1. Cost Effectiveness of Hepatitis B Vaccination at HIV Counseling and Testing Sites 
Sun-Young Kim, MPH, Kaafee Billah, PhD, Tracy A. Lieu, MD, Milton C. Weinstein, PhD 
American Journal of Preventive Medicine 
Volume 30, Issue 6, Pages e6 (June 2006)
DOI: /j.amepre
Copyright © 2006 American Journal of Preventive Medicine Terms and Conditions

2. Figure 1
Decision model for hepatitis B vaccination at HIV CTSs. This figure depicts the four vaccination strategies considered in the model. It was assumed that when clients would visit HIV CTSs seeking HIV testing, they would be screened with questions about their history of previous hepatitis B vaccination or infection. A client reporting no previous infection or vaccination would be considered eligible for vaccination and offered one of the four modeled strategies. Then, depending on the strategy chosen, their screening and/or vaccination would be offered free of charge, and clients can accept or refuse. Once clients initiate vaccination or testing, they either revisit each setting and receive the follow-up doses or do not revisit and fail to complete the vaccine series according to assumed dose-completion rates for each vaccine dose. Acceptance rates for testing and for each vaccine dose were taken into account at each node. For simplicity, the joint probability of “Prior vaccination (immunity)” and “Prior (HBV) infection” among “Not susceptible” was assumed to be zero. A circled M represents a Markov cohort model simulating the natural history of HBV infection as described in Figure 2.
CTS, counseling and testing sites; FN, false negative; FP, false positive; HBV, hepatitis B virus; TP, true positive; TN, true negative.
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3. Figure 2
Natural history model of hepatitis B virus (HBV) infection. Figure shows the health states included in the Markov model. Susceptible individuals acquire HBV infection based on estimated age-, gender-, race/ethnicity-, and risk-level–specific incidence rates. Acute infection can be symptomatic or asymptomatic. Those with symptomatic infection receive medical attention either at an outpatient facility or a hospital and can develop fulminant hepatitis (not shown because this is assumed to be a temporary state). Both symptomatic and asymptomatic acute infections mostly resolve in adults, but can develop into chronic infection. Persons in the chronic hepatitis state can move to the inactive carrier state but inactive carriers can relapse back to active chronic infection. Over time, chronic hepatitis may lead to liver cirrhosis or primary hepatocellular carcinoma (HCC). Those with fulminant hepatitis, decompensated cirrhosis, or HCC can undergo liver transplantation. Transitions from one state to another are assumed to occur at rates obtained from the European Association for the Study of the Liver consensus statements and other published literature (Table 2).
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4. Figure 3
Subgroup analysis results: incremental cost-effectiveness ratios (ICERs) of routine vaccination compared with no intervention at freestanding counseling and testing sites by subgroup. Results for “other” race/ethnicity are not shown in this graph. The result was cost-saving in those aged 20–29 and 30–39 years, and the ICER for persons aged 40–49 years was $4800 per quality-adjusted life year (QALY).
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5. Appendix 1
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6. Appendix 2
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7. Appendix 3
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8. Appendix 3
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9. Appendix 4
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10. Appendix 4
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