Rapid initiation of ART soon after HIV diagnosis increases number of people starting ART and is cost-effective
Presenter: Starley Shade, PhD University of California, San Francisco.
Costs and cost-effectiveness of immediate initiation of antiretroviral therapy upon diagnosis of HIV (Rapid Start) in the United States. Presented July 24, 2023.
Immediate initiation of antiretroviral therapy (ART) upon diagnosis of HIV (Rapid Start) is cost-effective during initial and sustained implementation and can increase the proportion of people with HIV who achieve viral suppression.
Rapid Start is an initiative that helps people who are newly diagnosed with HIV and who have not previously received ART begin HIV medication as soon as possible after diagnosis. ART is offered to people with HIV at their first clinic visit through the on-site pharmacy without waiting for HIV-related laboratory results. Rapid Start results in better viral suppression and retention in HIV care, but little is known about its cost or cost-effectiveness. To this end, investigators led by Starley Shade, PhD, University of California, San Francisco, estimated the per-person cost of Rapid Start within 7 established programs throughout the United States and modeled the potential cost-effectiveness of these programs. The project was conducted by Cicatelli Associates, Inc., under the Health Resources and Services Administration HIV/AIDS Bureau, Special Projects of National Significance, Rapid Antiretroviral Dissemination Assistance Provider (DAP).
Costs associated with initiation of ART and follow-up through 8 weeks during the year prior to implementation of Rapid Start, the first year of implementation, and during a year of sustained implementation were estimated, and the potential cost-effectiveness of Rapid Start services was modeled. Standardized cost tools included staffing, level of effort, and recurring goods and services expended toward initiation of ART.
For each of the 7 sites each year, the number of people who initiated ART, the cost per person to support ART initiation, quality-adjusted life-years (QALYs) saved, and the time spent virally suppressed were measured.
Rapid Start was associated with a 7- to 30-day reduction in time to start ART. The time from ART start to viral suppression was 60 days. For each year of viral suppression, 1/3 QALY were saved.
Compared with before implementation, “we saw an increase in the number of people who initiated ART in most settings,” said Dr. Shade. “As a result, we also saw a change [decrease] in the cost per person in most settings.” The increase in ART initiation during sustained implementation exceeded 200 people per year in 1 clinic (Max Clinic in Seattle).
“We see relatively few QALYs saved per year because we’re looking at a relatively small number of additional individuals and relatively short times that people are improving their viral suppression,” she said. “Nonetheless, we saw positive QALYs saved in all but 1 site.”
Rapid Start was cost-effective during sustained implementation in each of the settings. Implementation of Rapid Start was considered cost-effective if it cost less than an additional $76,399 per QALY saved. Based on this definition, immediate initiation of ART was cost-effective in 5 of 7 sites during the initial year of implementation and cost-effective or cost-saving in all sites during the year of sustained implementation.
“Not only did we see times getting shorter between people being diagnosed and the time that they’re initiating care, in addition we saw increasing numbers of people in almost all of our settings, in a time when the number of people being diagnosed was declining over time,” said Dr. Shade.
“Rapid Start programs were cost-effective during sustained implementation,” she said. “Scaling up Rapid Start programs may facilitate an increase in the proportion of people with HIV who initiate ART soon after diagnosis. It will be important to ensure that people who initiate ART immediately after diagnosis of HIV achieve viral suppression and are retained in care.”
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3,000,000.00, with 100% funded by HRSA/HHS and $0 by nongovernment sources.