Linkage to Care From EDs Is Critical in Controlling HIV

Among the highlights gleaned today from CROI in a session on “Economic Implications of ART”

Linkage to care from US emergency rooms to clinics is critical to controlling the HIV epidemic.

Dr Thomas C. Quinn, from the National Institute of Allergy and Infectious Diseases, and Dr Lucia V. Torian, from the New York City Department of Health and Mental Hygiene, presented the long-term Johns Hopkins Hospital (JHH) and New York City emergency room experiences, respectively, with linkage to care and retention in care.^1,2

• At JHH, in 2013, among those tested and found positive for HIV, only 7% were unaware of their diagnosis. In 1987, this figure was 80%.
• At JHH, in 2013, 88% of those found to be HIV infected were successfully linked to care within 90 days. In 2005, that figure was 45%. In NYC, that number in 2013 was around 76%, which increased from 69% in 2006.

• Retention in care is at least as important as linkage to care, according to the CDC.³ Among the 17 US States and Washington, DC, reporting CD4+ cell count and HIV RNA data, overall linkage to care was around 83%. However, retention in care was estimated to be in the range of 52% to 67%, depending on the surrogate marker used.

• In the US, lifetime medical costs of caring for a person infected with HIV at the age of 35 is estimated to be $326,500-or about $10,000 to $11,000 per year, assuming discounted drug costs.⁴ Of the total cost, approximately $200,000 (60%) is for antiretroviral therapy. Another $50,000 (15%) is for other medications, and the remainder (25%) is for other costs of clinical care. Looked at another way, the cost avoided in the US for each case of HIV prevented is $229,000.

• For comparison, the cost per year of life saved in South Africa among those infected with HIV and started on ART with CD4+ cell counts above 200/µL due to ART implementation is US$2000.⁵ Average life expectancy added is likely to be around 20 years.

• In a clinic in Guinea that specialized in the treatment of HIV/AIDS and TB, and subsequently, Ebola, there was only an 11% drop in return visits for HIV-infected persons during the height of the Ebola epidemic.⁶

Much work remains to be done, but the cost-effectiveness ratio for the effort is extremely favorable. And, as one questioner put it, “if a clinic in rural Guinea, in the middle of an Ebola outbreak, only experienced an 11% drop in clinic visits among the HIV-infected, all of us in the United States should be able to do a much better job of retaining our patients in care.”

References:

1. Kelen G, Patel EU, Hsieh Y-H, et al. Impact of Emergency Department HIV Testing and Linkage to Care: 25 Years’ Experience. Abstract 98; 2015 CROI; Seattle; 23 – 26 February 2015.
2. Wiewel EW, Torian LV, Xia Q, Braunstein SL. Linkage to Care and Viral Suppression Among New HIV Diagnoses, New York City, 2006-13. Abstract 99; 2015 CROI; Seattle; 23 – 26 February 2015.
3. Ike N, Hernandez AL, An Q, et al. Care and Viral Suppression Among Women, 18 US Jurisdictions. Abstract 100; 2015 CROI; Seattle; 23 – 26 February 2015.
4. Schackman BR, Fleishman J, Su A, et al. The Lifetime Medical Cost Savings From Preventing HIV in the United States. Abstract 1104; 2015 CROI; Seattle; 23 – 26 February 2015.
5. Bor J, Moscoe E, Chimbindi N. The Cost-Effectiveness of Early ART Initiation in South Africa: A Quasi- Experiment. Abstract 1110; 2015 CROI; Seattle; 23 – 26 February 2015.
6. Leuenberger D, H̩b̩lamou J, Strahm S, et al. Impact of the Ebola Epidemic on HIV Care in Macenta, Forest Guinea, 2014. Abstract 103LB; 2015 CROI; Seattle; 23 Р26 February 2015.