Resource utilization and cost-effectiveness of counselor- vs. provider-based rapid point-of-care HIV screening in the emergency department

• Published in: PloS one 2011-10, Vol.6 (10), p.e25575-e25575
• Main Authors: Walensky, Rochelle P, Morris, Bethany L, Reichmann, William M, Paltiel, A David, Arbelaez, Christian, Donnell-Fink, Laurel, Katz, Jeffrey N, Losina, Elena
• Format: Article
• Language: English
• Subjects: Acceptance tests; Acquired immune deficiency syndrome; Adult; AIDS; Antiretroviral Therapy, Highly Active; Clinical Trials as Topic; Comparative analysis; Cost analysis; Cost-Benefit Analysis; Costs; Counseling - economics; Economic aspects; Emergencies; Emergency medical services; Emergency Service, Hospital - economics; Evaluation; Female; Health Personnel - economics; Health Resources - economics; Health Resources - statistics & numerical data; HIV; HIV Infections - diagnosis; HIV Infections - economics; HIV tests; Hospital emergency services; Human immunodeficiency virus; Humans; Male; Mass Screening - economics; Mathematical models; Medical diagnosis; Medicine; Middle Aged; Models, Biological; Personnel; Physicians; Point-of-Care Systems - economics; Resource utilization; Return on investment; Robustness (mathematics); Screening; Sensitivity analysis; Sensitivity and Specificity; Social and Behavioral Sciences; Strategy; Womens health
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0025575

Routine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor. We employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs. Estimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs. The cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.