Testing strategies to detect acute and prevalent HIV infection in adult outpatients seeking healthcare for symptoms compatible with acute HIV infection in Kenya: a cost-effectiveness analysis

BMJ Journals

Number of Volumes: Volume 12, Issue 9

Detection of acute and prevalent HIV infection using point-of-care nucleic acid amplification testing (POC-NAAT) among outpatients with symptoms compatible with acute HIV is critical to HIV prevention, but it is not clear if it is cost-effective compared to existing HIV testing strategies. We developed and parametrised a decision tree to compare the cost-effectiveness of: (1) provider-initiated testing and counseling (PITC) using rapid tests, the standard of care; (2) scaled-up PITC (SU-PITC) in which all patients were tested with rapid tests unless they opted out; and (3) opt-out testing and counseling using POC-NAAT, which detects both acute and prevalent infection. The model-based analysis used data from the Tambua Mapema Plus randomised controlled trial of a POC-NAAT intervention in Kenya, supplemented with results from a stochastic, agent-based network model of HIV-1 transmission and data from the published literature. The analysis was conducted from the perspective of the Kenyan government using a primary outcome of cost per DALY averted over a 10-year time horizon. After analysing the decision-analytic model, the average per patient cost of POC-NAAT was $214.9 compared with $173.6 for SU-PITC and $47.3 for PITC. The mean DALYs accumulated per patient for POC-NAAT were 0.160 compared with 0.176 for SU-PITC and 0.214 for PITC. In the incremental analysis, SU-PITC was eliminated due to extended dominance and the ICER comparing POC-NAAT to PITC was $3,098 per DALY averted. The ICER was sensitive to disability weights for HIV/AIDs and the costs of antiretroviral therapy. The conclusion was that POC-NAAT offered to adult outpatients in Kenya who present for care with symptoms compatible with AHI is cost-effective and should be considered for inclusion as the standard of HIV testing in this population. 

SANTHE is an Africa Health Research Institute (AHRI) flagship programme funded by the Science for Africa Foundation through the DELTAS Africa programme; the Bill & Melinda Gates Foundation; Gilead Sciences Inc.; and the Ragon Institute of Mass General, MIT, and Harvard.