The cost-effectiveness of on-site rapid HIV testing in substance abuse treatment: results of the CTN 0032 randomized trial Schackman BR, Metsch LR, Colfax GN, Leff JA, Wong A, Scott CA, Feaster DJ, Gooden L, Matheson T, Mandler RN, Haynes LF, Paltiel AD, Walensky RP 6 th IAS Conference on HIV Pathogenesis, Treatment, and Prevention July 18, 2011

US National HIV/AIDS Strategy Target: increase proportion of people living with HIV who know their status from 79% to 90% by 2015 Implementation: Federally-funded substance abuse and mental health treatment clinics to offer voluntary, routine HIV testing 2

HIV testing in substance abuse treatment centers Less than one-third of US drug treatment programs offer HIV testing and counseling Less than one-half of community treatment programs in the National Drug Abuse Clinical Trials Network (CTN) make HIV testing available, either in the program or through referral 3

Objective To project the life expectancy gains, costs and cost-effectiveness of 3 HIV testing strategies in substance abuse treatment centers evaluated in the CTN Rapid Testing and Counseling Study randomized controlled trial (CTN 0032) 4

Analytic overview We used data on short-term outcomes from CTN 0032 (Abstract TUPE402) To project long-term clinical and economic outcomes, we used the Cost- Effectiveness of Preventing AIDS Complications (CEPAC) model, a computer simulation state-transition model of HIV disease natural history, detection and treatment 5

Model outcomes For HIV-infected individuals: –Life expectancy, undiscounted –Quality-adjusted life years (QALYs) gained and cost of additional care due to early detection, discounted at 3% annually For HIV-uninfected individuals: –Cost of HIV testing offer All costs are in 2009 US dollars 6

Cost-effectiveness is about value for money Incremental cost-effectiveness ratio: US cost-effectiveness threshold: <$100,000/QALY 7 Additional Resource Use ($) Additional Health Benefits (QALYS)

Strategies examined 1)No HIV testing 2)Offer of referral to off-site HIV testing only 3)Offer of on-site rapid HIV testing with verbal information about testing only 4)Offer of on-site rapid HIV testing with risk reduction counseling 8

Cohort description Male61% White65% Injection drug use history49% Prevalence of undetected HIV0.4% Mean CD4 cells at time of detection with intervention*551/ul Time between HIV tests elsewhere*5.3 years Eligibility for HIV test offer: Not known to be HIV+ Did not receive results of an HIV test performed in the last 12 months 9 *estimated

Input parameters by strategy Accepted & received HIV test result Cost per offer Mean number of unprotected sex acts after 6 months Off-site referral18.4%$ On-site testing + information 84.8%$ On-site testing + counseling 79.7%$

Base case cost-effectiveness results Life expectancy HIV+ (years) Population avg total cost Population avg total HIV+ QALM CE ratio ($/QALY) No intervention17.1$1, Off-site referral17.9$1, dominated (inefficient) On-site testing + information 20.8$1, $60,300 On-site testing + counseling 20.5$1, Dominated (higher cost, lower QALY) 11

Sensitivity analysis: cost- effectiveness of on-site testing + information vs. no intervention 12

Limitations Assume HIV+ individuals who receive test results will be linked to care, and consistently receive guideline-concordant care Potential benefit of reduced HIV transmission due to earlier detection is not included Additional start-up costs will be required to implement on-site HIV testing 13

Conclusions In substance abuse treatment centers: –Referral for off-site testing is less costly but also less efficient than on-site testing –On-site risk reduction counseling adds cost without either reducing sexual risk behavior or increasing acceptance of HIV testing, and is not cost-effective Offering rapid HIV testing on-site in substance abuse treatment programs is cost-effective using the current US threshold of <$100,000/QALY 14

Funding National Drug Abuse Treatment Clinical Trials Network (CTN): U10 DA013720, U10DA S, U10 DA020036, U10DA15815, U10DA13034, U10DA013038, U10 DA013732, U10 DA13036, U10 DA13727, U10DA015833, HHSN C, HHSN C National Institute on Drug Abuse: R01 DA027379, K23 DA National Institute of Mental Health: R01 MH National Institute of Allergy and Infectious Diseases: R37 A

Special thanks to site coordinators, staff, and participants CPCDS: Antoine Douiah, Dorothy Sandstrom, Carrie Baron- Myak La Frontera: Pat Penn, Roger Owen, and Sue McDavitt Daymark: Robert Werstlein, Jessica Sides Chesterfield: Dace Svikas, Ned Snead, Laurie Safford Glenwood: Robert Schwartz, Lil Donnard, Lynn Calvin MCCA: Steve Martino, David Avila, Stacy Botex Wheeler: Steve Martino, Ray Muszynksi, Brandi Welles CODA: Todd Korthuis, Katharina Weist, Diane Lape Lifelink: Sarah Erickson, Michael DeBernardi, Meredith Davis LRADAC: Louise Haynes, Beverly Holmes Morris Village: Louise Haynes, Kim Pressley Gibson: Angela Case-Williams, Kevin Steward, Andrew Johnson 16