Nurse-Initiated Rapid HIV Testing was Cost-Effective and Increased Screening Rates among Veterans

FINDINGS:

• Nurse-initiated routine screening (i.e. recommending HIV testing to all Veterans) with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results among Veterans - and was cost-effective compared with traditional risk-based HIV testing strategies.
• When benefits to sexual partners from reduced transmission was considered, rapid testing with streamlined counseling was even more favorable.
• Traditional risk-based HIV counseling and testing resulted in the lowest costs and effectiveness.
• For a Veteran with HIV, nurse-initiated routine screening with traditional counseling/testing increased life expectancy by 0.64 years or 0.47 QALYs compared to traditional counseling/testing. If the nurse-initiated strategy included rapid testing and streamlined counseling, life expectancy increased by 0.87 years or 0.63 QALYs compared to traditional counseling/testing.

IMPACT:
There is sufficient evidence to show that HIV rapid-testing can be an effective means to increase testing and receipt of results among Veterans. HIV/Hepatitis-QUERI has developed implementation tools to increase the use of rapid testing and will disseminate these across VHA.

BACKGROUND:
The CDC recommends that HIV screening be performed routinely for all patients between the ages of 13-64 in healthcare settings, yet HIV testing rates are low, even among individuals with identifiable risk. Also, many patients who are screened do not return for test results. This study examined the cost-effectiveness of three alternative models for implementing HIV testing: traditional HIV counseling and testing; nurse-initiated routine screening with traditional counseling and testing; and nurse-initiated routine screening with streamlined counseling and rapid HIV testing. Investigators used a Markov model developed to assess the cost-effectiveness of voluntary HIV screening in healthcare settings, replicating the rates of HIV testing and receipt of results for each strategy from a previously conducted randomized controlled trial. The RCT included 251 Veterans who received care at one of two VA primary care clinics, with urgent care services. Outcomes in the current study included costs and quality-adjusted life years (QALYs).

LIMITATIONS:

• Implications for implementation of screening outside a trial are not known (i.e. informed consent and follow-up requirements may have discouraged some patients from participating).
• The cost-effectiveness analysis assumed that identified patients would have access to HIV care, which is true in VA, but may not be the case in other healthcare settings.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Drs. Anaya and Asch are part of HSR&D's Center for the Study of Healthcare Provider Behavior in Los Angeles; Dr. Asch is also part of VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (HIV/Hepatitis-QUERI).

Sanders G, Anaya H, Asch S, et al. Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial. Journal of General Internal Medicine March 4, 2010; E-pub ahead of print.