Economic evaluation of the HIV counseling and testing program at Hampden County Correction Center (HCCC) Beena Varghese, PhD Division of HIV/AIDS Prevention, CDC CDC: TA Peterman, C Mugalla, K Irwin, T Gift HCCC: T Lincoln, T Conklin, A Miller, J Vivian, and HIV VCT staff

Background Limited resources and competing priorities Economic evaluation tools can: –Quantify the costs and benefits of a program, especially prevention programs –Guide resource allocation HIV counseling and testing (CT) program at HCCC is one of the many health care programs for inmates

Background HIV CT program Well established and functional Standard testing (EIA & WB) Most of the eligible inmates (sentenced & who stay > 2 weeks) get tested –Drug use or sexual exposure was main risk

Objective Estimate the cost of CT program to detect a newly identified HIV case Model the cost-effectiveness of CT program compared to no program in preventing HIV

Methods – Data Sources From January 1 – December 31, 2000 Annual cost data (HCCC) –Labor (wages adjusted for % time on CT) –Material (phlebotomy related) –Laboratory (charges for HIV tests) –Other costs (biohazard waste disposal) Test data (Massachusetts Dept. of Public health, MDPH) –Inmate demographics & risk behavior –Test results

Methods – Data Sources Effectiveness data (literature) Decision model (Varghese 2001) –Adjusted for prior knowledge of serostatus (41%) –Reduction in annual risk for HIV due to CT 25% for infected inmates (from 7% to 5.2%) 10% for uninfected inmates (from 0.3% to 0.27%)

Decision Tree: Effectiveness of HIV CT Program

HIV CT Program:Test data (Calendar year 2000) Number of HIV tests: 1192 Number positive: 16 – previously negative or unknown: 14

HIV CT program: Direct Annual Costs * * Fixed costs of facility and overhead costs are not included

Effectiveness of HIV CT program at HCCC Newly identified HIV positive cases: 14 Annual risk of HIV infection: 7% Reduction in risk due to CT: 25% Cases prevented:14 x 7% x 25% = 0.25

Effectiveness of HIV CT program at HCCC Inmates tested negative: 1176 Risk of HIV acquisition: 0.3% (Kamb 1998) Reduction in risk due to CT: 10% Cases prevented: Benefits for only those previously untested (59%) 1176 x 59% x 0.3% x 10% = 0.21 Benefits for all with Project RESPECT style counseling 1176 x 0.3% x 20% = 0.71

Cost-effectiveness of HIV CT program for 1192 inmates at HCCC -Summary

HIV CT program Summary Offered only to ~ 50% of inmates (sentenced and who stay > 2 weeks) Costs $6071 per new HIV infection identified May avert 0.46 cases and would save societal dollars

Limitations CE tools are best suited for comparisons of different programs Fixed and overhead costs not included Secondary cases from uninfected inmates not included

Discussion Despite frequent testing, new positives identified –Increased focus on prevention? –Risk-specific prevention? Client centered counseling of HIV negatives? Rapid testing (Increase testing)? Prevention for positives ?

Conclusions HIV CT program at HCCC Is effective in identifying new HIV cases Saves money for society in averted treatment costs Increased focus on prevention may be beneficial for both HIV positive and negative inmates Potential to increase testing with existing personnel