Return on Public Health Investment: CDC s Expanded HIV Testing Initiative ACCEPTED

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1 JAIDS Journal of Acquired Immune Deficiency Syndromes Publish Ahead of Print DOI: /QAI.0b013e31823e5bee Return on Public Health Investment: CDC s Expanded HIV Testing Initiative Angela B Hutchinson, Paul G Farnham, Nadezhda Duffy, Richard J Wolitski, Stephanie L Sansom, Samuel W Dooley, Janet C Cleveland, Jonathan H Mermin Authors Affiliation: Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, GA Correspondence to: Angela Hutchinson ( ash2@cdc.gov); telephone: Author Disclaimer: The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. Conflicts of Interest/Souces of Funding: none to disclose Abstract word count: 253 Manuscript word count: 3,399 Key words: HIV, testing, economics, return on investment, cost, resource allocation 1

2 Abstract Background: Over a three-year period, CDC invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative, for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing. Methods: We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared to when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1-5 year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection. Results: Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3,381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 $2.01 for alternative testing intervals of one to five years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%. Conclusion: The Expanded Testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs. 2

3 Human immunodeficiency virus (HIV) testing is the cornerstone of HIV prevention and care and an essential step in the treatment of people living with HIV. In 2006, the Centers for Disease Control and Prevention (CDC) issued HIV testing guidelines that updated portions of the 2001 testing guidelines. The 2006 guidelines provide specific guidance for health care settings that promote routine, opt-out HIV testing for all people between 13 and 64 years of age in populations with a prevalence of undiagnosed HIV of >0.1% 1,2. These guidelines are supported by evidence that timely awareness of serostatus and access to antiretroviral therapy (ART) can increase the life expectancy of persons with HIV by decades and may reduce HIV transmission due to reductions in risk behavior and treatment-based reductions in infectiousness 3, 4. Transmission rates for persons unaware of their infection are estimated to be three times as great as those for persons aware of their infection 5. Additionally, for people without HIV, especially those in HIV-discordant partnerships, diagnosis and disclosure of a partner s status allow individuals and couples to make informed HIV prevention choices 6. While there has been a modest increase in HIV testing since publication of the 2006 guidelines, the majority of Americans still have not been tested for HIV. Among those tested, approximately one third of new HIV diagnoses are late diagnoses made simultaneously with, or within 12 months of an AIDS diagnosis 7. In 2007, CDC announced the Expanded HIV Testing Initiative, which increased health department funding for HIV testing, early diagnosis and linkage to care and prevention services and focused on jurisdictions with a relatively high proportion of AIDS diagnoses among blacks (Funding Opportunity Announcement, FOA CDC-PS ). Over a three-year period (October 2007 September 2010), CDC invested $102.3 million in 25 jurisdictions (23 states and large cities in the first year and two additional states in the second and third years) to conduct testing and related services. Health departments were required to focus 80% of their activities on promoting opt-out HIV screening in high-morbidity clinical settings, such as emergency departments, sexually transmitted disease clinics and 3

4 community health centers. Up to 20% of resources could be used to test high-risk populations in nonclinical settings 8. Grantees also were required to implement sustainable HIV screening practices using either rapid or conventional testing 8. The primary objective of the Initiative was to increase HIV testing opportunities for populations disproportionately affected by HIV, primarily blacks, and to increase the proportion of HIV-infected persons who were aware of their infection and linked to appropriate medical care and prevention services. In 2008, blacks accounted for 51.2% of new HIV diagnoses, and the HIV diagnosis rate for blacks was nine times as high as that of whites 9. Additionally, blacks and Hispanics, as well as men who have sex with men (MSM) and injection drug users (IDUs) of all races and ethnicities, are over-represented among HIV-infected persons unaware of their status 10. Cost-effectiveness analysis supports routine and expanded HIV testing However, economic analyses are needed to determine the value of the benefits associated with investments in large-scale testing, or the financial return on investment. Such analyses are helpful to government agencies that must optimize outcomes for public health given a set budget, and may assist with resource allocation during times of economic constraint In this paper, we report the results of a return-on-investment (ROI) analysis that compares expenditures of the Expanded HIV Testing Initiative to benefits in terms of HIV transmissions averted and associated medical care costs. METHODS We conducted a ROI analysis of the Initiative using expenditure and outcome data reported over the three years of the program. Using a published mathematical model of HIV transmission, we estimated the number of HIV transmissions averted by the Initiative based on the number of persons tested, newly diagnosed with HIV infection, and linked to care 16. We estimated the costs associated with these averted HIV infections and the return on investment in the program. Benefits of HIV transmissions averted were valued using published estimated lifetime HIV treatment costs discounted to the time of infection 17. We adjusted all costs and expenditures to 2009 dollars, and discounted future costs and effects at a 3% annual rate. We conducted our analysis in Microsoft Excel. 4

5 We calculated return on investment for programmatic expenditures on HIV testing and related services by CDC and partners, such as state and local governments, and the larger health system. Return on CDC/partner investment was calculated as program benefits (the averted medical costs associated with HIV transmissions prevented) divided by expenditures by CDC and partners. Return on the health system investment was calculated as program benefits divided by all program expenditures, regardless of source, and including the medical costs of treating newly diagnosed index patients through the period of analysis. Policy interest focused on whether program benefits (treatment costs averted) exceeded the investment in the Initiative (an ROI value >$1, or a positive return on investment). Program Expenditures and Treatment Costs For the CDC/partner investment, we defined the program investment as the actual expenditures for the three fiscal years of the program, FY FY 2009, as reported by the grantees to CDC. We also calculated additional non-cdc expenditures for the Initiative based on a survey of 7 of the 25 funded jurisdictions regarding outside funding used to implement the Initiative. The average proportion of CDC expenditures for the Initiative to total expenditures for testing under the Initiative was 81 percent in these jurisdictions. Thus, we increased CDC expenditures accordingly to estimate expenditures by CDC and partners. For the health system investment, we also included costs incurred by the health system for HIV treatment provided to persons newly identified as HIV-infected through the Initiative for the early awareness period, the estimated period of time before these persons would have been otherwise diagnosed with HIV. These costs were derived from the lifetime HIV treatment cost estimate. Program Benefits Benefits of the testing program were defined as the value of HIV transmissions averted from persons newly identified with HIV through the Initiative. We used lifetime HIV treatment costs of $367,134 (adjusted to 2009 dollars) to value each transmission averted 17. We did not include benefits to the index client from earlier diagnosis. Additionally, it should be noted that regardless of testing interval, the benefits of averted medical costs due to HIV transmission accrue over a lifetime. 5

6 HIV Transmission Model The mathematical model of HIV transmission incorporated the effects of awareness of HIV status on risk behavior and the use of antiretroviral therapy (ART) 5, 18. We modeled transmissions averted as the difference between the transmissions likely to occur by those who were unaware of their infection and the transmissions likely to occur by those who became aware of their infection earlier through the Initiative. We calculated transmissions averted from the time individuals with HIV learned of their infection through the Initiative until the estimated time on average those persons would have learned of their infection without the screening program, which we refer to as the alternative testing interval. We chose a 3-year testing interval for our base case, which is the mid-point between the 5-year interval commonly used in economic evaluations of HIV screening 12, 13 and the 1-year testing recommendations for high-risk groups 2. In sensitivity analyses we assessed the effect of 1-, 2-, 4- and 5- year alternate testing intervals. We used program outcome data from funded jurisdictions for FY 2007 through FY 2009 on the number of persons tested and the number of newly infected persons identified, informed of their results and linked to care. Under the Expanded HIV Testing Initiative, a total of 2,786,739 people were tested for HIV, 18,432 (0.7%) were newly diagnosed with HIV, and 15,737 (91%) of these persons were notified of their test results (Table 1). We adjusted these data for the expected number of infected persons who would have been identified through background testing, or testing that would have occurred in the absence of the Initiative. The background annual testing level (17%) was based on a CDC HIV prevention resource allocation model 19, (Lasry, CDC unpublished data). We then applied estimated transmission probabilities for aware versus unaware HIV-infected persons to calculate the total number of transmissions averted attributable to the Initiative. To estimate sexual HIV transmissions averted, we applied annual transmission rates for HIV-infected persons who were unaware of their HIV status 20, those who were aware of their status and on ART, and those aware of their status and not on ART (derived from Prabhu et al., 2009) 20 (Table 1). The reduced likelihood of sexual transmission of HIV following a new diagnosis was due to a combination of the index person s 6

7 engagement in fewer risky behaviors and in reduced transmission due to viral load suppression following treatment. We used the same method to estimate HIV transmissions averted due to injection drug use (IDU) as we did for sexual transmission. However, we adjusted IDU transmission rates only by awareness of infection and not by treatment status. IDU transmission rates, which were based on injection drug use behaviors alone (exclusive of sexual transmission by IDUs), were drawn from the literature 13, 21. The estimated proportions of HIV transmissions from sexual activity and injection drug use were derived from 2006 national HIV incidence surveillance data 22. In our model, 75 percent of newly identified HIV-infected persons were linked to care based outcome data from the Initiative. We assumed that 80 percent of persons diagnosed were eligible to start ART at diagnosis based on program data on the number of new HIV diagnoses by setting, and data from the literature on the distribution of CD4 counts at diagnosis by testing setting. Thirty percent of persons tested through the Initiative were tested in emergency departments (EDs), 20 percent in sexually transmitted disease (STD) clinics and 23 percent in community health centers or community-based organizations 8. Based on data from White et al. 23, we estimated that 50 percent of patients in EDs were tested at CD4 counts of 350 or fewer cells/µl, 20 percent were tested at CD4 counts between 350 and 500 cells/µl, and 30 percent were tested at CD4 counts greater than 500 cells/µl. For STD clinics and community health centers, we estimated that 35 percent of patients were tested at CD4 counts of 350 or fewer cells/µl, 25 percent were tested at CD4 counts between 350 and 500 cells/µl, and 40 percent were tested at CD4 counts greater than 500 cells/µl 24,25. We then assumed that all patients with a CD4 count of 350 or fewer cells/µl started ART at diagnosis, as did 90 percent of patients diagnosed with a CD4 count between 350 and 500 cells/µl and 50 percent of patients diagnosed with a CD4 count greater than 500 cells/µl. These assumptions, which assume relative adherence to current guidelines regarding initiation of ART, resulted in the estimate that 80 percent of all patients were eligible to start ART at diagnosis 26. We assumed newly diagnosed patients who did not start ART remained untreated for the duration of the period of the analysis. The HIV transmission model is summarized in equation (1) : 7

8 Total transmissions averted = (T S * P S + T IDU * P IDU )* N (1) Where, T S = Sexual transmissions averted per person with HIV diagnosed and notified T IDU = IDU transmissions averted per person with HIV diagnosed and notified P S = proportion of transmissions due to sexual activity in the U.S. in 2006 (.865) P IDU = proportion of transmissions due to injecting drug use in the U.S. in 2006 (.134) N = Number of persons newly diagnosed with HIV and notified of their infection adjusted for background testing (Table 1). Sexual transmissions averted, T S = T noinitiative T INITIATIVE (2) IDU transmissions averted, = D* [µ SUA ((P L *µ SAART ) + ( 1 - P L )*µ SANART )] T IDU = T noinitiative T INITIATIVE (3) = D* (µ IUA µ IA ) Where, T noinitiative T INITIATIVE = Number of transmissions without the Initiative = Number of transmissions with the Initiative D = Duration individuals would be undiagnosed in the absence of the Initiative (3 years) P L = Proportion of newly diagnosed persons linked to care from the Initiative (.75) µ SUA = Sexual annual HIV transmission rates for unaware persons (.1117) µ SAART = Sexual annual HIV transmission rates for aware persons on ART (.0097) µ SANART = Sexual annual HIV transmission rates for aware persons not on ART (.0484) µ IUA = IDU annual HIV transmission rates for unaware persons (.165) µ IA = IDU annual HIV transmission rates for aware persons (.126) Sensitivity and Threshold Analysis 8

9 We conducted additional sensitivity analyses to determine how robust our findings are to alternative testing intervals of one to five years and smaller differences in transmissions averted by adjusting the base case values downward 25%, 50% and 75%. We also conducted a threshold analysis to determine the lowest prevalence of undiagnosed HIV infection at which ROI values would be 1.0 or positive, for the base case, 3-year, alternative testing interval. RESULTS Under base case assumptions that infected persons were diagnosed 3 years earlier because of the Initiative, we estimated that 3,381 HIV infections were averted from persons newly diagnosed (Table 2). Return on the Health System Investment The health system investment included an estimated total expenditure of $599,096,000, which consisted of investments in the Initiative from CDC of $102,335,000; additional funding from sources, such as state and local government, of $24,049,000; and estimated medical costs for newly diagnosed persons of $472,712,000. Medical care costs from HIV infections averted were estimated to be $1,169,887,000 resulting in net benefits (total benefit minus total cost) of $570,791,000 and a return on investment of $1.95 for every dollar invested in the Initiative (Table 2). The return on investment ranged from $1.46 $2.01 for the 1- to 5-year alternative testing intervals. ROI values remained above $1, a positive return on investment, with a prevalence of undiagnosed HIV infection as low as 0.12% (data not shown) and with a 25% reduction in transmissions averted. ROI approached $1 ($0.98) at a 50% reduction in transmissions averted from base case values (Figure 1). Return on CDC s Investment The total investment in the program from CDC and partners for the three years was $126,384,000. Medical care costs from HIV infections averted were estimated to be $1,169,887,000 resulting in net benefits of $ 1,043,503,000 or a return on investment of $9.26 for every dollar invested in the Initiative (Table 2). When considering only CDC s investment in the Initiative, the ROI was $

10 The number of HIV infections averted, net benefits, and ROI values increased with the length of the alternative testing interval, or the time the infected persons would have been diagnosed on average without the Initiative. The return on CDC and partners investment ranged from $ $14.54 for the 1- to 5-year alternative testing intervals (Table 2). ROI values remained above $1 with the prevalence of undiagnosed HIV infection as low as 0.07% and with reductions in transmissions by 75% (data not shown). DISCUSSION Our findings showed considerable gains from investments in CDC s Expanded HIV Testing Initiative when quantified in dollar terms. The return on the health system investment, which takes into account the medical care and treatment costs for those diagnosed with HIV, was $1.95 saved for every dollar invested. Our ROI value, which reflects the value of investment in prevention, compared favorably to ROI values calculated for US investments in treatment of prevalent heath conditions such as heart attack (ROI, $1.10), stroke (ROI, $1.49), and type 2 diabetes (ROI, $1.55) 14. Additionally, positive return on investment is a high threshold for healthcare interventions as the majority of medical interventions that improve health require an investment greater than the value of the benefits (ROI < 1) 27. Our sensitivity analysis indicated that net benefits may accrue to testing programs with much lower undiagnosed seroprevalence (0.12%) than the 0.7% observed in this program. Our analysis is conservative for several reasons. Because we assumed all persons diagnosed under the Initiative would have been diagnosed at a later date, we did not assign a benefit in terms of extended survival and quality of life from earlier treatment to the index case. There is evidence from the costeffectiveness analysis literature that HIV diagnosis at slightly earlier stages of disease can be cost-saving when the benefits of averted HIV transmissions are included 28. Cost-effectiveness analyses, however, measure actual costs, whereas ROI is based on expenditures. If we included benefits for the index case, if the Initiative resulted in an earlier diagnosis than we assumed, or if persons were diagnosed who would never have been diagnosed otherwise, our ROI estimates would be greater. Additionally, our analysis 10

11 focused only on persons with newly diagnosed HIV infection. Other persons diagnosed through the Initiative were previously known by the health department to be infected. Some of these individuals may not have received their previous HIV test results, while others may have been linked or re-linked to care as a result of the program. Because data on re-linkage were incomplete, we were not able to assess this potential benefit. ROI changed with alternative testing intervals. If the average retesting interval was longer, the benefits of reduced transmission would have been greater and many clients would have accrued additional benefits from early initiation of ART. While a 1-year testing interval is recommended for high-risk populations, it is not yet current practice on a population level and represents benefits that populations with higher frequencies of testing (e.g., MSM) may experience. In addition, for the health system investment, our findings were sensitive to a reduction of 50% or more in HIV transmissions averted. However, even with a 50% reduction, the Initiative produced health gains valued at $0.98 for every dollar invested. Our analysis was subject to a number of limitations. The lifetime medical costs we used to value the benefits of HIV transmissions averted assume individuals will remain in treatment and receive optimal care. Thus the benefits could be overestimated in populations in which HIV infected persons are not retained into care. We limited our calculations of HIV transmissions averted to a first generation of transmissions, which underestimated the total number of averted HIV transmissions attributable to the Initiative. However, we also counted HIV infections averted as permanently averted rather than delayed. We did not include acute phase detection of HIV infection because most screening tests detect HIV infection after the acute phase 29. Recently approved fourth generation HIV enzyme immunoassays can detect infections as early as the acute phase 30. Detection of acute infections could have additional transmission benefits. In our model, the same transmission rates were used for MSM and heterosexual populations, so our estimates should be considered conservative with regard to MSM populations. Caution should be used when applying these findings more broadly than CDC s Expanded HIV Testing Initiative, as key parameters such as testing and diagnostic rates, and expenditures were specific to the 11

12 Initiative. There were also some aspects of the program that we did not explicitly value in our analysis such as the benefits of prevention services, including partner services. Additionally, we included expenditures for the first year that had lower testing rates due to start-up activities, which may have yielded more conservative ROI values for the project period. With continued testing, however, the program could gradually experience a decrease in HIV positivity over time which would decrease ROI values. We did not value downstream HIV treatment costs that may be incurred as a result of earlier diagnosis outside of the early awareness period conferred by the Initiative. A recent study has assessed the budget impact, or stream of financial costs, of expanded HIV screening in the United States on government programs over a 5-year period 31. These authors found that expanded testing would increase total HIV testing and treatment costs; however, they did not assign financial benefits to preventing HIV transmission to partners 31. Despite these limitations, a strength of our study is that we used actual expenditure and outcome data from a large-scale program and assessed expenditures by agencies and organizations other than CDC. We thereby were able to reduce the uncertainty associated with relying on data from other studies. We find that CDC s Expanded HIV Testing Initiative yielded positive returns on investment over a broad range of assumptions, supporting large-scale HIV testing programs as beneficial from public health and economic standpoints. Return on investment analysis, along with cost-effectiveness analysis, can assist policy makers in optimizing public health given a set budget. 12

13 REFERENCES 1. Centers for Disease Control and Prevention (CDC). Revised Guidelines for HIV Counseling, Testing, and Referral. MMWR Recomm Rep. 2001;50(RR19): CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17; Lohse N, Hansen AB, Pedersen G, et al. Survival of persons with and without HIV infection in Denmark, Ann Intern Med. 2007;146(2): Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2009;375(9731): Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20(10): Gorbach PM WR, Jeffries R, Javanbakht M, Drumright LN, Daar ES, Little SJ. Behaviors of recently HIV-infected men who have sex with men in the year post-diagnosis: effects of drug use and partner types. J Acquir Immune Defic Syndr CDC. Late HIV Testing States, MMWR Morb Mortal Wkly Rep. 2009;58(24): CDC. Results of the Expanded HIV Testing Initiative - 25 Jurisdictions, United States, MMWR Morb Mortal Wkly Rep. 2011;60(24): CDC. Vital Signs: HIV Testing and Diagnosis Among Adults --- United States, MMWR Morb Mortal Wkly Rep. 2010;59(47): Campsmith M, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of J. Acquired Immune Defic. Syndr. 2010;53(5): Long EF, Brandeau ML, Owens DK. The Cost-Effectiveness and Population Outcomes of Expanded HIV Screening and Antiretroviral Treatment in the United States. Ann Intern Med. 2010;153(12): Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med. 2005;352(6): Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352(6): Luce BR, Mauskopf J, Sloan FA, Ostermann J, Paramore LC. The return on investment in health care: from 1980 to Value Health. 2006;9(3): Grosse SD, Sotnikov SV, Leatherman S, Curtis M. The business case for preconception care: methods and issues. Matern Child Health J. 2006;10(5 Suppl):S Hutchinson AB, Patel P, Sansom SL, et al. Cost-effectiveness of pooled nucleic acid amplification testing for acute HIV infection after third-generation HIV antibody screening and rapid testing in the United States: a comparison of three public health settings. PLoS Med. 2010;7(9):e Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care. Nov 2006;44(11): Marks G, Crepaz N, Senterfitt JW, Janssen RS. 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. J Acquir Immune Defic Syndr. 2005;39(4): Lasry A, Sansom SL, Hicks KA, Uzunangelov V. A model for allocating CDC's HIV prevention resources in the United States. Health Care Manag Sci. 2011;14(1):

14 20. Prabhu VS, Hutchinson AB, Farnham PG, Sansom SL. Sexually acquired HIV infections in the United States due to acute-phase HIV transmission: an update. AIDS. 2009;23(13): Zaric GS, Barnett PG, Brandeau ML. HIV transmission and the cost-effectiveness of methadone maintenance. Am J Public Health. Jul 2000;90(7): Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. Aug ;300(5): White DE SA, Schulden JD. Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Annals of Emergency Medicine. 2009;54: Golden MR Stekler J KJ, Wood RW. Trends in the Frequency of HIV Testing and CD4 Count at Diagnosis Among Persons Tested Through a Public Health Program in Seattle, WA USA, th Conference on Retroviruses and Opportunistic Infections. 2009;Montreal, Canada. 25. Lyons MS, Lindsell CJ, Hawkins DA, et al.. Contributions to early HIV diagnosis among patients linked to care vary by testing venue ;8(1):220. BMC Public Health. 2008;8(1): Panel on Antiretroviral guidelines for Adults and Adolescents (2011). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2011: Available at: Available: Accessed April Trogdon J, Finkelstein EA, Reyes M, Dietz WH. A return-on-investment simulation model of workplace obesity interventions. J Occup Environ Med. Jul 2009;51(7): Prabhu VS Farnham PG, Hutchinson AB, Soorapanth S, Heffelfinger JD, Golden MR, Brooks JT, Rimland D, Sansom SL. Cost-effectiveness of HIV screening in STD clinics, emergency departments, and inpatient units: a model-based analysis. PLoS One. 2011;6(5):e Owen SM, Yang C, Spira T, et al. Alternative algorithms for human immunodeficiency virus infection diagnosis using tests that are licensed in the United States. J Clin Microbiol. May 2008;46(5): Patel P, Mackellar D, Simmons P, et al. Detecting acute human immunodeficiency virus infection using 3 different screening immunoassays and nucleic acid amplification testing for human immunodeficiency virus RNA, Arch Intern Med. Jan ;170(1): Martin EG, Paltiel AD, Walensky RP, Schackman BR. Expanded HIV screening in the United States: what will it cost government discretionary and entitlement programs? A budget impact analysis. Value Health. Dec 2010;13(8):

15 Figures/Tables: Figure 1: Sensitivity Analysis: Return on Health System Investment with 25%, 50% and 75% Reductions in HIV Transmissions Averted Table 1: Model Input Parameters Table 2: Return on Investment from CDC s Expanded HIV Testing Initiative,

16 Table 1: Model Input Parameters Parameter ART antiretroviral therapy Parameter value Source # Tested fiscal years, FY ,786,739 Expanded Testing Initiative program data # of newly identified HIV-infected persons, FY 18, # of newly HIV positives that received test 15,737 results, FY Proportion of new HIV positives linked to care,.75 FY CDC & partner expenditures on the Initiative $126,385,000 FY Adjustment for background testing Transmission rate ratio from persons unaware to aware of their HIV serostatus Transmission rates: 3.5 Sexual aware, not on ART annual.0484 Transmission Sexual aware, on ART annual transmission.0097 Sexual unaware annual transmission.1117 IDU aware annual transmission.126 IDU unaware annual transmission.165 Lifetime HIV treatment costs $367, , calculated 20, calculated 13, 21 13,

17 Table 2: Return on Investment from CDC s Expanded HIV Testing Initiative, Testing Interval Averted HIV Transmissions* Averted Medical Care Costs* ($) Total Investment ($) Net Benefit** ($) Return on Investment($) Health System Investment 1 year 1, ,711, ,955, ,756, years 2, ,322, ,525, ,797, years 3,381 1,169,887, ,096, ,791, years 4,507 1,514,416, ,666, ,750, years 5,634 1,837,884, ,237, ,647, CDC and Partner Investment 1 year 1, ,711, ,384, ,327, years 2, ,322, ,384, ,938, years 3,381 1,169,887, ,384,000 1,043,503, years 4,507 1,514,416, ,384,000 1,388,032, years 5,634 1,837,884, ,384,000 1,711,500, Rounded to the nearest $1,000. *Future costs and infections averted discounted at a 3% annual rate **Net benefit is the total benefit - the total cost. Base case value Return on $1 investment in CDC s Expanded HIV Testing Initiative Investment by CDC and partners=$126,384,000 Health system total investment = Investment by CDC and partners+ medical costs for newly infected person identified through the Initiative (range, $157,571,000 to $787,853,000 for the 1 to 5 year alternative testing interval) 2

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