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Primary care testing for HIV is cost-effective and ‘should be rolled out’, finds study

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Patients should be routinely offered an HIV test when they register with a new GP surgery, if they live in an area where the disease is highly prevalent, according to UK researchers.

They concluded that offering HIV testing to patients as part of health checks when they registered at a new GP surgery in high-prevalence areas was both cost-effective and would save lives.

“We’ve shown that HIV screening in UK primary care is cost effective and potentially cost saving”

Werner Leber

The study, which involved over 86,000 people from 40 GP surgeries, was led by Queen Mary University of London and the London School of Hygiene and Tropical Medicine.

The researchers highlighted that commissioners needed reliable estimates of cost-effectiveness of screening but estimates had not previously been based on robust data from randomised trials.

Their study, published in the journal The Lancet HIV, examined data from an earlier research trial in Hackney – the deprived inner London borough has an HIV prevalence rate of eight per 1,000 adults.

In the trial, practices 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 model that factored in all costs from testing and treatment, the new study showed that routine primary care screening in high prevalence settings reached cost-effectiveness in 33 years.

“Public health, specialist and CCG commissioners should take note of these important results”

Clare Highton

The initial cost of more patients being identified and treated ultimately would be balanced out over time by reduced HIV transmission through earlier diagnosis and better quality of life, they suggested.

In addition, by factoring in the higher costs of care for patients whose HIV was diagnosed late, they predicted that screening could become cost-effective far sooner and may even become cost-saving.

“General practice-based HIV screening leads to increased and probably earlier diagnosis of HIV, which improves the length and quality of life of people who are HIV positive and might reduce onward transmission,” said the study authors.

Eleven local authorities have HIV prevalence similar to Hackney and 74 out of 325 authorities in England are defined by the National Institute for Health and Care Excellence as high prevalence – with more than two diagnosed HIV infections per 1,000 adults.

The estimated annual cost of rolling out the screening programme to all 11 Hackney-level HIV prevalence authorities would be around £600,000 and £4m for roll-out to all 74 high prevalence authorities.

“We urgently need new approaches to HIV testing that are delivered at scale”

Michael Brady

The researchers called on health care commissioners to invest urgently in the roll out of HIV screening to all high HIV prevalence local authorities in England.

They noted that, in the UK, around 13,500 people did not know that they had HIV, meaning they missed out on treatment, remained infectious and became more expensive to treat in the future.

Study author Dr Werner Leber said: “We’ve shown that HIV screening in UK primary care is cost effective and potentially cost saving, which is contrary to widespread belief.

He noted that financial pressures, particularly within council public health budgets, meant that the costs of HIV testing were “under intense scrutiny” and in some areas investment in it had fallen.

London School of Hygiene and Tropical Medicine

Primary care testing for HIV cost-effective and ‘should be rolled out’

Rebecca Baggaley

Lead study author Dr Rebecca Baggaley added: “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,” she said. “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 study was funded by City and Hackney Clinical Commissioning Group and the Department of Health, and involved University College London, Homerton University Hospital NHS Foundation Trust, the University of Warwick, and the University of British Columbia in Canada.

Dr Clare Highton, City and Hackney CCG, said: “Public health, specialist and CCG commissioners should take note of these important results showing the value for money of screening for HIV in primary care.

“This intervention means that people with HIV are able to live longer and healthier lives and the spread of infection to other people is halted,” she said.

Dr Michael Brady, medical director at the charity the Terrence Higgins Trust, said: “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.

Michael Brady

Michael Brady

Michael Brady

“We urgently need new approaches to HIV testing that are delivered at scale and targeted at those at risk,” he said. “Testing in general practice is a key component of this.

“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,” he said.

“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,” he added.

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