This analysis of rapid HIV testing and counseling at 45 U.S. hospitals produced mean cost estimates of $48.07 for a negative test result and $64.17 for a preliminary-positive result. These cost estimates do not include the cost of confirmatory testing or follow-up counseling for preliminary-positive patients, which elsewhere have been estimated at $34.10
Considerable variability in testing and counseling costs was observed across study hospitals. For example, the overall cost per HIV-negative patient ranged from $24.64 to $87.94, or approximately half to twice the mean cost estimates. Similar variability was observed for preliminary-positive test costs.
Differences in the personnel costs associated with pre- and posttest counseling were a main source of variability in overall testing costs. On average, counseling costs accounted for 38.4% of the total cost of rapid testing for HIV-negative patients and 53.7% of the cost for preliminary-positive patients.
As expected, higher counseling costs were associated with higher overall costs. Hospitals that spent less time in counseling activities, or that used less well-compensated personnel (e.g., HIV counselors and social workers) to conduct pre- and posttest counseling sessions, had significantly lower overall counseling and testing costs than did other hospitals.
This analysis is subject to several limitations. First, hospitals were included in the study only if both the departmental and hospital laboratory agreed to participate and provided detailed, somewhat sensitive cost information. The overall study inclusion rate, 49.5%, reflects limitations of this two-stage survey process.
Second, although the survey asked which personnel types performed each of the five rapid test–related procedures, it did not ascertain the proportions with which each personnel type performed each activity. The main analysis assumed that all personnel types who sometimes performed the procedure were equally likely to perform the procedure. If, instead, each procedure was performed by the lowest-paid or highest-paid personnel type who sometimes performed the procedure, the mean cost for a negative test would be ~12% larger or smaller, respectively.
Third, the study survey did not ask about the type of specimen (e.g., oral fluid or whole blood) collected for the rapid test.
Finally, because of the large number of hospitals involved in the study, it was not practical to conduct time–motion analyses to estimate the amount of time spent performing counseling and testing-related procedures at study hospitals. Instead, the study relied on hospital estimates of procedure times. With one exception, these time estimates were consistent with those of Farnham et al.,8
who used a decision-analytic framework to estimate the cost of rapid testing and counseling at a sexually transmitted disease clinic and rapid antibody screening (testing without pretest counseling) at a hospital emergency department. Hospitals' estimates of the time required to process a rapid-test specimen were problematic, however. Although the survey question that asked about the time to process a test explicitly stipulated that respondents should include “only time spent running the test, including time for set-up, reading results, and recording results,” not “the time that the test is running,” the mean (19.5
min) and median (15
min) values reported by study hospitals suggest that some respondents may have reported the total elapsed time required to run the test, including the time the test was developing before results were available. The CDC estimates that as few as 3 to 5
min of personnel time are required to process a rapid-test specimen.9
We conducted a sensitivity analysis in which processing times exceeding 3.5
min were replaced by a uniform value of 3.5
min. The resultant cost estimates were $40.51 for a negative test and $56.60 for a preliminary-positive test (15.7% and 11.8% smaller than the base-case values, respectively).
The present study was conducted in 2005 through 2006, prior to the September 2006 release of the CDC's revised recommendations for HIV testing in health-care settings.1
Although these guidelines encourage “prevention counseling” for patients at high risk of HIV infection, they further clarify that “in general, prevention counseling should not be required
in health care settings.” Study hospitals spent an average of 11.9
min in pretest counseling activities and 8.3
min providing posttest counseling to patients who tested HIV negative. We conducted a sensitivity analysis to assess the potential cost implications of eliminating pretest counseling and reducing the time spent counseling persons who tested negative to only 1
min, consistent with Farnham et al.8
Streamlining counseling in this manner reduced overall costs to $27.15 for HIV-negative patients (a reduction of 43.5% compared with the base-case cost estimate) and to $51.50 for preliminary-positive patients (a 19.7% reduction).