Less than half of community-based substance abuse treatment programs in the United States currently make HIV testing available on-site or through referral. A new study led by researchers at Weill Cornell Medical College shows the cost-effectiveness of integrating on-site rapid HIV testing into drug treatment programs.
The study, published in this issue of Drug and Alcohol Dependence, is a collaboration with the HIV Rapid Testing and Counseling Study trial, sponsored by the National Drug Abuse Clinical Trials Network. The randomized clinical trial conducted in 12 community-based substance abuse treatment programs in 2009 found that 80 percent of the participants offered on-site HIV testing with a rapid test accepted the testing offer and obtained test results, as compared with less than 20 percent of those referred for off-site testing. These recent results were published in the June issue of the American Journal of Public Health.
The new study measured the cost-effectiveness of on-site rapid HIV testing in drug abuse treatment programs using data from the HIV Rapid Testing and Counseling Study, including patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence and program costs. Researchers used the Cost Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model to project life expectancy, lifetime costs and quality-adjusted life years (QALYs) for the HIV-infected individuals. The researchers calculated the cost per QALY with and without on-site testing, also taking into account the costs associated with testing individuals who turn out not to be HIV-infected.
“Our cost-effectiveness analysis supports integrating HIV screening and prevention services with substance abuse treatment programs, which is called for in President Barack Obama’s National HIV/AIDS Strategy, ” says the study’s lead investigator Dr. Bruce R. Schackman, an associate professor of public health and chief of the Division of Health Policy at Weill Cornell Medical College. “We found that on-site testing with a description of the testing procedure, without pre-test risk-reduction counseling, resulted in a beneficial cost-effectiveness ratio. This strategy provides better value than off-site referral.”
Study results show a cost-effectiveness ratio of $60,300 per QALY, which is below one acceptable cost-effectiveness threshold of $100,000 per QALY used in the U.S. In addition, researchers found that participant-tailored risk-reduction counseling does not provide better value in this setting. Risk-reduction counseling increases the cost per participant by nearly 90 percent, and in the trial it had no significant effect on self-reported sexual risk behavior.
Although medical advances over the past 15 years have made HIV a substantially manageable illness, new HIV cases in the U.S. continue to emerge at a steady rate. More than 20 percent of infected individuals are unaware of their infection and are therefore not treated. This both reduces their life expectancy and quality of life and makes them more likely to transmit the infection to others. To identify more people infected with HIV, in 2006 the Centers for Disease Control and Prevention (CDC) recommended routine HIV screening for all adults in health care settings, as well as expanding testing in non-medical settings.
“This study shows that introducing on-site rapid HIV testing to substance abuse treatment programs should be an important element of the CDC’s strategy to identify and treat HIV-infected persons earlier to improve their lives and reduce transmission,” says study co-author Dr. Lisa R. Metsch, the Stephen Smith professor and chair of sociomedical sciences at the Mailman School of Public Health at Columbia University and the principal investigator of the initial HIV Rapid Testing and Counseling Study. “The study provides strong evidence of the societal value of on-site HIV testing. We need to overcome barriers to implementing HIV testing in non-medical settings for those not recently tested.”
“The study reinforces the clinical and economic value of offering on-site rapid HIV testing in drug abuse treatment programs by demonstrating its cost-effectiveness,” says senior author Dr. Rochelle P. Walensky, associate professor of medicine at Harvard Medical School and Massachusetts General Hospital. “Our study should serve as motivation for policymakers and substance abuse treatment leaders to seek funding for on-site rapid HIV testing in substance abuse treatment programs.”
The study’s co-authors include Dr. Grant N. Colfax and Dr. Tim Matheson from the San Francisco Department of Public Health; Jared A. Leff from Weill Cornell Medical College; Angela Wong and Callie A. Scott from Massachusetts General Hospital; Dr. Daniel J. Feaster and Dr. Lauren Gooden from the University of Miami, Miller School of Medicine; Louise F. Haynes of the Medical University of South Carolina; and Dr. A. David Paltiel of Yale School of Public Health.
The study was supported by the National Institute on Drug Abuse, the National Drug Abuse Treatment Clinical Trials Network, the National Institute of Mental Health, and the National Institute of Allergy and Infectious Diseases.