Expanded HIV screening in the United States: what will it cost government discretionary and entitlement programs? A budget impact analysis.

OBJECTIVE The US Centers for Disease Control and Prevention (CDC) recently revised their HIV screening guidelines to promote testing and earlier entry to care. Prior analyses have examined the policy's cost-effectiveness but have not evaluated its impact on government budgets. METHODS We used a simulation model of HIV screening, disease, and treatment to determine the budget impact of expanded HIV screening to US government discretionary, entitlement, and testing programs. We estimated total and incremental testing and treatment costs over a 5-year time horizon under current and expanded screening scenarios. We used CDC estimates of HIV prevalence and annual incidence, and considered variations in screening frequency, test return rates, linkage to care, test characteristics, and eligibility for government screening and treatment programs. RESULTS Under current practice, 177,000 new HIV cases will be identified over 5 years. Expanded screening will identify an additional 46,000 cases at an incremental 5-year cost of $2.7 billion. The financial burden of expanded HIV screening will fall disproportionately on discretionary programs that fund care for newly identified patients and will not be offset by entitlement program savings. Testing will represent a small proportion (18%) of the total budget increase. Costs are sensitive to the frequency of screening and the proportion linked to care. CONCLUSIONS The expanded HIV screening program will have a large downstream impact on government programs that fund HIV care. Expanded HIV screening will not meet early treatment goals unless government programs have sufficient budgets to expand testing and provide care for newly identified cases.

[1]  M. Niezen,et al.  Role of budget impact in drug reimbursement decisions. , 2008, Journal of health politics, policy and law.

[2]  Lisa M. Lee,et al.  Estimation of HIV incidence in the United States. , 2008, JAMA.

[3]  K. Freedberg,et al.  Understanding delay to medical care for HIV infection: the long-term non-presenter , 2001, AIDS.

[4]  R. Wolitski,et al.  Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials , 2006, AIDS.

[5]  J. Holahan,et al.  Rising Unemployment, Medicaid and the Uninsured , 2009 .

[6]  Douglas K Owens,et al.  Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. , 2005, The New England journal of medicine.

[7]  Milton C Weinstein,et al.  Expanded screening for HIV in the United States--an analysis of cost-effectiveness. , 2005, The New England journal of medicine.

[8]  J. Bartlett,et al.  Opt-out testing for human immunodeficiency virus in the United States: progress and challenges. , 2008, JAMA.

[9]  B. Branson,et al.  Comparing the Costs of HIV Screening Strategies and Technologies in Health-Care Settings , 2008, Public health reports.

[10]  Phalguni Gupta,et al.  Effect of Antiretroviral Therapy on HIV Shedding in Semen , 2000, Annals of Internal Medicine.

[11]  T. Quinn,et al.  Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. , 2000, The New England journal of medicine.

[12]  N. Sikka,et al.  Routine HIV Screening in the Emergency Department Using the New US Centers for Disease Control and Prevention Guidelines: Results From a High-Prevalence Area , 2007, Journal of acquired immune deficiency syndromes.

[13]  M. Lyons,et al.  Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. , 2005, Annals of emergency medicine.

[14]  B. Branson Current HIV epidemiology and revised recommendations for HIV testing in health‐care settings , 2007, Journal of medical virology.

[15]  R. Walensky,et al.  Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. , 2005, American journal of public health.

[16]  M. Weinstein,et al.  Budget Impact of Medicaid Section 1115 Demonstrations for Early HIV Treatment , 2005, Health care financing review.

[17]  M. Weinstein,et al.  TREATMENT FOR PRIMARY HIV INFECTION: PROJECTING OUTCOMES OF IMMEDIATE, INTERRUPTED, OR DELAYED THERAPY , 2002, Journal of acquired immune deficiency syndromes.

[18]  David R. Holtgrave,et al.  Counseling and testing for HIV prevention: costs, effects, and cost-effectiveness of more rapid screening tests. , 1996, Public health reports.

[19]  David R. Holtgrave,et al.  Cost comparison of three HIV counseling and testing technologies. , 2003, American journal of preventive medicine.

[20]  M C Weinstein,et al.  The cost-effectiveness of preventing AIDS-related opportunistic infections. , 1998, JAMA.

[21]  Kenneth A. Freedberg,et al.  A Monte Carlo Simulation of Advanced HIV Disease , 1998, Medical decision making : an international journal of the Society for Medical Decision Making.

[22]  R. Sesso,et al.  Gaining efficiencies: resources and demand for dialysis around the globe. , 2009, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[23]  Milton C Weinstein,et al.  The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States , 2006, Medical care.

[24]  B. Branson,et al.  Detecting Unsuspected HIV Infection With a Rapid Whole-Blood HIV Test in an Urban Emergency Department , 2007, Journal of acquired immune deficiency syndromes.

[25]  David R. Holtgrave Costs and Consequences of the US Centers for Disease Control and Prevention's Recommendations for Opt-Out HIV Testing , 2007, PLoS medicine.

[26]  M C Weinstein,et al.  The cost effectiveness of combination antiretroviral therapy for HIV disease. , 2001, The New England journal of medicine.

[27]  W. Cunningham,et al.  Consistency of State Statutes With the Centers for Disease Control and Prevention HIV Testing Recommendations for Health Care Settings , 2009, Annals of Internal Medicine.

[28]  W. McIsaac,et al.  Effect of an Explicit Decision-Support Tool on Decisions to Prescribe Antibiotics for Sore Throat , 1998, Medical decision making : an international journal of the Society for Medical Decision Making.

[29]  Lauren M. Mercincavage,et al.  Expanded HIV Screening in the United States: Effect on Clinical Outcomes, HIV Transmission, and Costs , 2006, Annals of Internal Medicine.

[30]  Mark Nuijten,et al.  Principles of good practice for budget impact analysis: report of the ISPOR Task Force on good research practices--budget impact analysis. , 2007, Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research.

[31]  Melissa Skanderson,et al.  Development and Verification of a “Virtual” Cohort Using the National VA Health Information System , 2006, Medical care.

[32]  S. Lyss,et al.  Implementing an HIV and sexually transmitted disease screening program in an emergency department. , 2007, Annals of emergency medicine.

[33]  Gary Marks,et al.  Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware They are Infected With HIV in the United States: Implications for HIV Prevention Programs , 2005, Journal of acquired immune deficiency syndromes.

[34]  Richard D Moore,et al.  Hospital and Outpatient Health Services Utilization Among HIV-Infected Adults in Care 2000–2002 , 2005, Medical care.

[35]  M. Weinstein,et al.  Preevaluation of clinical trial data: the case of preemptive cytomegalovirus therapy in patients with human immunodeficiency virus. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.