HIV testing at GP surgeries in high-prevalence areas is cost-effective and will save lives, according to a study involving over 86,000 people from 40 GP surgeries, led by Queen Mary University of London (QMUL) and the London School of Hygiene & Tropical Medicine.
The researchers are calling on health care commissioners to invest urgently in the roll out of HIV screening to all 74 high HIV prevalence local authorities in England (those with more than 2 diagnosed HIV infections per 1,000 adults).
People with HIV have a near normal life expectancy if they are diagnosed early and have treatment, and those taking effective treatment are no longer infectious to other people. But in the UK around 13,500 people do not know that they have HIV, meaning they miss out on treatment, remain infectious to others and become more expensive to treat in the future.
Dr Werner Leber from QMUL said: “We’ve shown that HIV screening in UK primary care is cost effective and potentially cost saving, which is contrary to widespread belief. This is an important finding given today’s austerity. Financial pressures, particularly within local authority’s public health budgets, mean that the costs of HIV testing are under intense scrutiny, and in some areas investment in testing has fallen.”
The study, published in The Lancet HIV
, examined data from an earlier research trial in Hackney - an inner London borough with an HIV prevalence rate of 8 per 1000 adults. The trial involved 40 general practices, where they tested the effect of rapid fingerprick HIV testing as part of the standard health check during registration, and found it led to a four-fold higher HIV diagnosis rate.
Using a mathematical model that includes all the costs associated with HIV testing and treatment, the team now show that primary care HIV screening in high prevalence settings becomes cost-effective in 33 years (according to National Institute for Health and Care Excellence [NICE] criteria).
Factoring in the higher costs of care for people whose HIV is diagnosed late, they were able to predict that HIV screening could become cost-effective far sooner than this, and may even become cost-saving if the long-term healthcare costs of late-diagnosed patients are much higher than those of patients diagnosed earlier, as has been observed in Canada.
The estimated annual cost of rolling out the screening programme to all 11 Hackney-level HIV prevalence authorities would be approximately £600,000 (£4 million for roll-out to all 74 high prevalence authorities). This does not include increased healthcare costs resulting from earlier HIV diagnosis and treatment which would fall under other NHS budgets.
Dr Rebecca Baggaley, lead author of the study and Honorary Lecturer at the London School of Hygiene & Tropical Medicine, said: “Currently NICE uses a threshold of £20,000 to £30,000 per Quality Adjusted Life Year (QALY) gained to gauge whether the health benefits of an intervention offer value for money to the NHS and its patients. ‘QALY’ is a widely used measure of health that combines length and quality of life. We found that over 40 years, primary care-based HIV screening in high prevalence areas would cost an estimated £26,626 per QALY gained and therefore warrants funding in the UK.”
The findings were welcomed by the Terrence Higgins Trust. Dr Michael Brady, Medical Director, said: "One in seven people living with HIV do not know that they have it. Undiagnosed HIV infection puts individuals at risk of preventable illness and death, disproportionally contributes to onward transmission and is an unnecessary burden of cost to the NHS.
“Effective HIV therapy means people can now expect to live a normal lifespan and won't pass the virus on to anyone else. But testing and early treatment is essential to be able to benefit from this. We urgently need new approaches to HIV testing that are delivered at scale and targeted at those at risk. Testing in General Practice is a key component of this because, whilst people living with undiagnosed HIV are not accessing existing HIV testing services, they do visit their GP and there are many missed opportunities to test.
"The UK’s national HIV testing guidance has been recommending HIV testing in General Practices in high prevalence areas since 2008. HIV testing guidelines from NICE recommend the same. This important research demonstrates this approach is cost effective, and may even be cost-saving. I hope that policy makers, commissioners and healthcare providers act on these findings and invest in HIV testing in primary care. We have the tools to end HIV transmission in the UK but we won’t achieve that without scaling up testing in General Practice and other community settings."
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