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Tuesday, 19 October 2004 - 10:45 AM

This presentation is part of: Oral Concurrent Session B - Screening in Chronic Disease

COST EFFECTIVENESS OF HIV SCREENING IN THE ELDERLY

Gillian D. Sanders, PhD1, Vandana Sundaram, MPH2, Ahmed M. Bayoumi, MD, MSc3, Mark Holodniy, MD2, and Douglas K. Owens, MD, MS4. (1) Duke, Medicine, Durham, NC, (2) VA Palo Alto Health Care System, AIDS Research Center, Palo Alto, CA, (3) St. Michael's Hospital, University of Toronto, Inner City Health Research Unit, Toronto, ON, Canada, (4) Stanford University, Medicine, Stanford, CA

Although Human Immunodeficiency virus (HIV) infection is more prevalent in people under age 45, a significant number of infections occur in older age groups. For example, in the Department of Veterans Affairs (VA), which is the largest provider of HIV care in the U.S., approximately 20% of HIV infections occurs in patients older than 55. We assessed the cost-effectiveness for screening for HIV and treatment with antiretroviral therapy for the elderly.

We developed a Markov model that evaluated costs, quality of life, and survival for patients in an HIV screening program compared to current practice. In both strategies, symptomatic patients could be identified through case finding. Identified patients started treatment when their CD4 count dropped to 350cells/mL or their viral load exceeded 55,000 copies/mL. Disease progression was based on CD4 and viral load levels. Sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling. In the base-case analysis, we considered the potential societal cost savings and health benefits associated with decreased HIV transmission after diagnosis and treatment.

For a 50-year old patient, one-time screening for HIV costs $13,700 per quality-adjusted life year (QALY) as compared to current practice. Because of the increased risk of age-specific mortality (unrelated to HIV infection), one-time screening for HIV of an 80- or 90-year old patient increases to $36,400/QALY and $99,900/QALY, respectively. If transmission to sexual partners is excluded, one-time HIV screening cost $ 45,500/QALY, $ 90,800/QALY and $250,300/QALY in 50-, 80-, and 90-year olds, respectively. If the cost-effectiveness threshold for implementing a screening program were $50,000/QALY, screening would be offered to under 84 years or 62 years of age depending on whether the effects of transmission were included or not.

Screening for HIV is cost effective in patients up to about 65 years of age, even if they are not sexually active. Screening is cost effective in patients older than 65 if they are sexually active and have a partner at risk for HIV transmission. Thus, HIV screening is cost effective in a substantially broader age range than is recommended in current guidelines.


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See more of The 26th Annual Meeting of the Society for Medical Decision Making (October 17-20, 2004)