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Routine HIV Screening in Portugal:
Clinical Impact and Cost-Effectiveness
Yazdan Yazdanpanah, MD
Julian Perelman, PhD
Joana Alves
Kamal Mansinho, MD
Madeline A. DiLorenzo
Ji-Eun Park
Elena Losina, PhD
Rochelle P. Walensky, MD, MPH
Farzad Noubary, PhD
Henrique Barros, MD
Kenneth A. Freedberg, MD, MSc
A. David Paltiel, PhD, MBA
HIV Epidemiological Burden in Portugal
Portugal
Iceland
Spain
Italy
France
Switzerland
Luxembourg
Austria
Ireland
UK
Netherlands
Belgium
Denmark
Sweden
Greece
Norway
Germany
Finland
0.4%
-0.4
0.3%
-0.3
0.2%
-0.2
0.1%
-0.1
2009 HIV Prevalence
0%0
00
10
10
20
20
30
30
2009 Incidence Per Million Population
40
40
HIV Care in Portugal
 The Portuguese National Health Service provides universal
coverage for HIV care (including free access to HIV testing
and ART) via a national network of public primary care
centers and hospitals.
 In 2011, the Portuguese Parliament adopted a resolution
calling for voluntary, routine population-based HIV testing,
counseling and referral (HIV-TCR).
 Portugal faces numerous challenges in implementing this
resolution.
Challenge: Economic / Fiscal Crisis
2010 GDP
 2010 Portuguese
GDP/capita: 16,300€
 Mean 2010 EU
GDP/capita: 24,000€
 2011 GDP growth rate:
-1.5%
<7,600€
7,600-12,900€
12,900-20,500€
>20,500€
Source: Eurostat, ACSS
Regional Disparities
2010 Undiagnosed HIV Prevalence (%)
< 0.05
0.05 - 0.09
0.10 - 0.20
> 0.20
2010 Annual HIV Incidence (%)
< 0.005
0.005 - 0.009
0.010 - 0.020
> 0.020
Objective
 To evaluate the clinical impact and cost-effectiveness of
routine HIV screening in Portuguese adults (vs. current
practice), focusing on the regional heterogeneity in burden
of disease.
 We examined three different strategies:



One-time screening
Screening every 3 years
Annual screening
Methods Overview
 Cost-Effectiveness of Preventing AIDS Complications
(CEPAC), a widely published Monte Carlo simulation model
of the detection, natural history and treatment of HIV
disease.
 Assembly of Portuguese national/regional input data on
 Epidemiology of HIV infection
 HIV clinical care
 Economic resource use
Selected Input Parameters
Variable
Value
Reference
Undiagnosed HIV
prevalence
0.16%
Portuguese National Institute of
Health 2010;
Hammers & Philips, HIV Med, 2008
Annual incidence
0.02%
INSA 2010
Test offer/acceptance rate
63.2%
Assumption +
Jauffret-Roustide, BEH, 2006
Linkage to care rate
78.4%
Portuguese CAD Report, 2010
Mean CD4 at care
initiation
292 cells/μL
2010 Survey at 3 Portuguese
Hospitals
HIV rapid test cost
5.40€
Ordinance 839-A/2009
Cost of 1st Line ART (EFV
+ TDF/FTC)
732.05€
Portuguese Central Administration of
the Health System, 2010
Selected Input Parameters
Variable
Value
Reference
Undiagnosed HIV
prevalence
0.16%
Portuguese National Institute
of Health 2010;
Hammers & Philips, HIV Med,
2008
Annual incidence
0.02%
INSA 2010
Test offer/acceptance rate
63.2%
Assumption +
Jauffret-Roustide, BEH, 2006
Linkage to care rate
78.4%
Portuguese CAD Report, 2010
Mean CD4 at care
initiation
292 cells/μL
2010 Survey at 3 Portuguese
Hospitals
HIV rapid test cost
5.40€
Ordinance 839-A/2009
Cost of 1st Line ART (EFV
+ TDF/FTC)
732.05€
Portuguese Central Administration of
the Health System, 2010
Model Outcomes
 Clinical (quality adjusted life years, or QALY)
 Economic (per-person lifetime costs, 2010 €)
 Incremental Cost-effectiveness (€/QALY)
Benchmarks for Cost-Effectiveness
in Portugal
 World Health Organization Commission on
Macroeconomics and Health guidance:
 “Cost-effective” if the CE ratio is less than
three times the per capita GDP for a given
country.
 Portuguese GDP per capita is 16,300€,
implying a threshold = 48,900 €/QALY.
 Portuguese Infarmed “informal threshold” for costeffectiveness of innovative drugs: ICER < 30,000
€/QALY.
Source: Pordata, 2011
Base Case Results For National Program
(Undiagnosed Prevalence = 0.16%, Annual Incidence = 0.02%)
Testing
strategy
Quality-adjusted
life months
HIV-infected1
Quality-adjusted life
months
Costs (€)1,2
total population1
ICER
(€/QALY) 3
Current
practice
174.62
193.21
720
Screen once
177.03
193.23
780
36,000
Screen every
three years
179.28
193.26
870
53,000
Screen
annually
181.07
193.27
980
75,000
1. Costs and quality-adjusted life months discounted at 5% per annum.
2. Costs rounded to nearest 10€.
3. ICERs are for the general population and are rounded to nearest 1000€/QALY.
---
Cost-Effectiveness of One-Time HIV
Screening in Different Regions
2010 Annual
Incidence (%)
<0.005
0.005-0.009
0.010-0.020
>0.020
CE of National OneTime Screening
CE of Regional OneTime Screening
Infarmed Threshold
WHO CE Threshold
>WHO Threshold
Cost-Effectiveness of HIV Screening
Every Three Years in Different Regions
2010 Annual
Incidence (%)
<0.005
0.005-0.009
0.010-0.020
>0.020
CE of National
Screening Every 3 Years
CE of Regional Screening
Every Three Years
Infarmed Threshold
WHO CE Threshold
>WHO Threshold
One-Way Sensitivity Analyses on CE of
National, One-Time, Routine Screening
Infarmed
Threshold
WHO
Threshold
Base
Case
HIV test cost
(5.4€-42.7€)
Linkage to care rate
(100%-15%)
Mean CD4 at care initiation
(255 cells/µL-350 cells/µL)
First-line ART Costs
(512€-732€)
Mean population age
(37.6y-42.6y)
Test acceptance rate
(100%-25%)
25,000
30,000
35,000
40,000
45,000
50,000
Cost-effectiveness
Cost-e
ffe ctiv e ne ssRatio
ratio(€/QALY)
(€/QALY)
55,000
60,000
Risk Group Results - MSM
(Undiagnosed Prevalence = 3.34%, Annual Incidence = 0.04%)
Testing
strategy
Quality-adjusted
life months
HIV-infected1
Quality-adjusted life
months
Costs (€)1,2
total population1
ICER
(€/QALY) 3
Current
practice
132.85
185.74
6,720
Screen once
138.96
186.03
7,500
33,000
Screen every
three years
139.60
186.05
7,620
dominated*
Screen
annually
141.10
186.12
7,880
48,000
1.
2.
3.
4.
Costs and quality-adjusted life months discounted at 5% per annum.
Costs rounded to nearest 10€.
ICERs are for the general population and are rounded to nearest 1000€/QALY.
“dominated”: costs more and confers fewer QALYs than an alternative strategy.
---
Risk Group Results - IDU
(Undiagnosed Prevalence = 6.69%, Annual Incidence = 0.09%)
Testing
strategy
Quality-adjusted
life months
HIV-infected1
Quality-adjusted life
months
Costs (€)1,2
total population1
ICER
(€/QALY) 3
Current
practice
109.88
164.67
9,740
Screen once
119.87
165.60
12,210
32,000
Screen every
three years
122.98
165.88
13,070
36,000
Screen
annually
126.58
166.21
14,080
36,000
1.
2.
3.
4.
Costs and quality-adjusted life months discounted at 5% per annum.
Costs rounded to nearest 10€.
ICERs are for the general population and are rounded to nearest 1000€/QALY.
“dominated”: costs more and confers fewer QALYs than an alternative strategy.
---
Limitations
 A simulation model of HIV screening and disease that
combines input data from disparate sources and relies on
multiple assumptions.
 Impact of expended HIV screening on disease transmission
was not considered.
 “Cost-effective” ≠ “Affordable”. Budget impact analysis will
be a useful next step to understand effects on individual
stakeholders.
Summary and Conclusion
 Overall, one-time screening of the national Portuguese
population:
 is “borderline cost-effective” by informal Portuguese
national standards
 is cost-effective by WHO standards.
 Given the economic crisis as well as the higher disease
burden in certain regions, we recommend initiating routine
screening in high-prevalence regions first.
 More frequent HIV screening may be considered in both
high-risk populations (IDUs, MSM) and high-prevalence
regions.
Acknowledgments
Escola Nacional de Saúde Pública – UNL
Harvard Medical School
Julian Perelman
Joana Alves
Céu Mateus
João Pereira
Kenneth A. Freedberg
Elena Losina
Rochelle P. Walensky
Farzad Noubary
Madeline A. DiLorenzo
Ji-Eun Park
Instituto de Saúde Pública – U. do Porto
Henrique Barros
NHS hospitals - Portugal
Kamal Mansinho, Ana Cláudia Miranda (CH Lisboa
Ocidental)
Francisco Antunes, Manuela Doroana (CH Lisboa
Norte)
Rui Marques (H São João)
José Saraiva da Cunha, Joaquim Oliveira (HUC)
José Poças (CH Setubal)
Eugénio Teófilo (CH Lisboa Central)
Yale School of Medicine
A. David Paltiel
Hôpital Bichat – U. Paris Diderot
Yazdan Yazdanpanah
Funding sources: Coordenação Nacional para a Infecção VIH/SIDA, Agence nationale de
recherche sur le SIDA et les hépatites virales, National Institute of Allergy and Infectious
Diseases, National Institute of Mental Health, National Institute on Drug Abuse.