Clinical impact and cost-effectiveness of expanded voluntary HIV testing in India.

Venkatesh, K.K.; Becker, J.E .; Kumarasamy, N .; Nakamura, Y.M.; Mayer, K.H .; Losina, E .; Swaminathan, S .; Flanigan, T.P .; Walensky, R.P .; Freedberg, K.A.

PLoS One; 2013; 8; e64604.

Abstract: Background: Despite expanding access to antiretroviral therapy (ART), most of the estimated 2.3 to 2.5 million HIV-infected individuals in India remain undiagnosed. The questions of whom to test for HIV and at what frequency remain unclear.

Methods: We used a simulation model of HIV testing and treatment to examine alternative HIV screening strategies: 1) current practice, 2) one-time, 3) every five years, and 4) annually; and we applied these strategies to three population scenarios: 1) the general Indian population (‘‘national population''), i.e. base case (HIV prevalence 0.29%; incidence 0.032/ 100 person-years [PY]); 2) high-prevalence districts (HIV prevalence 0.8%; incidence 0.088/100 PY), and 3) high-risk groups (HIV prevalence 5.0%; incidence 0.552/100 PY). Cohort characteristics reflected Indians reporting for HIV testing, with a median age of 35 years, 66% men, and a mean CD4 count of 305 cells/ml. The cost of a rapid HIV test was $3.33. Outcomes included life expectancy, HIV-related direct medical costs, incremental cost-effectiveness ratios (ICERs), and secondary transmission benefits. The threshold for ‘‘cost-effective'' was defined as 3x the annual per capita GDP of India ($3,900/year of life saved [YLS]), or for ‘‘very cost-effective'' was <1x the annual per capita GDP ($1,300/YLS).

Results: Compared to current practice, one-time screening was very cost-effective in the national population (ICER: $1,100/ YLS), high-prevalence districts (ICER: $800/YLS), and high-risk groups (ICER: $800/YLS). Screening every five years in the national population (ICER: $1,900/YLS) and annual screening in high-prevalence districts (ICER: $1,900/YLS) and high-risk groups (ICER: $1,800/YLS) were also cost-effective. Results were most sensitive to costs of care and linkage-to-care.

Conclusions : In India , voluntary HIV screening of the national population every five years offers substantial clinical benefit and is cost-effective. Annual screening is cost-effective among high-risk groups and in high-prevalence districts nationally. Routine HIV screening in India should be implemented.

Back to List of publications / Home