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Abstract: There are an estimated 3.2 million individuals in the United States who are chronically infected with hepatitis C virus (HCV), of whom only have had an HCV antibody test and less than a quarter have had a confirmatory HCV RNA test. The US Centers for Disease Control and Prevention (CDC) has set a goal to reduce the proportion of HCV-infected individuals unaware of their status from 55% to 33%. This analysis of data from the National Drug Abuse Treatment Clinical Trials Network, study CTN-0032 (HIV Rapid Testing and Counseling), aimed to evaluate the cost-effectiveness of rapid HCV and simultaneous HCV/HIV antibody testing in substance abuse treatment programs. Researcher used a decision analytic model to compare the cost-effectiveness of no HCV testing referral or offer, off-site HCV testing referral, on-site rapid HCV testing offer, and on-site rapid HCV and HIV testing offer. Base case inputs included 11% undetected chronic HCV, 0.4% undetected HIV, 35% HCV co-infection among HIV-infected, 53% linked to HCV care after testing antibody positive, and 67% linked to HIV care. Disease outcomes were estimated from established computer simulation models of HCV (HEP-CE) and HIV (CEPAC). Measurements included lifetime costs (2011 US dollars) and quality-adjusted life years (QALYs) discounted at 3% annually and incremental cost-effective ratios (ICERs). On-site rapid HCV testing had an ICER of $18,300/QALY compared with no testing, and was more efficient than (dominated) off-site HCV testing referral. On-site rapid HCV and HIV testing had an ICER of $64,500/QALY compared with on-site rapid HCV testing alone. In one and two-way sensitivity analyses, the ICER of on-site rapid HCV and HIV testing remained <$100,000/QALY, except when undetected HIV prevalence was <0.1% or when we assumed frequent HIV testing elsewhere. The ICER remained <$100,000/QALY in approximately 90% of probabilistic sensitivity analyses. Conclusions: On-site rapid hepatitis C and HIV testing in substance abuse treatment programs is cost-effective at a <$100,000/quality-adjusted life years threshold. On-site rapid HCV and HIV testing in substance abuse treatment programs represents good value as a public health investment. Policymakers should identify ways to improve the capacity of substance abuse treatment programs to implement on-site HCV and HIV testing, bill for these services, and ensure that individuals testing positive for either virus receive further evaluation and treatment. Related protocols: CTN-0032, CTN-0032-A-1

Abstract:

This is the Results Article for CTN-0032-A-1.

The President’s National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral.

This article reports on outcomes from ancillary investigation CTN-0032-A-1 (“Economic Analysis of HIV Rapid Testing in Drug Abuse Treatment Programs”) in which the cost-effectiveness of three HIV testing strategies used in 12 community-based substance abuse treatment programs was evaluated: off-site testing referral, on-site rapid testing with information only, and on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%), and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually. Referral for off-site testing was found to be less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,400/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit.

Conclusions: A strategy of on-site rapid HIV testing offered with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio < $100,000/QALY. Policy makers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.

Related protocols: CTN-0032-A-1

Abstract:

This presentation provides an overview of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0032, which examined the efficacy of on-site rapid HIV testing with risk-reduction counseling in increasing receipt of HIV test results and reducing HIV risk behaviors among persons in drug treatment. The study demonstrated the value of on-site rapid HIV testing in drug treatment centers but found no additional benefit from HIV sexual risk-reduction counseling. A follow-up study examining the cost-effectiveness of on-site testing (CTN-0032-A-1) found that referral for off-site testing is less costly, but also less efficient — the study determined that on-site testing is cost-effective, in that cast, using the current US threshold of <$100,000/QALY. Because on-site risk reduction counseling did not reduce sexual risk behavior or increase acceptance of HIV testing, it was not found to be cost-effective.

Related protocols: CTN-0032, CTN-0032-A-1