analyses indicate that the economic findings are robust across a wide range of values for key inputs. The program generates net savings of $5421 if HIV prevalence in CSWs is 25% rather than 50.3% and savings of S3591 if each CSW has an average of 10 clients per year rather than 25. A program focusing on non-CSWs with only one casual partner would save $199. We conclude that a well-designed FC program oriented to CSWs and other women with casual partners is likely to be highly cost-effective and can save public sector health funds in rural South Africa.

Coordination of health coverage for Medicare enrollees: living with HIV/AIDS in California.

Because Medicare does not cover a large part of the health care that its enrollees living with HIV/AIDS require, they need other coverage to supplement Medicare. Medicaid is a major source of that supplemental coverage. In California, Medicare enrollees with HIV/AIDS who were also enrolled in Medi-Cal (California's Medicaid program) had total payments from both programs of $177 million, or an average of $28,956 per person in the fee-for-service-system in 1998. Of that total, Medicare paid for 38 percent, mainly for inpatient visits and ambulatory care, while Medi-Cal paid 62 percent, mainly for prescription drugs. For these dual enrollees, many of Medicare's benefit gaps--including a large share of prescription drugs, nursing facility services and home care--are being filled by Medi-Cal. Data in this Medicare Brief indicate that the incremental cost to the federal government of filling gaps in the Medicare benefits package would be considerably less than the full cost of the additional benefits. Through Medicaid and other programs, the federal government is already paying a substantial part of public program expenditures for dual enrollees with HIV/AIDS. Other issues to consider are how the dual Medicare-Medicaid funding streams affect the programs' cost efficiency, and from the perspective of Medicare enrollees and providers, how well the dual programs coordinate to meet the needs of people with HIV/AIDS and other chronic conditions.

The efficacy of medical abortion: a meta-analysis.

Multiple clinical studies demonstrate the efficacy of medical abortion with mifepristone or methotrexate followed by a prostaglandin analogue. However, assessing predictors of success, including regimen, is difficult because of regimen variability and a lack of direct comparisons. This meta-analysis estimates rates of primary clinical outcomes of medical abortion (successful abortion, incomplete abortion, and viable pregnancy) and compares them by regimen and gestational age. We identified 54 studies published from 1991 to 1998 using mifepristone with misoprostol (18), mifepristone with other prostaglandin analogues (23), and methotrexate with misoprostol (13). Data abstracted from studies included regimen details and clinical outcomes by gestational age. We found that efficacy decreases with increasing gestational age (p<0.001), and differences by regimen are not statistically significant except at gestational age > or =57 days. For gestations < or =49 days, mean rates of complete abortion were 94-96%, incomplete abortion 2-4%, and ongoing (viable) pregnancy 1-3%. For gestations of 50-56 days, the mean rate of complete abortion was 91% (same for all regimens), incomplete abortion 5-8%, and ongoing pregnancy 3-5%. For > or =57 days, success was lower for mifepristone/misoprostol (85%, 95% confidence interval 78-91%) than for mifepristone/other prostaglandin analogues 95% (CI 91-98%, p = 0.006). For mifepristone/misoprostol, using > or =2 prostaglandin analogue doses seems to be better than a single dose for certain outcomes and gestational ages. We conclude that both mifepristone and methotrexate, when administered with misoprostol, have high levels of success at < or =49 days gestation but may have lower efficacy at longer gestation.

PIP: Multiple clinical studies demonstrate the efficacy of medical abortion with mifepristone or methotrexate followed by a prostaglandin analogue. However, assessing predictors of success, including regimen, is difficult because of regimen variability and a lack of direct comparisons. This meta-analysis estimates rates of primary clinical outcomes of medical abortion (successful abortion, incomplete abortion, and viable pregnancy) and compares them by regimen and gestational age. The authors identified 54 studies published from 1991 to 1998 using mifepristone with misoprostol (18), mifepristone with other prostaglandin analogues (23), and methotrexate with misoprostol (13). Data abstracted from studies included regimen details and clinical outcomes by gestational age. The authors found that efficacy decreases with increasing gestational age (p 0.001), and differences by regimen are not statistically significant except at gestational age 57 days or more. For gestations of 49 or fewer days, mean rates of complete abortion were 94-96%, incomplete abortion 2-4%, and ongoing (viable) pregnancy 1-3%. For gestations of 50-56 days, the mean rate of complete abortion was 91% (same for all regimens), incomplete abortion 5-8%, and ongoing pregnancy 3-5%. For 57 days or more, success was lower for mifepristone/misoprostol (85%; 95% CI, 78-91%) than for mifepristone/other prostaglandin analogues (95%; 95% CI, 91-98%; p = 0.006). For mifepristone/misoprostol, using 2 or more prostaglandin analogue doses seems to be better than a single dose for certain outcomes and gestational ages. The authors conclude that both mifepristone and methotrexate, when administered with misoprostol, have high levels of success at 49 or fewer days.

Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa.

BACKGROUND: Identification of economical interventions to decrease HIV-1 transmission to children is an urgent public-health priority in sub-Saharan Africa. We assessed the cost effectiveness of the HIVNET 012 nevirapine regimen. METHODS: We assessed cost effectiveness in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. Our main outcome measures were programme cost, paediatric HIV-1 cases averted, cost per case averted, and cost per disability-adjusted life-year (DALY). We compared HIVNET 012 with other short-course antiretroviral regimens. We also compared two implementation strategies: counselling and HIV-1 testing before treatment (targeted treatment), or nevirapine for all pregnant women (universal treatment, no counselling and testing). We did univariate and multivariate sensitivity analyses. FINDINGS: For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs. The associated cost-effectiveness ratios were $138 per case averted or $5.25 per DALY. At 15% seroprevalence, the universal treatment option would cost $83,333 and avert 302 cases at $276 per case averted or $10.51 per DALY. For targeted treatment at 30% seroprevalence, HIVNET 012 would cost $141,922 and avert 476 cases at $298 per case averted or $11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions. The cost effectiveness of HIVNET 012 was robust under a wide range of parameters in the sensitivity analysis. INTERPRETATION: The HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. In lower seroprevalence areas, when multidose regimens are not cost effective, nevirapine therapy could have a major public-health impact at a reasonable cost.

PIP: The cost effectiveness of HIVNET 012 nevirapine regimen for treatment of HIV-1-positive mothers was assessed in a hypothetical cohort of 20,000 pregnant women in sub-Saharan Africa. The program cost, pediatric HIV-1 cases averted, and cost per disability-adjusted life-year (DALY) were the main outcome measures. Univariate and multivariate analyses were used. Results showed that the nevirapine program would avert from 603 pediatric HIV-1 cases (universal treatment at 30% seroprevalence) to 246 cases (targeted treatment at 15% seroprevalence). At 30% seroprevalence, the universal treatment would cost $83,333 with 15,862 DALY. At 15% seroprevalence, it would cost $83,333 and avert 302 cases at $276 per case averted. The HIVNET 012 regimen was more effective and less costly than other regimens. The HIVNET 012 regimen would retain cost effectiveness at seroprevalence as low as 10.7% under the universal treatment option and 22% under the targeted treatment option. Furthermore, the HIVNET 012 regimen can be highly cost-effective in high seroprevalence settings. On the other hand, in areas with low seroprevalence, nevirapine therapy could have an important public health impact at a reasonable cost.

Which unruptured cerebral aneurysms should be treated? A cost-utility analysis.

OBJECTIVE: To determine which unruptured cerebral aneurysms should be treated considering the risks. benefits, and costs. BACKGROUND: Asymptomatic unruptured cerebral aneurysms are commonly treated by surgical clipping or endovascular coil embolization to prevent subarachnoid hemorrhage (SAH). METHODS: We performed a cost-utility analysis comparing surgical clipping and endovascular coil embolization with no treatment for unruptured aneurysms. Eight clinical scenarios were defined based on aneurysm size, symptoms, and history of SAH from a different aneurysm. Health outcomes of a hypothetical cohort of 50-year-old women were modeled over the projected lifetime of the cohort. Costs were assessed from the societal perspective. We compared net quality-adjusted life years (QALYs) and cost per QALY of each therapy to no treatment. RESULTS: For an asymptomatic unruptured aneurysm less than 10 mm in diameter in patients with no history of SAH from a different aneurysm, both procedures resulted in a net loss in QALYs, and confidence intervals (CI) were not compatible with a benefit from treatment (clipping, loss of 1.6 QALY [95% CI 1.1 to 2.1]; coiling, loss of 0.6 QALY [95% CI 0.2 to 0.8]). For larger aneurysms (> or = 10 mm), those producing symptoms by compressing neighboring nerves and brain structures, or in patients with a history of SAH from a different aneurysm, treatment was cost-effective. Coiling appeared more effective and cost-effective than clipping but these differences depended on relatively uncertain model parameters. CONCLUSIONS: Treatment of small, asymptomatic, unruptured cerebral aneurysms in patients without a history of SAH worsens clinical outcomes, and thus is neither effective nor cost-effective. For aneurysms that are > or = 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.

Pregnancies averted among U.S. teenagers by the use of contraceptives.

CONTEXT: The personal and social costs associated with teenage pregnancy in the United States concern many policymakers and researchers, yet the role of contraception in preventing these pregnancies has not been adequately quantified. METHODS: Published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices in order to estimate the number of pregnancies averted through the use of contraceptives by U.S. teenagers. Four scenarios of contraceptives access--from current levels of access to highly restricted access--and teenagers' sexual and contraceptive practices in response to such restrictions are used to project the potential impact on pregnancies among teenagers. RESULTS: Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15-19-year-old women in the United States during 1995. If these young women had been denied access to both prescription and over-the-counter contraceptive methods, an estimated one million additional pregnancies (ranging from 750,000 to 1.25 million) would have occurred, assuming some decrease in sexual activity. These pregnancies would have led to 480,000 live births, 390,000 abortions, 120,000 miscarriages, 10,000 ectopic pregnancies and 37 maternal deaths. CONCLUSIONS: Contraceptive use by teenage women prevents pregnancies and negative pregnancy-related health consequences that can disrupt the lives of adolescent women and that have substantial societal costs. Continued and expanded access to contraceptives for adolescents is a critically important public health strategy.

PIP: An analysis of the number of adolescent pregnancies and pregnancy outcomes that are averted in the US each year by contraceptive use highlighted the importance of continued and expanded access on the part of young people to contraception. In this analysis, published estimates of contraceptive effectiveness were applied to 1995 National Survey of Family Growth data on sexual and contraceptive practices among US teenagers. Four scenarios of contraceptive access--from current levels to highly restricted access--and sexual and fertility control practices in response to such restrictions were constructed. The 651 sexually active female adolescents enrolled in the national survey had used contraception during 80% of the times in which they were at risk of pregnancy. Current levels of contraceptive use averted an estimated 1.65 million pregnancies among 15- to 19-year-old US women in 1995. If these adolescents had been denied access to prescription and over-the-counter contraceptive methods, an estimated 750,000 to 1.25 million additional pregnancies would have occurred, assuming some decrease in sexual activity. These pregnancies would have resulted in 480,000 live births, 390,000 induced abortions, 120,000 miscarriages, 10,000 ectopic pregnancies, and 37 maternal deaths. The prevalence of adolescent sexual activity would have to decrease by 83% over current levels to avert the same number of pregnancies that are presently prevented by contraceptive use.