Apresentação em tema: "Julian Perelman, Joana Alves Escola Nacional de Saúde Pública"— Transcrição da apresentação:
1 Economic analysis of voluntary testing, counselling and referral (VTCR) for HIV in Portugal Julian Perelman, Joana AlvesEscola Nacional de Saúde PúblicaUniversidade Nova de Lisboa
2 Research teamA project commissioned by the Coordenação Nacional para a Infecção VIH/SIDAHarvard Medical SchoolKenneth Freedberg, MD, MScElena Losina, PhDRochelle Walensky, MD, MPHMadeline Di LorenzoJi-Eun ParkYale School of Public HealthDavid Paltiel, PhDUniversity of LilleYazdan Yazdanpanah, MD, PhDEscola Nacional de Saúde Pública – UNLJulian Perelman, PhDJoana Alves, MACéu Mateus, PhDJoão Pereira, PhDNHS hospitals - PortugalKamal Mansinho, MD, and Ana Cláudia Miranda, MD (CH Lisboa Ocidental)Francisco Antunes, MD, PhD, and Manuela Doroana, MD (CH Lisboa Norte)Rui Marques, MD (H São João)José Saraiva da Cunha, MD, PhD, and Joaquim Oliveira, MD (HUC)José Poças, MD (CH Setubal)Eugénio Teófilo, MD (CH Lisboa Central)
3 Contribution of economic analysis Resources are scarceChoices must be made concerning their deploymentUsing resources in one setting: opportunity costsEconomic evaluation of health care programsEconomic analysis makes explicit the efficiency criteriaSystematic comparison of costs and consequences“Value for money”
4 Contribution of economic analysis COSTATreatment ACONSEQUENCESAChoiceCOSTBTreatment BCONSEQUENCESBCost-effectiveness analysis links costs to a medical outcome: cost of achieving one additional unit of medical outcome, “cost per life-year gained”, “cost per QALY”
5 Contribution of economic analysis Some examples for HIV/AIDSCost/QALYZDV+3TC vs ZDV (Chancellor et al., 1997)£6,276ZDV+3TC+ABC vs ZDV+3TC (Trueman et al., 2000)£10,254HAART (2 NRTI + 1 PI) vs no treatment (Freedberg et al., 2001)$23,000Personal risk assessment, counselling and education – gay and bissexual male adolescents (Tao et al., 1998)$6,180Condom distribution – national US population (Pinkerton et al., 1999)Cost-savingAntenatal HIV screening (Ades et al., 1999)<£10,000Expansion methadone maintenance program - IV drug users(Zaric et al., 2000)$10,900Needle exchange program – IV drug users (Laufer et al., 2001)$20,947/case avoided
6 Rationale for a new HIV testing strategy PortugalSituation 31/12/2010: 39,347 diagnosed casesDiagnosed prevalence yo: 0.48%Estimated undiagnosed prevalence yo: 0.21%Europe740,000 people living with HIV or AIDSNo decrease in HIV incidence in the recent pastEstimation: 30% undiagnosed cases
7 Source: European Commission - Public Health, 2010
8 Source: Health at a glance, OECD 2010 New cases per million, 2007
9 Rationale for a new HIV testing strategy Source: Health at a glance, OECD 2010
10 Rationale for a new HIV testing strategy PortugalFranceMean CD4 at care initiation292372Viral load at care initiation> 100,00042.10%18.75%30, ,00023.71%21.15%10, ,00014.03%15.19%3, ,0008.22%13.88%,0004.76%11.19%20-50019.84%< 202.41%0.00%
11 Rationale for a new HIV testing strategy Proposal of a new HIV testing strategy in PortugalTesting at all health care settings as part of routine careAll populationProvider-initiated test (rapid test)Counselling of positive cases and linkage to careVoluntary (opting-out approach)Confidentiality and anonymityVoluntary provider-initiated HIV testing, counselling and referral(here-below “expanded testing”)
12 Rationale for a new HIV testing strategy Proposal of a new HIV testing strategy in PortugalNecessity to evaluate different strategiesAll population versus high-risk groupsWhole country versus high-prevalence areasScreen once versus every year versus every 3, 5 or 10 yearsScreen at primary care centres versus emergency unitsResearch project: evaluate the cost-effectiveness of different expanded testing strategies in Portugal
13 Cost-effectiveness of expanded testing Balancing costs and benefitsExpanded testingHigher cost of testing, counselling and referralEarlier detection:Earlier treatment:Lower viral replicationLess drug-related AELower costs (?)Higher life expectancyBetter quality of lifeLower rate of transmissionBackground strategyLower cost of testing, counselling and referralLater detection:Later treatment:Higher costs (?)Lower efficacyLower life expectancyLower quality of lifeHigher rate of transmission
14 Cost-effectiveness of expanded testing Other less documented and measurable issues:HIV as “normal” diseaseCosts of waiting and costs of knowingHow the test is performed (versus opportunity of testing)Confidentiality and anonymityCounselling and referralAnti-discrimination laws
15 Cost-effectiveness of expanded testing Widely published CEPAC* Monte Carlo simulation model of HIV acquisition/detection/care (see eg Paltiel et al., N Engl J Med 2005)Examine the impact of expanded screening in Portugal, compared to current risk-factor-based screeningThe model captures data onHIV screening: HIV prevalence and incidence, test offer/acceptance rates, returns for test results, linkage to care, and HIV counseling and testing costsHIV disease: incidence of opportunistic diseases, HIV treatment, mortality rates, and all associated costs and quality of life effects*Cost-effectiveness of Preventing AIDS Complications
16 Cost-effectiveness of expanded testing Primary HIVInfectionChronic HIVInfectionAcute ClinicalEventThis figure depicts four general HIV disease states defined within this model, primary HIV infection, Chronic Infection, Acute Clinical Events, like an OI or a drug-related toxicity, and Death.Patients enter the model with primary infection as depicted in the upper left hand corner. After 1-2 months they transition to chronic HIV infection. In each month, they can remain in the Chronic State or transition to an acute clinical event or death. Patients who transition to the Acute State due to acute events, may likewise return to the Chronic HIV State, develop another acute event in the following month, or die.Within each state, the model tracks HIV RNA (current on therapy and setpoint); CD4 cell count (current and nadir); antiretroviral therapy (including success, failure, and prior regimen failure); use of resistance tests; history of opportunistic infections and use of prophylaxis; and treatment-related toxicity.DeathThe CEPAC Int’l ModelFreedberg et al.Supported by NIAID6
17 Cost-effectiveness of expanded testing Inputs required to estimate the CE of HIV expanded testing in PortugalEpidemiology of HIV: incidence/prevalence, undiagnosed prevalence, CD4 and viral load at detectionProgression of disease and efficacy of treatments: international literatureTreatment costs of HIV (by stage of disease), cost of testing and counselling, prices of anti-retroviral and prophylaxis drugsBehaviours: test acceptance and return rate, linkage to care, attitude towards risk and transmission of disease
19 Cost-effectiveness of expanded testing Inputs for the CEPAC Model (1)
20 Cost-effectiveness of expanded testing Inputs for the CEPAC Model (2)
21 Cost-effectiveness of expanded testing Base Case Results(Costs and life expectancy discounted at 5%)All population (undiagnosed prevalence 0.21%)ScenarioLife monthsQuality-adjusted life monthsCosts (€) 1ICER(€/LY) 2(€/QALY) 2Current practice193.11192,98980-Screen once193.14193.011,07033,86538,601Screen every 5 years193.16193.021,15046,53151,818Screen annually193.19193.051,32062,76980,6321. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.
22 Cost-effectiveness of expanded testing Base Case Results(Costs and life expectancy discounted at 5%)Lisboa (undiagnosed prevalence 0.39%)ScenarioLife monthsQuality-adjusted life monthsCosts (€) 1ICER(€/LY) 2(€/QALY) 2Current practice192.86192.631,820-Screen once192.92192.681,99032,93737,309Screen every 5 years192.96192.712,12043,12046,627Screen annually193.02192.772,39052,35761,0021. Costs rounded to nearest 10€.2. ICERs rounded to nearest €/LY or €/QALY.
23 Cost-effectiveness of expanded testing Cost-effectiveness of one-time expanded testing improves with higher estimated undiagnosed prevalenceLisboa 0.39%, Setúbal 0.33%, Porto 0.26%, Faro 0.26%Highly cost-effective among high-risk groups (undiagnosed prevalence >1%): MSM, IDUsAdditional preliminary results for IDUs: testing cost-effective every 5 years
25 Cost-effectiveness of expanded testing Cost-effectiveness of one-time HIV testing at different undiagnosed HIV prevalence values*Base Case*Costs and life expectancy discounted at 5%
26 Cost-effectiveness of screening strategies Cost/QALYScreening hypertension, asymptomatic men 20+ (Littenberg, Ann Intern Med 90)$80,400Colon cancer, FOBT + SIG q5y, adults (Frazier, JAMA 2000)$57,700Biennal breast cancer screening, women 50-69Biennal breast cancer screening, women (Salzmann, Ann Intern Med 1997) (Salzmann, Ann Intern Med 1997)$21,400/LYG$105,000/LYGHPV vaccine at 12 and cytologic screening every 3y after 25 (Goldie, Journal Nacional Cancer Institute, 2004)$58,500
27 Cost-effectiveness of expanded testing Main limitationsDisease transmission not accounted for. US results:37,100$/QALY without transmission effect30,800$/QALY with transmission effectUncertainty for undiagnosed prevalence & incidenceUse international published literature for quality of lifeUse data for specific settings: emergency rooms
28 Implicações para a tomada de decisão Valores razoáveis para um rastreio único e alargado, proposto pelo médico, acompanhado de aconselhamento e referenciaçãoValores aceitáveis para populações e regiões alvoIDUs de 5 em 5 anosMSMRegiões de alta prevalência: Lisboa, Setúbal, Porto, FaroCaracterísticas do teste alargadoTeste único e teste rápido‘Opting-out’ e aconselhamento limitado a seropositivosCentros de saúde, internamentos e urgênciasEstimativas para o grupo anos
29 Implicações para a tomada de decisão O que poderia ainda melhorar o custo-efectividade?Ter em conta a questão da transmissãoDiminuição dos preços da medicação ART e teste confirmatórioMelhor referenciação
30 International: US recommendations Source: CDC Recommendations 2006, Morbidity and Mortality Weekly Report, 22/9/2006, vol. 55, RR-14
31 International: French recommendations Source: Dépistage de l’infection VIH en France, Recommendations en Santé Publique, Haute Autorité de Santé, October 2009.
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