Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India

PLoS One. 2013 May 31;8(5):e64604. doi: 10.1371/journal.pone.0064604. Print 2013.

Abstract

Background: Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.

Methods: We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population ("national population"), i.e. base case (HIV prevalence 0.29%; incidence 0.032/100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/µl. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for "cost-effective" was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for "very cost-effective" was <1x the annual per capita GDP ($1,300/YLS).

Results: Compared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.

Conclusions: In India, voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • CD4 Lymphocyte Count
  • Cost-Benefit Analysis / statistics & numerical data*
  • Female
  • HIV Infections / diagnosis
  • HIV Infections / economics*
  • HIV Infections / epidemiology
  • HIV Infections / transmission
  • Humans
  • India / epidemiology
  • Life Expectancy
  • Male
  • Mass Screening / economics*
  • Mass Screening / methods
  • Models, Statistical*
  • Prevalence
  • Risk-Taking

Grant support

The Cost-effectiveness of Prevention AIDS Complications – International(CEPAC-I) Group is funded by National Institute of Allergy and Infectious Diseases (Grant no. National Institute of Allergy and Infectious Diseases, R01 AI058736). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.