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Emily P. Hyle, MD Division of Infectious Diseases Massachusetts General Hospital

HIV, Communicable, and Non-Communicable Diseases: Costs and Cost-Effectiveness of Integrated Care. Emily P. Hyle, MD Division of Infectious Diseases Massachusetts General Hospital. Conflicts of interest: None.

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Emily P. Hyle, MD Division of Infectious Diseases Massachusetts General Hospital

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  1. HIV, Communicable, and Non-Communicable Diseases: Costs and Cost-Effectiveness of Integrated Care Emily P. Hyle, MD Division of Infectious Diseases Massachusetts General Hospital Conflicts of interest: None The projects described were supported by T32 AI007433, R01 AI058736, R01 AI093269 from NIAID, P30 AI060354from HU CFAR, & NIH Fogarty International Center The contents are solely the responsibility of the author and do not necessarily represent the official views of the awarding offices

  2. Overview • Global response to the HIV pandemic 2. Costs, cost-effectiveness, and modeling 3. Data needed to assess the value of integration

  3. Global Response to HIV Pandemic

  4. Funding for the Global Response http://www.kff.org/globalhealth/upload/8002-05.pdf

  5. Three Questions for Any Intervention Is it effective? Does it work? **If it is not effective, it is not cost-effective.** Is it cost-effective? What is its value? Where and how can it best be implemented? Is it affordable?

  6. “Cost-Effective” = “Cheap” “Cost-Effective” = “Saves money” “Cost-Effective” = Additional benefit worth the additional cost Common Misconceptions

  7. Formal methodology to assess the comparative value of at least 2 interventions Two different outcome measures: Cost: $, Rand, Rupee Effectiveness: Years of life saved (YLS) QALYs or DALYs Incremental cost-effectiveness ratio (ICER): Additional Resource Use Additional Health Benefits Cost-Effectiveness Analysis

  8. The Commission on Macroeconomics and Health and WHO have suggested that interventions are: Cost-effective: the ICER is <3 x GDP per capita for that country Very cost-effective: the ICER is <1 x annual GDP per capita for that country Cost-Effectiveness Thresholds Macroeconomics and Health: WHO 2001. WHO-CHOICE 2008.

  9. Budget Impact Analysis • Examines the impact of a new intervention on one or multiple payers • Specific payer perspective • Specific site • Limited to a defined budgetary horizon • Annual • 5-year

  10. Objective • To project the cost-effectiveness of early compared to delayed ART for treatment and prevention in serodiscordant couples • Analyses were conducted for two countries, South Africa and India, to assess regional differences in value Collaboration: HPTN 052/CEPAC-I Walensky et al., NEJM. 2013.

  11. Methods: CEPAC-International Model* • Mathematical model of HIV natural history and treatment • Clinical and resource utilization data from South Africa and India • Cohort and ART efficacy parameters from HPTN 052 trial (Cohen et al, NEJM2011) *Funded by NIAID R37 AI42006, R01 AI058736, R01 AI093269

  12. Methods: Two Strategies • Delayed ART (CD4 <250/µl) • Early ART (at presentation) • Evaluate outcomes in: • Clinical benefit, cost and transmissions • 5-year and lifetime horizons Walensky et al., NEJM. 2013.

  13. Results: Cost-Effectiveness (Lifetime, South Africa) †Including projected survival losses and cost increases associated with 1st- and 2nd-order transmissions per capita GDP in South Africa: $8,100 Walensky et al., NEJM. 2013.

  14. Data Needed:Cost-Effectiveness of Integrated Care Epidemiology Screening Treatment Quality of Life Costs Cost- Effectiveness Analysis

  15. Effectiveness: Data Needed • Epidemiology: • Prevalence • Incidence • Attributable mortality

  16. Effectiveness: Data Needed • Screening: • Test characteristics • Linkage to care after positive screening • Treatment: • Effectiveness of management or cure • Adverse events • Quality of life: • With or without symptoms • Effects of stigma

  17. Resource Utilization: Data Needed • Infrastructure: • Effects of using existing sites and personnel • Fixed vs. marginal costs • Impact of economies of scale • Staff training: • In multiple domains • Decentralized vs. specialized sites • Monitoring and evaluation: • Diversity of outcomes • Quality control

  18. Integrated clinical care for HIV patients could offer opportunities to improve outcomes for good value Model-based budget impact and cost-effectiveness analyses are critical to understanding how to expand or integrate care, especially when resources are limited Data are needed to inform such analyses, which can help to prioritize resources and scale-up to improve patient outcomes Conclusions

  19. Acknowledgements MGH Medical Practice Evaluation Center Ingrid Bassett, MD, MPH Andrea Ciaranello, MD, MPH Kenneth Freedberg, MD, MSc N. Kaye Horstman, PhD, MPH Robert A. Parker, ScD, Cstat Rochelle Walensky, MD, MPH Jordan Francke Michael Girouard Melanie Gaynes Margo Jacobsen Sarah Park Marion Robine Amanda Su United States NaliniAnand, JD, MPH WafaaEl-Sadr, MD, MPH, MPA Paolo Miotti, MD KM Venkat Narayan, MD, MSc StenVermund, MD, PhD South Africa KogieNaidoo, MBChB Linda-Gail Bekker, MD, PhD KerenMiddlekoop, MBChB, PhD Robin Wood, MBBCh, MMed

  20. Is It Worth It? Comparison of Strategies Incremental Cost + - Evaluate ICER + Yes Incremental Health Benefits (Evaluate ICER) - No

  21. Model Input Parameters: Cohort, Treatment, and Transmission

  22. Model Input Parameters: Costs (2011 US$) *WHO thresholds: “Very cost-effective”: <1x per capita GDP * “Cost-effective”: <3x per capita GDP 1WHO Global Price Reporting Mechanism

  23. Results: Cost-effectiveness (Lifetime) • †Including projected survival losses and cost increases associated with 1st- and 2nd-order transmissions • per capita GDP: South Africa ($8,100); India ($1,500) Walensky et al. NEJM. 2013.

  24. The “Tutu Tester”Cape Town, South Africa • 4,000 people, 2010-2012 • HIV prevalence 10.2% • Hypertension 38.2% • Diabetes 4.1% Govindasamy et al, PLoS One. 2013. PEPFAR Supplement to AI 058736

  25. Cost-effectiveness Ratiosfor Other Screening Programs C-E ratio Screening Program ($/QALY)* Reference HIV screening inpatients $38,600 Walensky AJM 2005 HIV screening every 5 years high risk patients $50,000 Paltiel NEJM 2005 Breast cancer screening Salzmann Annual mammogram, 50–69 y/o $57,500 Ann Intern Med 1997 Colon cancer FOBT + SIG q5y, adults 50–85 y/o $57,700 Frazier JAMA 2000 Diabetes Mellitus, Type 2 fasting plasma glucose, adults >25 y/o $70,000 CDC JAMA 1998 *All costs adjusted to 2001 US dollars

  26. C-E Ratio Intervention Agent ($/QALY)* Reference PCP/Toxo proph. TMP-SMX $2,800 Freedberg JAMA 1998 ART AZT/3TC/EFV $11,700 Freedberg NEJM 2001 Resistance Test --- $20,200 Weinstein Annals 2001 Resistance Test (naïve) --- $23,900 Sax CID 2005 Inpt HIV screening --- $38,600 Walensky AJM 2005 MAC proph. Azithromycin $43,300 Freedberg JAMA 1998 HIV screening q5y --- $50,000 Paltiel NEJM 2005 high risk patients Cost-effectiveness Ratios for HIV Care *All costs adjusted to 2001 US dollars

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