Expanded HIV screening programmes in the US will place additional pressure on Ryan White federal funding for HIV care as more people are diagnosed with HIV, according to a study published in the online edition of
Value in Health.
Expanded testing is likely to identify more people with HIV in need of treatment. Treatment costs will mainly fall on discretionary programmes
whose funding is set annually by Congress. The investigators express concern that this “may
result in large numbers of individuals learning that they are HIV-infected but
unable to receive care”.
It is estimated that 21% of the 1.1 million HIV-positive
individuals in the US are unaware of their infection.
Undiagnosed people typically only learn that they have
HIV when they are extremely ill with the virus, and this not only increases the
risk of death but also has considerable cost implications. Moreover, some
studies suggest that undiagnosed individuals are responsible for a large number
of onward HIV transmissions.
In 2006, the US Centers for Disease Control and Prevention
(CDC) issued revised guidance on HIV testing. This included a recommendation
for routine HIV testing in all healthcare settings for the general population
and annual HIV tests for those in high-risk groups.
The CDC calculated that this expansion of HIV testing would
However, a team of investigators were concerned that the
impact on government budgets was unclear. They especially wanted to see what
the implications would be for discretionary HIV treatment programmes, whose
fixed budgets are set annually.
There are a number of sources of public funding for HIV care
in the US. These include the entitlement programmes Medicaid and MediCare. These
provide free healthcare to the 'disabled' and the elderly. There is also the
discretionary Ryan White HIV/AIDS Program. This provides a safety net for those
who neither qualify for the eligibility programmes, nor have adequate private
Treatment and care costs for ex-military personnel are met
by the Department of Veterans Affairs, and others have adequate private medical
insurance. The investigators did not examine the likely cost implications of
earlier HIV diagnosis for these care providers.
The investigators’ model was based on 2008 HIV surveillance
data. This showed that there were 1.1 million HIV-positive individuals in the
US, but that 189,000 of these were unaware of their status. Annual HIV
incidence was assumed to be 46,000.
Data concerning the health and CD4 cell count of prevalent
cases of HIV were extrapolated from surveillance cohorts.
Costs were assumed to include the testing of individuals
whose results were HIV-negative and those who were positive, with the latter
group requiring post-test counselling. Currently 97% of individuals return for
their HIV test result, and 80% of those testing positive are linked to care.
This pattern of behaviour was included in the model. Drug costs were calculated
using published wholesale costs. These were adjusted for average state
reimbursement rates and discounts.
It was estimated that individuals currently have an HIV test
every ten years. The model assumed that expanded testing would mean that
individuals would now be tested every five years.
The model suggested that if average testing frequency
remained once every ten years, then there would be 177,000 new HIV diagnoses
between 2009 and 2013. This figure included 116,000 individuals with
undiagnosed HIV and 61,000 newly infected with the virus.
After diagnosis, 68% of those diagnosed late and 49% of people with incident infections were expected to progress to AIDS.
Increasing the frequency of testing to once every five years
would lead to an additional 46,000 new diagnoses. But earlier detection of HIV
would lead to a fall in the number of those who progressed to AIDS.
Continued testing at the current rate was estimated to cost
$83.7 billion over five years. Expanded testing and increases in the number of
diagnosed patients would increase this to $86.4 billion.
Only 18% of this additional cost ($502 million) was attributed to screening programmes. The
rest was taken up by treatment and care.
The investigators projected that the cost to discretionary
programmes would increase by $2.9 billion (from $26 billion to $28.9 billion).
However, because there would be a fall in the number of patients progressing to
AIDS, costs to entitlement programmes would fall by $280 million.
This meant that then an additional $2.7 billion would be
needed for screening and treatment programmes, with most falling on
discretionary treatment programmes.
“If expanded screenings were implemented consistent with CDC
guidelines, the policy may not be feasible without additional funds from state
and local governments,” comment the authors. The cost burden “will fall
disproportionately on discretionary programs, because people identified will be
less likely to be immediately eligible for entitlement programs”.