Sanders GD (Duke University, Durham NC), Anaya H
(HIV/HEP QUERI, Los Angeles), Asch S
(HIV/HEP QUERI, Los Angeles), Goetz M
(HIV/HEP QUERI, Los Angeles), Hoang T
(HIV/HEP QUERI, Los Angeles), Golden J
(HIV/HEP QUERI, Los Angeles), Gifford A
(HIV/HEP QUERI, Los Angeles), Bowman C
(VA San Diego Healthcare System, La Jolla, CA), Owens DK
(7VA Palo Alto Health Care System, Palo Alto CA)
The CDC recommends routine voluntary HIV testing of all patients. HIV testing rates however are low even among those at identifiable risk. Once tested, many patients do not return to receive their results. To increase testing rates and receipt of results, nurse-initiated testing, streamlined counseling, and rapid testing have been proposed. The cost-effectiveness of these strategies is uncertain.
As part of a RCT, we evaluated costs, quality of life, and survival for patients who underwent: (1) traditional counseling and HIV testing initiated by physicians (PHYSICIAN-TRADITIONAL); (2) nurse-initiated screening with traditional counseling and testing (NURSE-TRADITIONAL); or (3) nurse-initiated screening with streamlined counseling and rapid testing (NURSE-RAPID). Testing acceptance and return rates were based on the RCT trial of 251 patients at two VA clinics (HIV prevalence=0.40%). Long-term outcomes were based on a Markov model that simulated outcomes over the lifetime of the patient. We modeled disease progression based on CD4 and viral load levels, and assumed identified patients started treatment according to current guidelines.
In the RCT, 41% of patients in the PHYSICIAN-TRADITIONAL strategy received HIV testing and 35.3% of these patients returned for their results. The NURSE-TRADITIONAL and NURSE-RAPID strategies had higher testing rates (84.5% and 89.3% respectively) but only 36.6% of the NURSE-TRADITIONAL patients received their results compared with 89.3% in the NURSE-RAPID strategy. Our analysis estimated that patients in the PHYSICIAN-TRADITIONAL strategy had a lifetime cost of $48,656 and a quality-adjusted life expectancy (QALE) of 16.271 years. The NURSE-TRADITIONAL strategy increased costs by $53 and QALE by 0.48 days while patients in the NURSE-RAPID strategy cost $66 more than those in the PHYSICIAN-TRADITIONAL strategy with a 0.66 day QALE increase (incremental cost-effectiveness of $36,400/QALY). Including the effect of early identification on transmission of HIV, the cost-effectiveness of NURSE-RAPID versus PHYSICIAN-TRADITIONAL became more favorable ($10,689/QALY).
Nurse-initiated streamlined counseling with rapid testing was cost-effective compared with traditional testing strategies and should be considered by clinical managers and policymakers when implementing HIV testing into primary or urgent care.
Implementation of nurse-based testing with streamlined counseling could substantially improve participation in HIV screening relative to current practice.