1. Cost-Effectiveness of the National HIV/AIDS
Strategy (NHAS) Goal of Increasing Linkage to
Care for HIV-Infected Persons
Chaitra Gopalappa, Ph.D., Paul Farnham, Ph.D.,
Angela Hutchinson, Ph.D., and Stephanie Sansom, Ph.D.
Prevention Modeling and Economics Team
National HIV Prevention Conference
August 14-17, 2011
Atlanta, GA
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention

2. Outline of Talk
• Benefits of treatment and early treatment
• Current linkage to care status in the US
• NHAS goal for linkage to care
• Cost-effectiveness analysis of achieving the NHAS
goal
• Threshold cost of linkage to care intervention to
achieve NHAS goal
– Intervention cost below which achieving the NHAS goal will be
cost-effective
1

3. Benefits of Treatment
• Antiretroviral therapy (ART) has increased the life
expectancy of HIV-infected persons (Antiretroviral
Therapy Cohort Collaboration study, Lancet 2008)
– Life expectancy in period1996-99 when ART was first
implemented
• 36 years for those on treatment at age 20
• 25 years for those on treatment at age 35
– Life expectancy in period 2003-05
• 49 years for those on treatment at age 20
• 37 years for those on treatment at age 35
– Approximately 13 year increase over this time period
• Approximately 80% of persons on ART have an
undetectable viral load (Gardner et. al., CID, 2011)
– Reduces risk of heterosexual HIV transmission by 90% 2

4. Benefits of Early Treatment
• Successful viral load suppression is higher when
treatment is started early in the disease stage
– Persons delaying treatment until CD4 count of <200 cells/µL
might not achieve a normal CD4 count even after a decade of
effective treatment (Kelley et. al., CID, 2009)
• Life expectancy is higher with early treatment
(Antiretroviral Therapy Cohort Collaboration study, Lancet 2008)
– chances of surviving to age 44 for those on treatment at age 20
was
• 60% when treatment started at CD4 count of <100 cells/µL
• 90% when treatment started at CD4 count of ≥200 cells/µL
3

5. Current Statistics on HIV-infected Individuals
Linked to Care in the U.S.
• Although 80% of people living with HIV/AIDS are
diagnosed (Gardner et. al., CID, 2011; Marks et. al. AIDS 2010)
– only 65% of diagnosed persons enter initial care within 3 months
of diagnosis
– 50% of those diagnosed are not engaged in care,
– those on treatment constitute only approximately 24% of people
living with HIV/AIDS
• Increasing early linkage to care is essential for HIV-
infected individuals to fully benefit from early
diagnosis and the availability of effective therapy
4

6. National HIV/AIDS Strategy (NHAS)
• The NHAS released in 2010 by the White House
– developed to identify areas of change that will help reduce HIV
incidence, increase access to care and optimize health
outcomes of HIV-infected individuals, and reduce HIV-related
health disparities
• One of the goals of the NHAS is to
• increase the proportion of newly diagnosed HIV-infected persons
entering care within 3 months of diagnosis from 65% to 85%
5

7. OBJECTIVE OF RESEARCH
• Analyze cost-effectiveness of achieving NHAS goal
for linkage to care
– increase the proportion of newly diagnosed HIV-infected
persons entering care within 3 months of diagnosis from 65% to
85%
• Obtain threshold cost of linkage to care intervention
– Cost below which an intervention would be cost-effective
6

8. Methods
• Cost-effectiveness measure
– incremental cost-effectiveness ratio (ICER or the change in costs
/ change in the quality-adjusted life years (QALYs))
– Costs estimated from provider perspective
• To estimate life-time treatment costs and QALYs for
HIV-infected individuals we used the Progression and
Transmission of HIV/AIDS (PATH) model
– PATH is a simulation model that tracks HIV-infected index
persons through disease phases from time of infection to death
(Prabhu, et al., PLoS One 2011, 6(5))
• PATH run under two linkage to care scenarios:
current and the NHAS goal
– Simulated 10,000 individuals and estimated the average life-time
costs and QALYs per index person in each scenario to obtain the
ICER of achieving the NHAS goal 7

9. Assumptions for the Analysis
• CD4 count at diagnosis was 350 cells/µL based on
emergency department setting
• Treatment initiation CD4 threshold of 350 cells/µL
• The two linkage to care scenarios differed in
proportion of persons in categories of CD4 count at
treatment
CD4 count at start of ART Percent of HIV-infected persons linked
in cells/µL Current scenario NHAS goal
350 (immediate care)* 65 85
200 (delayed care) 15 10
36 (delayed care) 20 5
*in care within 3 months of diagnosis
• Once linked individuals were retained in care (base
case)
8
– We varied this assumption in sensitivity analysis

10. Linkage to Care Intervention Cost
• Cost of intervention to achieve the NHAS goal was
assumed as $600 per person diagnosed
– Based on costs data from ARTAS (Antiretroviral Treatment
Access Study, AIDS, 2005)
– ARTAS was a case management trial conducted in health
departments and CBOs in the U.S. in partnership with CDC
• Due to limited data on intervention costs, we also
estimated the threshold program cost under which
the intervention would be cost-effective
– i.e., program cost that would provide an ICER of < $100,000 per
QALY gained
9

11. Results of Achieving NHAS goal
Table 1: Average values under linkage to care scenarios*
Population Un- Number of
Onset of
linkage to discounted trans-
AIDS or ICER
care life missions Discounted
death from (Cost
scenario Discounted
expectancy per cost (2009 per
(% linked time of QALYs lost
with 10,000 $) QALY
within 3 infection
infection persons gained)
months of (years)
diagnosis) (years)
Current
32.94 20.57 12,754 343,373 6.47
(65%)
51,950
NHAS goal
34.09 23.66 12,491 373,438 5.89
(85%)
*Estimates based on average values per HIV-infected index person
10

12. Sensitivity Analysis:
Retention and Re-entry to Care
Retention in care Re-entry to care
100% of those linked were
Base case Not applicable
retained in care
Of those linked to care: Of those who dropped out of care:
•26% were retained in care •27-60% re-entered care within 1
Sensitivity •39% dropped out of care in to 2 years
analysis 1.5 to 2 years (Gardner et. al., CID, 2011)
case •And remaining 35% •The rest re-entered when their
dropped out in 3 to 5 years CD4 count dropped to either 200
(Marks et. al., AIDS 2010) or 36 cells/µL
11

13. Results of Sensitivity Analysis:
Retention and Re-entry to Care
Table 2: Cost-effectiveness of achieving NHAS goal*
Population linkage to
Discounted
care scenario Discounted ICER (cost per
cost (2009 $)
(% linked within 3 QALYs lost** QALYs gained) **
**
months of diagnosis)
286,735 -
Current (65%) 7.53 - 7.28
310,115
45,483 – 53,889
309,644 -
NHAS goal (85%) 7.02 - 6.79
336,534
*Estimates based on average values per HIV-infected index person
** Range based on different proportions of retention and re-entry to care 12

14. Summary of Results
• Achieving NHAS goal* generated the following
average measures per HIV diagnosed index person
– an ICER of $51,950 per QALY gained with ARTAS-type
intervention
– a delay of 3 years in the onset of AIDS
– an increase in life expectancy of 1.16 years
– prevention of 263 cases of life-time transmissions per 10,000
diagnosed persons
*Increasing the proportion linked to care within 3 months of diagnosis to 85% from 65%
13

15. Summary of Results (cont.)
• Threshold average program cost below which an
intervention is cost-effective (ICER of <100,000 per
QALY gained)
• $28,406 per diagnosed person when considering 100%
retention
• $23,205 to $28,059* per diagnosed person when retention
was <100%
* Range based on different proportions of retention and re-entry to care
14

16. Limitations
• Estimated only first-level transmissions, hence
underestimating the number of transmissions
averted
• Limited data on efficacy and cost of intervention
program to increase linkage to care
15

17. Discussion and Conclusions
• Benefits of early diagnosis and availability of
effective treatment can be fully realized only when
diagnosed individuals are linked to care to start
timely treatment
• Achieving the NHAS goal of increasing the
proportion linked to care within 3 months of
diagnosis from 65% to 85% was cost-effective
– Achieving the NHAS goal increased average life-expectancy and
delayed onset of AIDS or death
– The above results held even when retention in care was less
than 100%
• An intervention program could cost up to
approximately $28,400 per diagnosed person and
still be cost-effective 16

18. Acknowledgments
• James D. Heffelfinger, Division of HIV/AIDS
Prevention, CDC , Atlanta, GA
• Paul Weidle , Division of HIV/AIDS Prevention, CDC ,
Atlanta, GA
• John T. Brooks , Division of HIV/AIDS Prevention,
CDC, Atlanta, GA
• David Rimland, Veterans Affairs Medical Center,
Decatur, GA, Emory University School of Medicine,
Atlanta, GA
17

19. Thank you!
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of
the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention