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Routine HIV Screening in France: Clinical Impact and Cost-effectiveness

This study explores the clinical impact and cost-effectiveness of routine HIV screening in France, including the benefits, acceptability, and efficiency of targeted screening. The findings suggest that routine screening can reduce the burden of HIV at individual and population levels.

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Routine HIV Screening in France: Clinical Impact and Cost-effectiveness

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  1. Feedback from HIV Europe France:The new recommendation fromthe French National Authority for Health D Costagliola U943 INSERM and Universite Pierre et Marie Curie

  2. Objective • To assess whether change in strategies and organization of screening was necessary

  3. Method • Systematic literature search and critical review on • Screening and counselling benefit • Targeted screening • Clinical benefit • Acceptability of screening • Efficiency of general population screening • Modelling the cost-effectiveness and clinical impact of routine HIV screening in France • Done by Yazdan Yazdanpanah, with InVS, CRESGE, HAS associated with INSERM U943, Partners AIDS Research Center from Harvard Medical School and the Yale School of Public Health) • Discussion within a working group including 22 health professionals, researchers and NGO and critical review of the recommendation by an independent group including the different categories of people (n=47)

  4. Background 1 In France, roughly 40,000 of the estimated 113,000 – 141,000 people currently infected with HIV remain unaware of their infection (2007 estimates)

  5. Background 2: Access to care with advanced HIV disease in France FHDH ANRS CO4, 2009

  6. Background 3: Excess death risk in patients with advanced HIV disease when accessing care Lanoy, AVT 2007

  7. Background 4 In the era of lifesaving antiretroviral therapy (ART), effective prevention counselling and early detection can reduce the burden of HIV at the individual and population levels

  8. ROUTINE HIV SCREENING IN FRANCE: CLINICAL IMPACT AND COST-EFFECTIVENESS Yazdan Yazdanpanah, Caroline E. Sloan, Cécile Charlois-Ou, Stéphane Le Vu, Caroline Semaille, Dominique Costagliola, Anne-Isabelle Poullié, Olivier Scémama, Sylvie Deuffic-Burban, Elena Losina, Rochelle P. Walensky, Kenneth A. Freedberg, A. David Paltiel Centre Hospitalier de Tourcoing, EA 2694, Institut de Veille Sanitaire, U943 INSERM, Université Pierre et Marie Curie, Haute Autorité de Santé, and INSERM U795, France; Massachusetts General Hospital, Boston University School of Public Health, and Brigham and Women’s Hospital, Boston, MA; Yale University School of Medicine, New Haven, CT Supported by the Haute Autorité de Santé, the Institut de Veille Sanitaire, Sidaction, the National Institute of Allergy and Infectious Diseases (R37 AI042006, P30 AI42851, and K24 AI062476), the National Institute of Mental Health (R01 MH65869) and the Doris Duke Charitable Foundation Clinical Scientist Development Award. Presented at ICAAC, 2009

  9. Objective To estimate the life-expectancy, costs and cost-effectiveness associated with routine, voluntary HIV counseling, testing and referral (CTR) in the French general population and certain sub-populations, including MSMs, IDUs and the population of French Guyana

  10. Analytic framework 1 We used a widely published Monte Carlo simulation of HIV acquisition, detection and care to examine the impact of routine HIV CTR in France, compared to current risk-factor-based screening practices The model captures data on: HIV screening: HIV prevalence and incidence, test offer/acceptance rates, returns for test results, linkage to care, and HIV counseling and testing costs HIV disease: incidence of opportunistic diseases, HIV treatment, mortality rates, and all associated costs and quality of life effects

  11. Analytic framework 2 We evaluated routine HIV CTR once, every five years, and annually in adults ages 18-69 years We evaluated outcomes (life-expectancy, quality-adjusted life expectancy, cost and cost-effectiveness) from the societal perspective, using a 3% annual discount rate. Cost-effectiveness was defined as value in 2007 € per quality-adjusted life-year (QALY) gained We assumed ART had a moderately favorable effect on transmission We used sensitivity analysis to examine the stability of results to changes in input parameters

  12. Input data

  13. Base case Performance of routine screening in the general French population

  14. Sensitivity analysis 1 Base case 5.0% Effect of prevalence on the cost effectiveness one-time voluntary HIV CTR vs. current practice with base case incidence

  15. Sensitivity analysis 2 Among IDUs (prevalence 6.2%; incidence 0.17/PY), MSM (prevalence 1.7%; incidence 0.99/PY) in French Guyana (prevalence 0.38%; incidence 0.30/PY), annual screening led to ICERs of €53,300, €73,400 and €38,900/QALY compared to current practice

  16. Limitations A simulation model of HIV screening and disease that combines input data from several sources and relies on multiple assumptions The prevalence of undiagnosed HIV is from a back calculation performed in 2000 The estimated rate of background testing outside of the routine screening program is low. Higher estimates have an impact on results, but the rate of background testing is likely to decrease as routine HIV tests become increasingly available

  17. Conclusions One-time universal routine HIV CTR reduces the delay between HIV infection and diagnosis, decreases the number of secondary infections, and has a cost-effectiveness ratio consistent with common screening interventions recommended in France. This strategy should be implemented throughout France In specific sub-populations with higher prevalence and incidence, annual routine HIV CTR is economically justifiable These strategies will only be successful if efforts to increase the acceptability of HIV screening and linkage to care are implemented

  18. Main HAS recommendations 1 • Systematic HIV screening proposal to all people 15 to 70 years of age, in the absence of signs or symptoms and whatever the characteristics • Based on the mobilization of GP and all Health professionals including community initiatives • To evaluate this new strategy and the proportion of late diagnosis after 5 years • To promote the benefit of the knowledge of the personal HIV status both at the individual and the population level and to change the opinion on the HIV diagnosis

  19. Main HAS recommendations 2 • Targeted HIV screening every year for MSM, IDUs, heterosexual people from sub-Saharan Africa and Carribean region with multiple partners • In addition to the actual screening strategy in people at risk

  20. Main HAS recommendations 3 • Given the fact that in French Guyana the epidemic is generalized, • specific programs should be organized to insure the test offer to all inhabitants once a year

  21. Main HAS recommendations 4 • The screening proposal in the general population should be associated with the appropriate information in order • to get an informed consent and • To evaluate the capacity of the person to understand the test result • Outside this case, a targeted counselling should be offered dependent of the various contexts

  22. Full recommendations • Can be found (in French) at • www.has-sante.fr

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