displays clinical characteristics of newly-identified HIV-infected adults eligible for government-financed testing and care (excluding the VA), for the base case of each screening scenario. If testing continues at an average frequency of once every ten years, 177,000 cases (116,000 prevalent; 61,000 incident) will be identified from 2009 to 2013. Over the course of their lifespan, 68 percent of currently unidentified prevalent cases and 49 percent of incident cases will receive a diagnosis after presenting to care with an AIDS-defining OI. If expanded testing increases testing to once every five years, an additional 46,000 cases (17,000 prevalent; 29,000 incident) will be identified from 2009 to 2013. The fraction of cases receiving a diagnosis as a result of an AIDS-defining OI will drop to 58 and 32 percent for prevalent and incident cases, respectively. The mean CD4 count at detection (a measure of HIV disease progression) will be higher under expanded screening for all cases, reflecting earlier detection.
Clinical characteristics of newly detected HIV-infected individuals eligible for care through discretionary and entitlement programsa
lists the projected total testing and care costs to public payers, under each screening scenario. Costs are separated by program type (testing, discretionary, and entitlement) and then summed at the bottom of the table. In the base case, continued testing at the current rate will incur a total cost of $83.7 billion over five years. Expanded screening will incur an additional cost of $2.7 billion, for a total of $86.4 billion. Five-year testing costs will increase from $504 million to $1.0 billion. Budget projections are dominated by treatment costs. Testing costs represent a small fraction of total costs (0.6 percent and 1.2 percent for the current practice and expanded screening scenarios, respectively) and 18.3 percent of additional costs for expanded screening. Five-year projected costs to discretionary programs will increase by $2.9 billion (from $26.0 billion to $28.9 billion), which will be partially offset by a savings of $624 million in the entitlement program budget. In both scenarios, most costs will be incurred by entitlement programs.
Projected five-year costs (in millions) to US government testing, discretionary, and entitlement programs for HIV screening and care, 2009-2013
Under a ten-year time horizon, 158,000 cases will be identified under current practice (19,000 prevalent; 139,000 incident) in the second 5-year period from 2014 to 2018. Over time, an increasing number of incident cases are identified via current practice as they progress through HIV disease and develop OIs. However, continuing expanded screening for the additional 5 years yields an additional 31,000 cases identified between 2014 and 2018. Compared to current practice, expanded screening will yield incremental costs of $1.1 billion to testing programs and $10.9 billion to discretionary programs, and incremental savings of $2.8 billion to entitlement programs.
shows annual incremental costs for people identified through expanded screening. In each budget year, expanded screening would incur an additional screening program cost of approximately $101 million. This incremental cost remains constant. The projected annual incremental cost of care to discretionary budgets would rise throughout the period, from $133 million in 2009 to $983 million in 2013. Entitlement programs will experience cost savings, which will increase over time. We project annual savings of $2 million in 2009 and $280 million in 2013. Incremental costs to discretionary programs are not fully offset by cost savings to entitlement programs.
Incremental costs (in millions) to US government testing, discretionary, and entitlement programs, comparing current practice and expanded screening, 2009-2013.
displays the projected pharmaceutical costs to discretionary programs under current and expanded screening in comparison to the 2007 RW AIDS Drug Assistance Program (ADAP) budget (inflated to $2009), including federal and state contributions (17
). In the first year, pharmaceutical costs to discretionary programs would be about $3.2 billion under both scenarios, in comparison to the 2007 ADAP budget of $1.5 billion. By 2013, the annual pharmaceutical cost would increase by $0.2 billion under current screening and $0.8 billion under expanded screening.
Projected pharmaceutical costs (in millions) to US discretionary programs under current practice and expanded screening, 2009-2013, compared to current ADAP budget.
Results of sensitivity analyses are shown in . Using ELISA tests will decrease testing costs to $384 million and $766 million for current practice and expanded screening, due to the lower test cost and return rate. Inclusion of pre-test counseling will increase testing costs to $699 million and $1.4 billion for current practice and expanded screening. Perfect rates of test return and linkage to care would increase total care costs to $83.8 billion for current practice ($26.9 billion discretionary; $56.9 billion entitlement) and $86.5 billion for expanded screening ($30.3 billion discretionary; $56.2 billion entitlement). Low rates of test return and linkage to care would decrease total care costs to $82.1 billion for current practice ($24.6 billion discretionary; $57.5 billion entitlement) and $83.5 billion for expanded screening ($26.5 billion discretionary; $57.0 billion entitlement).
Combining these sensitivity analyses, we estimate that the high-cost scenario (rapid test with pre-test counseling and perfect rates of test return and linkage to care) will incur total testing and care costs of $84.5 billion and $87.9 billion for current practice and expanded screening, for an incremental cost of $3.4 billion. The low-cost scenario (ELISA test with no pre-test counseling and low rates of test return and linkage to care) will incur total costs of $82.4 billion and $84.3 billion for current practice and expanded screening, for an incremental cost of $1.9 billion.
If there is a 10 percent increase in the population eligible for government-financed testing and care, total costs will increase to $92.0 billion under current practice and $95.1 billion under expanded screening, for an incremental cost of $3.0 billion.