National HIV Prevention Conference | 2015
Background: Viral suppression, the end point of the human immunodeficiency virus (HIV) care continuum, has been shown to reduce morbidity, mortality and transmission. National goals emphasize maximizing coverage along the HIV care continuum. However, the costs of such interventions are poorly understood, and the relative benefits of interventions at varying ‘steps’ of the HIV care continuum are not easily compared. Our objective was to develop a standardized reporting framework to improve comparability of costing data between interventions at different stages of the HIV care continuum with the goal to identify optimal combinations of interventions to increase the percentage of persons living with HIV who achieve viral suppression.
Methods: We conducted a literature review on interventions along the HIV care continuum including: 1) HIV testing; 2) Linkage to HIV care after HIV diagnosis; 3) Maintenance in care among persons already in care; 4) Re-engagement in care among persons who have been disengaged from care for >1 year; 5) Adherence support among those on ART. Using data from our literature review, we developed a standardized reporting framework that combines data on cost and intervention efficacy for each intervention along the HIV care continuum into a unified model that can be used to estimate the cost per virally suppressed person per year for each intervention along the HIV care continuum and thus compare the relative cost effectiveness of continuum interventions. The costing framework is submitted as part of a panel presentation on a Centers for Disease Control and Prevention (CDC)/National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention-funded modeling cooperative agreement begun in 2015.
Results: Our literature review suggests that current reporting of costs and efficacy of interventions along the HIV care continuum are inadequate to guide allocation of resources by policy makers. Substantial variability exists in literature estimates of resource input costs, targeted populations, and methods for reporting of efficacy for continuum interventions. To overcome this barrier, our framework incorporates available data on population sizes at each ‘step’ of the HIV care continuum to calculate the relative and absolute reach of proposed interventions, applies standardized efficacy measures to each care continuum intervention, and applies standard costs (e.g. standard cost per staff person) based on existing CDC and Health Resource and Services Administration budgets for programmatic activities. This framework is being developed into an open-source tool for policy makers and researchers; our tool will accept inputs on observed costs and efficacy of HIV care continuum interventions, and provide a standardized assessment of comparative (step-specific and overall) cost-effectiveness.
Conclusions/Implications: Relative incremental costs per additional virally suppressed persons per year may vary substantially across different interventions in the HIV care continuum. Future studies of continuum interventions should utilize a standardized reporting framework to allow informed comparisons that include: a) standardized ‘step’ specific measures for costs and efficacy and b) cost-effectiveness expressed as the incremental cost per virally suppressed person per year. This costing framework can be applied at the federal, state and local levels to allocate resources for maximal impact to improve outcomes along the HIV care continuum.