Cost-Effectiveness of HIV Screening in Patients Older than 55 Years of Age

17 June 2008 | Volume 148 Issue 12 | Pages 889-903

Background: Although HIV infection is more prevalent in people younger than age 45 years, a substantial number of infections occur in older persons. Recent guidelines recommend HIV screening in patients age 13 to 64 years. The cost-effectiveness of HIV screening in patients age 55 to 75 years is uncertain.

Objective: To examine the costs and benefits of HIV screening in patients age 55 to 75 years.

Design: Markov model.

Data Sources: Derived from the literature.

Target Population: Patients age 55 to 75 years with unknown HIV status.

Time Horizon: Lifetime.

Perspective: Societal.

Intervention: HIV screening program for patients age 55 to 75 years compared with current practice.

Outcome Measures: Life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness.

Results of Base-Case Analysis: For a 65-year-old patient, HIV screening using traditional counseling costs $55 440 per QALY compared with current practice when the prevalence of HIV was 0.5% and the patient did not have a sexual partner at risk. In sexually active patients, the incremental cost-effectiveness ratio was $30 020 per QALY. At a prevalence of 0.1%, HIV screening cost less than $60 000 per QALY for patients younger than age 75 years with a partner at risk if less costly streamlined counseling is used.

Results of Sensitivity Analysis: Cost-effectiveness of HIV screening depended on HIV prevalence, age of the patient, counseling costs, and whether the patient was sexually active. Sensitivity analyses with other variables did not change the results substantially.

Limitations: The effects of age on the toxicity and efficacy of highly active antiretroviral therapy and death from AIDS were uncertain. Sensitivity analyses exploring these variables did not qualitatively affect the results.

Conclusion: If the tested population has an HIV prevalence of 0.1% or greater, HIV screening in persons from age 55 to 75 years reaches conventional levels of cost-effectiveness when counseling is streamlined and if the screened patient has a partner at risk. Screening patients with advanced age for HIV is economically attractive in many circumstances.

Editors' Notes Context Although many HIV infections occur in older adults, national guidelines recommend screening only for persons age 13 to 64 years. Contribution This analysis suggests that screening persons age 55 to 75 years is reasonably cost-effective under the following circumstances: HIV prevalence is 0.1% or greater; a streamlined counseling process is implemented; and the person has a partner at risk for HIV infection. Implication This information on the cost-effectiveness of screening in older adults should inform decisions about expanding screening recommendations to older people. —The Editors

 

Author and Article Information

From Duke Clinical Research Institute, Durham, North Carolina; St. Michael's Hospital, Toronto, Ontario, Canada; Veterans Affairs Palo Alto Health Care System, Palo Alto, California; and Stanford University School of Medicine, Stanford, California.

Disclaimer: The views expressed in this publication are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care.

Grant Support: This research is supported in part by the Department of Veterans Affairs, the National Institute on Drug Abuse (R01 DA15612-01); the National Institute of Aging through the Stanford Center on the Demography and Economics of Health and Aging (P30-AG017253); the Ontario HIV Treatment Network; and the Ontario Ministry of Health and Long-Term Care.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement: Study protocol: Available from Dr. Sanders (e-mail, gillian.sanders{at}duke.edu). Statistical code: Not available. Data set: Available from Dr. Sanders (e-mail, gillian.sanders{at}duke.edu).

Requests for Single Reprints: Gillian D. Sanders, PhD, Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715; e-mail, gillian.sanders{at}duke.edu.

Current Author Addresses: Dr. Sanders: Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715.

Dr. Bayoumi: Centre for Research on Inner City Health, St. Michael's Hospital, 30 Bond Street, Toronto, M5B 1W8 Ontario, Canada.

Dr. Holodniy: Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304.

Dr. Owens: Center for Primary Care and Outcomes Research/Center for Health Policy, Stanford University, 117 Encina Commons, Stanford, CA 94305-6019.

Author Contributions: Conception and design: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Analysis and interpretation of the data: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Drafting of the article: G.D. Sanders, D.K. Owens.

Critical revision of the article for important intellectual content: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Final approval of the article: G.D. Sanders, A.M. Bayoumi, M. Holodniy, D.K. Owens.

Statistical expertise: G.D. Sanders, A.M. Bayoumi.

Obtaining of funding: D.K. Owens.

Collection and assembly of data: G.D. Sanders, A.M. Bayoumi, M. Holodniy.