Estimating the Cost to U.S. Health Departments to Conduct HIV Surveillance

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1 Reserch Articles Estimting the Cost to U.S. Helth Deprtments to Conduct HIV Surveillnce Rm K. Shresth, PhD Stephnie L. Snsom, PhD, MPP, MPH Benjmin T. Lffoon, BS Pul G. Frnhm, PhD R. Luke Shouse, MD Kren McMster, MPA b H. Irene Hll, PhD ABSTRACT Objectives. HIV cse surveillnce is primry source of informtion for monitoring HIV burden in the United Sttes nd guiding the lloction of prevention nd tretment funds. While the number of people living with HIV nd the need for surveillnce dt hve incresed, little is known bout the cost of surveillnce. We estimted the economic cost to helth deprtments of conducting high-qulity HIV cse surveillnce. Methods. We collected primry dt on the unit cost nd quntity of resources used to operte the HIV cse surveillnce progrm in Michign, where HIV burden (i.e., the number of HIV cses) is moderte to high (n514,864 cses). Bsed on Michign s dt, we projected the expected nnul HIV surveillnce cost for U.S., stte, locl, nd territoril helth deprtments. We bsed our cost projection on the vrition in the number of new nd estblished cses, respecific wges, nd potentil economies of scle. Results. We estimted the nnul totl HIV surveillnce cost to the Michign helth deprtment to be $1,286,524 ($87/cse), the nnul totl cost of new cses to be $108,657 ($133/cse), nd the nnul totl cost of estblished cses to be $1,177,867 ($84/cse). Our projected medin nnul HIV surveillnce cost per helth deprtment rnged from $210,600 in low-hiv burden sites to $1,835,000 in high-hiv burden sites. Conclusions. Our nlysis shows tht systemtic pproch to costing HIV surveillnce t the helth deprtment level is fesible. For HIV surveillnce, substntil portion of totl surveillnce costs is ttributble to mintining estblished cses. Centers for Disese Control nd Prevention, Ntionl Center for HIV/AIDS, Virl Heptitis, STD, nd TB Prevention, Division of HIV/ AIDS Prevention, Atlnt, GA b Michign Deprtment of Community Helth, Lnsing, MI Address correspondence to: Rm K. Shresth, PhD, Centers for Disese Control nd Prevention, Ntionl Center for HIV/AIDS, Virl Heptitis, STD, nd TB Prevention, Division of HIV/AIDS Prevention, 1600 Clifton Rd. NE, MS-E48, Atlnt, GA 30333; tel ; fx ; e-mil <rshresth@cdc.gov>. 496

2 HIV Surveillnce Cost to U.S. Helth Deprtments 497 An estimted 1.2 million people ged 13 yers nd older re living with humn immunodeficiency virus (HIV) in the United Sttes, nd bout 47,500 people re infected with the virus ech yer. 1,2 A recent HIV surveillnce report shows tht the number of people living with HIV incresed by 8% from 2006 through The U.S. Centers for Disese Control nd Prevention (CDC) hs developed n HIV surveillnce system for collecting, nlyzing, nd disseminting ccurte informtion on the number of people with new HIV dignoses (new cses) nd those living with HIV infection (estblished cses). 4,5 Access to timely nd high-qulity surveillnce dt is essentil to detect trends in the HIV burden nd develop pproprite prevention nd control mesures. 4,6,7 The U.S. Deprtment of Helth nd Humn Services hs closely ligned the $16 billion it spent in 2010 on HIV cre, tretment, nd prevention with the number of reported HIV cses in ech stte. 8 HIV cse surveillnce dditionlly guides the implementtion of test-nd-tret prevention strtegies tht require dt on timing of dignosis, entry into nd retention in cre, nd virl lod (VL) suppression The Institute of Medicine recently identified HIV cse surveillnce s one of the dt collection systems tht could be used to monitor progress in chieving Ntionl HIV/AIDS Strtegy gols. 11,12 The purpose of this nlysis ws to estimte the economic cost to helth deprtments to conduct high-qulity HIV cse surveillnce, where high qulity is defined s meeting or exceeding CDC dt qulity stndrds regrding the completeness nd timeliness of reporting dignosed HIV cses nd scertining duplicte cses nd deths. 6,7 We exmined potentil vrition in costs cross helth deprtments bsed on differences in the number of new vs. estblished HIV cses, re-specific wges, nd potentil economies of scle. Results from the nlysis could help inform surveillnce funding lloction cross helth deprtments nd enble helth deprtments to more ccurtely ssess their own costs ttributble to new nd estblished HIV cses. METHODS CDC provides federl funding to conduct HIV cse surveillnce in 59 helth deprtments, including the 50 sttes, the District of Columbi, six seprtely funded cities, Puerto Rico, nd the Virgin Islnds. Federl finncil nd technicl ssistnce is provided to ensure tht helth deprtments conduct HIV surveillnce using stndrdized frmework for collecting complete, timely, nd high-qulity dt. 13 While the helth deprtments my provide dditionl finncil support for HIV cse surveillnce efforts, the level of support vries. Our cost estimte reflects the totl economic cost to CDC-funded helth deprtments to conduct HIV cse surveillnce, regrdless of funding source. Another six U.S.-dependent res, funded under different mechnism, were not included in this nlysis. The key product of HIV surveillnce in the U.S. is n electronic HIV cse surveillnce record for ech infected person (Figure). 4,5,14 The surveillnce record includes dt from clinicl nd lbortory reports nd vitl records tht provide informtion on demogrphics, HIV trnsmission risk fctors, fcilities of dignosis or cre, referrls to cre nd services, HIV-relted lbortory results, nd clinicl nd vitl records. 6,7,14 The dt rrive t the helth deprtment in hrd copies or electroniclly; the electronic dt my be specific to n individul or btched for mny people. All HIV cse surveillnce records re mintined in the Enhnced HIV/AIDS Reporting System (ehars), CDC softwre system developed for HIV surveillnce. HIV cse surveillnce dt reported to CDC re stripped of personlly identifible informtion. The helth deprtment surveillnce stff review incoming clinicl nd lbortory dt nd determine if they relte to new HIV dignosis or n estblished cse (i.e., person who hs previously been reported nd is still live). To scertin new cse, the surveillnce stff member serches the ehars dtbse to determine if the cse hs lredy been reported. If not, the stff member ssigns stte or locl identifiction number; enters informtion from the cse report form on demogrphics, HIV risk fctors, HIV-relted lbortory results (e.g., confirmtory dignostic test, CD4 counts, nd VLs), nd clinicl sttus; contcts the reporting helth-cre fcility for dditionl informtion, if needed; nd initites prtner services. To updte n estblished cse, the stff member serches the ehars dtbse to ensure tht the cse hs lredy been reported nd updtes the surveillnce record with newly reported informtion for the ptient nd helth-cre provider, including HIV-relted lbortory results nd occurrence of ny HIV-relted opportunistic infections or deth. For btched dt received electroniclly, dt processing involves clening the dt using SAS softwre, editing the dt, mtching the dt with estblished records or identifying the dt s belonging to new cse, nd merging the dt into estblished or new cse records. Throughout the process, surveillnce stff members ensure tht the dt entered re ccurte nd complete. We begn our nlysis with surveillnce dt on the number of new HIV cses reported during 2009 nd estblished cses s of December Using these

3 498 Reserch Articles Figure. Surveillnce process nd ctivities involved in HIV cse surveillnce conducted by U.S. stte nd locl helth deprtments, nd the process nd ctivities used for micro-costing dt collection nd nlysis, 2011 Ascertining new cses involves serching electronic dtbses to ensure the cse hs not lredy been reported; ssigning stte or locl identifiction number; entering informtion from the cse report form on demogrphics, HIV risk fctors, HIV-relted lbortory results, nd clinicl sttus; contcting the ptient s helth-cre provider for dditionl informtion, s needed; nd inititing prtner services. Updting estblished cses involves serching the electronic dtbses to ensure the cse hs been reported nd updting records with ptient s contct informtion, helth-cre provider informtion, CD4 counts, virl lods, nd occurrence of HIV-relted opportunistic infections. Boxes with dotted lines re not prt of the cost nlysis. HIV 5 humn immunodeficiency virus CDC 5 Centers for Disese Control nd Prevention DHAP 5 Division of HIV/AIDS Prevention dt, we strtified the helth deprtments funded by CDC to perform HIV cse surveillnce into HIV burden quintiles bsed on the number of totl HIV cses: low (#1,768; n512), low to moderte (1,769 5,703; n512), moderte (5,704 14,302; n511), moderte to high (14,303 20,602; n512), nd high ($20,603; n512). 4 We invited six helth deprtments representing four of the five strt to voluntrily prticipte in our cost nlysis. Although ll six helth deprtments greed to prticipte nd two of them piloted nd provided comments on CDC-designed cost collection forms, only one site, the Michign Deprtment of Community Helth (MDCH), moderte-to-high HIV burden site, completed the form. This nlysis is bsed primrily on micro-costing dt provided by the MDCH. We used micro-costing direct mesurement methods to estimte the economic cost tht helth deprtments incur to conduct HIV cse surveillnce Micro-costing is direct enumertion nd costing out of every input used in n intervention to generte prticulr helth outcome (e.g., n electronic HIV cse surveillnce record for ech infected person). 17,18 The nnul totl cost included ll fixed nd vrible costs of the surveillnce progrm. Fixed costs remin constnt regrdless of the number of cses, nd the fixed cost per cse decreses s the number of cses increses. This sitution rises when the helth deprtments re required to mintin certin number of stff nd other infrstructure to implement the surveillnce progrm, nd they re unble to chnge those inputs during short time frme. The fixed costs in our nlysis included stff time spent on progrm supervision, generl dministrtion, trining, nd trvel. They lso included durble items, such s computers, softwre, equipment, nd office spce. We bsed office spce costs on the verge rentl rte of similr fcility in

4 HIV Surveillnce Cost to U.S. Helth Deprtments 499 the locl mrket. Totl vrible costs, which increse in direct proportion to the number of cses, included stff time spent on scertining new cses or updting estblished cses. Vrible costs lso included office supplies. We collected ll cost dt from August to November 2011 nd nnulized them. To estimte the progrm cost, we directly mesured the unit cost nd quntity of ech resource used by the MDCH to operte the surveillnce progrm. Surveillnce stff recorded in ctivity logs time spent on scertining new HIV cses nd updting estblished cses, bsed on vitl records nd the most recent lbortory dt (in pper or electronic formt). Stff lso recorded their time spent on other progrmmtic ctivities, including progrm supervision, coordintion, dt mintennce, dministrtive duties, trining, nd trvel. Time spent by ech stff person on surveillnce ctivities ws multiplied by his or her hourly compenstion (wge nd fringe benefits) to estimte lbor costs. We nnuitized equipment costs during the useful life of ech piece of equipment using 3% discount rte. 16,18,20 The primry outcomes of our nlysis were the helth deprtment s nnul totl progrm cost, verge cost per cse overll, nd verge cost per new nd estblished cse. We ssessed the vrible costs for scertining new cses or updting estblished cses seprtely, but we ssumed the verge fixed cost would be the sme for new nd estblished cses. For ll of the nlyses, we used helth deprtment cost perspective in tht we did not include the costs ssocited with HIV cse reporting by helth-cre fcilities to the helth deprtments, or CDC s dministrtive overhed. All costs were expressed in 2011 U.S. dollrs. Bsed on the Michign dt, we projected the expected nnul surveillnce cost of ll 59 CDC-funded stte, locl, nd territoril helth deprtments, including Michign. We bsed the projection on three steps: (1) ssigning the re-specific hourly compenstion rtes obtined for the other helth deprtments to the number of lbor hours clculted for Michign to estimte the lbor cost for ech helth deprtment; (2) djusting the fixed cost to ccount for potentil economies of scle mong helth deprtments; 18,22,23 nd (3) identifying the minimum fixed cost of stff time, equipment, nd services required for ny helth deprtment to conduct HIV cse surveillnce bsed on CDC s dt security nd confidentility guidelines, regrdless of HIV burden. For step 1, we derived hourly wges for the metropolitn re where ech helth deprtment s surveillnce stff ws bsed from the 2011 U.S. Bureu of Lbor Sttistics (BLS) Occuptionl Employment Sttistics survey. 24 We used the medin hourly wge from the survey s ctegory for generl nd opertions mngers to correspond to surveillnce supervisory stff nd the medin hourly wge for life, physicl, nd socil science workers to correspond to surveillnce progrmmtic stff. In ddition, we dded 35% djustment to the hourly wge, bsed on informtion bout verge fringe benefits for stte nd locl government workers in helth-cre nd socil ssistnce occuptions obtined from the 2011 BLS Ntionl Compenstion Survey: Employer Cost for Employee Compenstion. 20,25,26 For step 2, using Michign s reference cse, we djusted the fixed cost per cse to ccount for potentil economies of scle in helth deprtments operting in res with higher or lower HIV burden. Economies of scle occur when the verge cost per HIV cse record decreses s the totl number of cses increses due to lrger scle of opertion. Economies of scle cn result from spreding fixed costs over greter number of cses, more efficient use of lbor or equipment, nd helth deprtments bility to use specilized surveillnce processes. 18,22 Given the lck of dt on economies of scle in HIV surveillnce, we bsed our scle ssumption on expert judgment, nd we djusted fixed costs only. Fixed costs for Michign nd other moderte-to-high HIV burden sttes were undjusted. For the high burden res, we hlved the fixed cost per cse, ssuming potentil economies of scle. For the moderte, low-to-moderte, nd low burden sites, we incresed fixed costs per cse by 50% per strt, ssuming less economies of scle. Compred with Michign, the djustment in fixed costs worked out to be 50% increse in moderte burden res, 125% increse in low-to-moderte burden res, nd 238% increse in low burden res. In sensitivity nlysis, we estimted the fixed costs without djusting for economies of scle. For step 3, to estimte the minimum fixed cost, we identified the equipment, office spce, technology, nd stff time required to conduct HIV surveillnce, regrdless of HIV burden. The equipment included computer, fx nd copier, nd shredder; the office spce ws conservtively ssumed to be 150 squre feet; nd the technology included n ehars server, n SQL server, server mintennce, nti-virus softwre, nd phone nd Internet services. We included 20 hours/ week of progrmmtic stff time s minimum for lbor. We pplied these lbor nd non-lbor minimum fixed costs to ll sites, regrdless of HIV burden. These minimum costs were seprte from the other fixed costs per cse described in step 2. They were the sme for ech helth deprtment except for differences in wge rtes pplied to the 20 hours week of progrmmtic stff time.

5 500 Reserch Articles We estimted the totl surveillnce progrm cost for ech helth deprtment by multiplying the fixed cost, djusted for economies of scle, nd vrible cost per new nd estblished HIV cse by the number of new nd estblished HIV cses reported by ech helth deprtment, nd dding it to the minimum cost for ech helth deprtment. RESULTS A totl of 14,864 HIV cses were reported to the Michign helth deprtment s of 2009, of which 818 (6%) were newly reported cses nd 14,046 (94%) were estblished cses. We estimted the nnul surveillnce progrm cost in Michign to be $1,286,524 ($87/cse), with 92% of the cost llocted to estblished HIV cses. The totl cost per cse ws $133 for ech new cse nd $84 for ech estblished cse (Tble 1). In Michign, the mjority (88%) of the surveillnce cost ws ttributble to lbor costs, nd those costs were lrgely fixed (i.e., relted to dministrtion, coordintion, supervision, or dt mintennce). Fixed costs per cse were ssumed to be the sme ($77) for new nd estblished cses, but vrible costs were higher for new cses ($56) thn for estblished cses ($7, Tble 1). Higher vrible costs per new cse were ttributble to the verge of 1.42 hours per cse spent determining if new cse hd been previously reported (Tble 2). Helth deprtment stff spent n verge of 0.02 hours (one minute) per cse on pper-bsed lbortory dt processing, which included CD4 counts, VLs, nd confirmtory dignostic tests, while they spent only hours (0.2 minutes) per cse processing the btched dt received electroniclly. Projecting the nnul cost of HIV surveillnce for ll 59 helth deprtments in the U.S. from the Michign micro-costing dt, we estimted tht the medin nnul cost per helth deprtment by HIV burden level rnged from $210,600 (low HIV burden) to $1,835,000 (high HIV burden) (Tble 3). In sensitivity nlysis, when we estimted the cost without djusting for the economies of scle, the medin cost per helth deprtment rnged from $112,500 to $3,223,300 (dt not shown). Our cost projection ccounted for the reltively higher cost borne by helth deprtments with higher proportion of new HIV cses. In Michign, where no djustments for the economies of scle were required, we estimted the projected cost to be $1,245,600, which is slightly lower ( 3%) thn the ctul reported progrm cost. The vrition between the ctul cost derived from micro-costing nd the projected cost ws solely due to the differences in hourly wge nd benefits of the stff s reported by the surveillnce progrm nd the BLS. We estimted the projected fixed minimum cost of the surveillnce progrm in Michign to be $66,800 (ctul cost 5 $70,535) (dt not shown). The estimted medin fixed minimum cost in other helth deprtments rnged from $63,000 in low HIV burden sites to $69,300 in high HIV burden sites, with the vrition due to the differences in the re-specific wges reported by the BLS (Tble 3). Tble 1. Summry of HIV surveillnce cses, nnul totl progrm cost, nd cost per cse using micro-costing dt collected from August to November 2011 in Michign HIV cses nd progrm cost New cses Estblished cses Totl progrm HIV cses nd stff time Number of HIV cses ,046 14,864 Stff time spent per cse, in hours Totl progrm cost b $108,657 $1,177,867 $1,286,524 Lbor/non-lbor costs, proportion of the totl Lbor Non-lbor Fixed/vrible costs, proportion of the totl Fixed Vrible Cost per cse, in U.S dollrs Fixed $77.04 $77.04 $77.04 Vrible $55.79 $6.82 $9.51 Totl $ $83.86 $86.55 Surveillnce dt represent new HIV cses reported during 2009 nd estblished cses s of December 2009 bsed on: Centers for Disese Control nd Prevention (US). Dignoses of HIV infection nd AIDS in the United Sttes nd dependent res, HIV Surveill Rep 2012;22:1-79. b Includes the fixed minimum costs. All costs re expressed in 2011 U.S. dollrs. HIV 5 humn immunodeficiency virus

6 HIV Surveillnce Cost to U.S. Helth Deprtments 501 Tble 2. Vrible nd fixed costs of HIV surveillnce in Michign, by progrm ctivity, using micro-costing dt collected from August to November 2011 Vrible Time per cse (in hours) Cost per cse (in 2011 U.S. dollrs) Totl time (in hours) Annul cost (in 2011 U.S. dollrs) Vrible cost: lbor Ascertining new cses 1.42 $ ,158 $43,975 Updting estblished cses b 0.13 $4.78 1,770 $67,203 Reporting most recent lbortory dt (pper formt) c 0.02 $ $9,635 Reporting most recent lbortory dt (electronic formt),0.01 $ $2,558 Ascertining survivl sttus or births using vitl records 0.01 $ $2,923 Vrible cost: non-lbor Office supplies NA $1.02 NA $15,135 Fixed cost: lbor Progrm supervision 0.13 $6.93 1,896 $103,047 Progrm coordintion d 0.43 $ ,390 $263,877 Intergency coordintion d 0.03 $ $13,133 Generl dministrtion 0.36 $ ,404 $212,408 Dt mintennce e 0.31 $ ,641 $189,682 Internet technology services f 0.15 $7.04 2,256 $104,583 ehars dt importing g 0.04 $ $21,051 Trining nd trvel 0.01 $ $7,106 Field work nd trvel 0.11 $2.86 1,631 $42,439 Other supplementl projects h 0.01 $ $3,987 Fixed cost: non-lbor Computer NA $0.22 NA $3,283 Computer softwre NA $0.85 NA $12,662 Softwre license nd updte NA $0.45 NA $6,641 Computer support fees NA $1.60 NA $23,823 Computer server NA $0.07 NA $1,045 Fx, copier, nd shredder NA $0.13 NA $1,965 Phone service NA $0.19 NA $2,758 Internet NA $0.30 NA $4,524 Office spce NA $3.25 NA $48,345 Lbortory spce NA $0.55 NA $8,200 Fixed minimum cost i NA NA NA $70,535 Totl cost NA NA NA $1,286,524 Ascertining new cses involves serching electronic dtbses to ensure the cse hs not lredy been reported; ssigning stte or locl identifiction number; entering informtion from the cse report form on demogrphics, HIV risk fctors, HIV-relted lbortory results, nd clinicl sttus; contcting the ptient s helth-cre provider for dditionl informtion, s needed; nd inititing prtner services. b Updting estblished cses involves serching the electronic dtbses to ensure the cse hs been reported nd updting records with ptient s contct informtion, helth-cre provider informtion, CD4 counts, virl lods, nd occurrence of HIV-relted opportunistic infections. c Lbortory dt included the reporting for CD4 counts, virl lods, nd confirmtory dignostic test. The totl time (e.g., 254 hours) included stff time spent on dding only the most recent lbortory dt in the surveillnce records. For consistency in the nlysis, we clculted the verge time per cse by dividing the totl time by the totl number of cses (14,864). d Progrm coordintion included plnning, reporting, ccounting, nd budgeting; intergency coordintion included informtion shring with sexully trnsmitted disese clinics nd other helth-cre providers. e Dt mintennce included dt processing, clening, qulity ssurnce, nd out-of-stte/routine interstte duplicte review. f Internet technology service included server mintennce nd dt security. g ehars is browser-bsed HIV surveillnce system deployed by stte nd locl helth deprtments; the server cost ws included in the fixed minimum cost. h Other supplementl projects included geogrphic informtion system nd vrint, typicl, nd resistnt HIV surveillnce. i Included the bsic minimum cost of lbor (20 hours/week), computer, fx nd copier, shredder, office spce (150 squre feet), ehars nd SQL servers, server mintennce, nti-virus softwre, nd phone nd Internet services HIV 5 humn immunodeficiency virus ehars 5 Enhnced HIV/AIDS Reporting System NA 5 not pplicble

7 502 Reserch Articles Tble 3. Medin number of HIV cses nd medin projected surveillnce progrm cost per helth deprtment per yer, by HIV burden level: 50 U.S. sttes, the District of Columbi, six seprtely funded cities, Puerto Rico, nd the Virgin Islnds, bsed on micro-costing dt collected from August to November 2011 in Michign HIV burden level New HIV cses in 2009 b N Estblished HIV cses, end of 2009 N Fixed minimum cost (in 2011 U.S. dollrs) c Cost of new HIV cses (in 2011 U.S. dollrs) Cost of estblished HIV cses (in 2011 U.S. dollrs) Totl cost/ll cses (in 2011 U.S. dollrs) d Low (n512) $63,000 $7,800 $136,300 $210,600 Low-to-moderte (n512) 165 2,808 $64,100 $32,700 $425,500 $518,000 Moderte (n511) ,482 $69,100 $68,500 $1,098,400 $1,262,000 Moderte-to-high (n512) ,357 $67,500 $102,600 $1,280,300 $1,487,700 High (n512) 1,865 35,301 $69,300 $178,700 $1,552,500 $1,835,000 HIV burden level (quintile rnge of totl HIV cses): low ( 1,768), low-to-moderte (1,769 5,703), moderte (5,704 14,302), moderte-to-high (14,303 20,602), nd high ( 20,603). b Surveillnce dt represent new HIV cses reported during 2009 nd estblished cses s of December 2009 bsed on: Centers for Disese Control nd Prevention (US). Dignoses of HIV infection nd AIDS in the United Sttes nd dependent res, HIV Surveill Rep 2012;22:1-79. c Cost projection bsed on micro-costing dt collected from Michign from August to November 2011, nd djustment on fixed costs for potentil economies of scle for low- nd high-burden sttes compred with Michign. d Medin costs t ech HIV burden level, not the sum of the costs reported in the three preceding columns HIV 5 humn immunodeficiency virus DISCUSSION We estimted the cost to U.S. helth deprtments of conducting high-qulity HIV cse surveillnce, ccounting for the number of new nd estblished cses, re-specific wges, nd potentil economies of scle. The medin cost per helth deprtment rnged from $210,600/yer in low HIV burden res to $1,835,000/ yer in high HIV burden res. To our knowledge, this study is the first to comprehensively estimte the resources required to conduct HIV surveillnce in U.S. stte, locl, nd territoril helth deprtments. In Michign, we found tht lrge proportion of totl costs (92%) re relted to updting records for estblished cses. As the number of estblished cses increses, with more intense focus on expnded HIV screening, erly dignosis, monitoring of cre, nd HIV VL suppression, surveillnce costs re likely to increse s well. 4 However, we lso showed tht the surveillnce cost of new HIV cse is 58% higher thn tht of n estblished cse becuse identifying nd documenting new cse tkes extr time. This finding suggests tht helth deprtments with higher proportion of new cses might incur greter costs compred with helth deprtments tht hve lower proportion of new cses. In recent yers, helth deprtments hve emphsized the electronic reporting of surveillnce dt, prticulrly dt received in btches from the testing lbortories nd helth-cre fcilities. 6,27,28 In Michign, more thn hlf of the surveillnce dt were received electroniclly, nd our results indicte tht those dt cn be dded to n HIV surveillnce record t frction of the cost of dt rriving on pper. Although CDC encourges helth deprtments to mke greter use of electronic reports, much vrition exists mong helth deprtments concerning current levels of use. We did not ccount for this vrition; we ssumed the sme degree of electronic reporting in other sttes s in Michign. Greter or lesser use of electronic reporting could decrese or increse totl helth deprtment surveillnce costs. Although disese surveillnce is criticl to public helth, 29,30 few studies hve ttempted to mesure how much it costs for helth deprtments to conduct surveillnce For HIV surveillnce, one study reported on the funding per cse of HIV in the U.S., bsed on helth deprtments reported expenditures. 27 These expenditures, or budgetry dt, do not necessrily equl cost dt collected through micro-costing techniques becuse budgetry dt my include unrelted costs, such s those for reserch, or exclude relevnt costs (e.g., when the progrm ws prtilly funded by the gency from whose perspective the cost nlysis ws conducted), nd the nlysis ccounted for ll of the surveillnce cses. 15 Limittions Our nlysis ws subject to severl limittions. We developed systemtic pproch to estimte helth deprtment costs for conducting HIV cse surveillnce bsed on empiricl dt obtined from one

8 HIV Surveillnce Cost to U.S. Helth Deprtments 503 micro-costing study. However, our projected costs for other helth deprtments ccounted for re-specific vrition in wges, potentil economies of scle mong surveillnce progrms, nd differences in the number of new vs. estblished HIV cses. Additionl microcosting dt will be needed to vlidte our estimte of the surveillnce cost of other helth deprtments. Becuse we used helth deprtment cost perspective, our nlysis excluded the costs potentilly incurred by helth-cre fcilities while reporting HIV cses to the helth deprtments nd lso CDC s dministrtive overhed. Thus, the societl cost of HIV cse surveillnce could be much higher thn our estimte. CONCLUSIONS Our nlysis showed tht systemtic pproch to costing public helth surveillnce ctivities is fesible nd micro-costing methods cn estimte the cost of surveillnce. Our findings my help guide future lloction of HIV surveillnce funds cross helth deprtments nd ssist helth deprtments in estimting their own costs. Although surveillnce is crucil prt of public helth prevention plnning nd priority setting, limited informtion is vilble on how much it costs helth deprtments to conduct high-qulity HIV surveillnce. Additionlly, little is known bout how those costs vry depending on the HIV epidemic chrcteristics in ech helth deprtment re. We provide n pproch to estimting the helth deprtment costs of conducting high-qulity HIV surveillnce in the U.S. As HIV prevention incresingly depends on the vilbility of dt on dignosis, linkge to cre, initition of tretment, nd VL suppression, providing high-qulity surveillnce dt will continue to be n importnt prt of our ntionl effort to control HIV. The uthors thnk the helth deprtment mngers nd stff who prticipted in the study design, piloted cost forms, nd provided surveillnce cost dt. The dt nlyses in this study were bsed on humn immunodeficiency virus surveillnce dt. Public helth disese surveillnce ctivities re not considered reserch; therefore, institutionl review bord review ws not required. The findings nd conclusions in this rticle re those of the uthors nd do not necessrily represent the views of the Centers for Disese Control nd Prevention. REFERENCES 1. Centers for Disese Control nd Prevention (US). Estimted HIV incidence in the United Sttes, HIV Surveill Suppl Rep 2012;17: Torin L, Chen M, Rhodes P, Hll HI. HIV surveillnce United Sttes, [published errtum ppers in MMWR Morb Mortl Wkly Rep 2011;60(25):852]. MMWR Morb Mortl Wkly Rep 2011;60(21): Centers for Disese Control nd Prevention (US). Monitoring selected ntionl HIV prevention nd cre objectives by using HIV surveillnce dt United Sttes nd 6 U.S. dependent res HIV Surveill Suppl Rep 2012;17: Centers for Disese Control nd Prevention (US). Dignoses of HIV infection nd AIDS in the United Sttes nd dependent res, HIV Surveill Rep 2012;22: Centers for Disese Control nd Prevention (US). HIV surveillnce supported by the Division of HIV/AIDS Prevention [cited 2014 Jun 6]. Avilble from: URL: /recommendtions/publictions.html 6. Hll HI, Mokotoff ED; Advisory Group for Technicl Guidnce on HIV/AIDS Surveillnce. Setting stndrds nd n evlution frmework for humn immunodeficiency virus/cquired immunodeficiency syndrome surveillnce. J Public Helth Mng Prct 2007;13: Hll HI, Song R, Gerstle JE 3rd, Lee LM; HIV/AIDS Reporting System Evlution Group. Assessing the completeness of reporting of humn immunodeficiency virus dignoses in : cpture-recpture methods. Am J Epidemiol 2006;164: Mnsergh G, Vldiserri RO, Ykovchenko V, Koh H. Aligning resources to fight HIV/AIDS in the United Sttes: funding to sttes through the US Deprtment of Helth nd Humn Services. J Acquir Immune Defic Syndr 2012;59: Bertolli J, Shouse RL, Beer L, Vlverde E, Fgn J, Jenness SM, et l. Using HIV surveillnce dt to monitor missed opportunities for linkge nd enggement in HIV medicl cre. Open AIDS J 2012;6: Gry KM, Kjese T, Crndell-Alden E, Anderson BJ, Wendell D, Crutchfield A, et l. Enhnced collection of lbortory dt in HIV surveillnce mong 5 sttes with confidentil nme-bsed HIV infection reporting, Open AIDS J 2012;6: Institute of Medicine. Monitoring HIV cre in the United Sttes: indictors nd dt systems. Wshington: Ntionl Acdemies Press; White House (US), Office of Ntionl AIDS Policy. Ntionl HIV/ AIDS strtegy for the United Sttes [cited 2014 Jun 6]. Avilble from: URL: /onp/nhs 13. Centers for Disese Control nd Prevention (US). Technicl guidnce for HIV/AIDS surveillnce progrms, volume I: policies nd procedures. Atlnt: CDC; Schneider E, Whitmore S, Glynn KM, Dominguez K, Mitsch A, McKenn MT. Revised surveillnce cse definitions for HIV infection mong dults, dolescents, nd children ged 18 months nd for HIV infection nd AIDS mong children ged 18 months to 13 yers United Sttes, MMWR Recomm Rep 2008;57(RR-10): Shresth RK, Snsom SL, Frnhm PG. Comprison of methods for estimting the cost of humn immunodeficiency virus-testing interventions. J Public Helth Mng Prct 2012;18: Drummond M, McGuire A. Economic evlution in helth cre: merging theory with prctice. New York: Oxford University Press; Frick KD. Micro-costing quntity dt collection methods. Med Cre 2009;47(7 Suppl 1):S Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in helth nd medicine. New York: Oxford University Press; Gorsky RD. A method to mesure the costs of counseling for HIV prevention. Public Helth Rep 1996;111(Suppl 1): Hddix AC, Teutsch SM, Corso PS. Prevention effectiveness: guide to decision nlysis nd economic evlution. 2nd ed. New York: Oxford University Press; Smith MW, Brnett PG. Direct mesurement of helth cre costs. Med Cre Res Rev 2003;60(3 Suppl):74S-91S. 22. Long MJ, Ament RP, Drechslin JL, Kobrinski EJ. A reconsidertion of economies of scle in the helth cre field. Helth Policy 1985;5: Follnd S, Goodmn AC, Stno M. The economics of helth nd helth cre. New Jersey: Prentice Hll, Inc.; Census Bureu (US). Occuptionl employment sttistics. Wshington: Bureu of Lbor Sttistics (US); Also vilble from: URL: [cited 2014 Jun 6]. 25. Census Bureu (US). Employer costs of employee compenstion, Mrch Wshington: Bureu of Lbor Sttistics (US); Also

9 504 Reserch Articles vilble from: URL: _ pdf [cited 2014 Jun 6]. 26. Grosse SD, Krueger KV, Mvundur M. Economic productivity by ge nd sex: 2007 estimtes for the United Sttes. Med Cre 2009;47(7 Suppl 1):S Pge MJ, Hrrison KM, Wei X, Hll HI. Federl funding for reporting cses of HIV infection in the United Sttes, Public Helth Rep 2010;125: Murwski L. Mximizing federl funds for HIV/AIDS: improving surveillnce nd reporting. Scrmento (CA): Legisltive Anlyst s Office; Nsubug P, White ME, Thcker SB, Anderson MA, Blount SB, Broome CV, et l. Public helth surveillnce: tool for trgeting nd monitoring interventions. In: Jmison DT, Bremn JG, Meshm AR, Alleyne G, Cleson M, Evns DB, et l., editors. Disese control priorities in developing countries. 2nd ed. Wshington: World Bnk; p Smith PF, Hdler JL, Stnbury M, Rolfs RT, Hopkins RS; CSTE Surveillnce Strtegy Group. Blueprint version 2.0 : updting public helth surveillnce for the 21st century. J Public Helth Mng Prct 2013;19: Elbsh EH, Fitzsimmons TD, Meltzer MI. Costs nd benefits of subtype-specific surveillnce system for identifying Escherichi coli O157:H7 outbreks. Emerg Infect Dis 2000;6: Hinds MW, Skggs JW, Bergeisen GH. Benefit-cost nlysis of ctive surveillnce of primry cre physicins for heptitis A. Am J Public Helth 1985;75: Somd ZC, Meltzer MI, Perry HN, Messonnier NE, Abdulmumini U, Mebrhtu G, et l. Cost nlysis of n integrted disese surveillnce nd response system: cse of Burkin Fso, Eritre, nd Mli. Cost Eff Resour Alloc 2009;7: Vogt RL, LRue D, Klucke DN, Jillson DA. Comprison of n ctive nd pssive surveillnce system of primry cre providers for heptitis, mesles, rubell, nd slmonellosis in Vermont. Am J Public Helth 1983;73: Morris S, Gry A, Noone A, Wisemn M, Jthnn S. The costs nd effectiveness of surveillnce of communicble disese: cse study of HIV nd AIDS in Englnd nd Wles. J Public Helth Med 1996;18:

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