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HIV Screening of Pregnant Women and Newborns APPENDIX C COST ESTIMATES: EARLY INTERVENTION FOR HIV INFECTION The following tables offer crude estimates of HIV screening program costs. Part 1 provides estimates of the costs per intervention, which include counseling, testing, and partner notification (Table C-1) and subsequent medical surveillance, prophylaxis, and treatment (Table C-2). Part 2 (Tables C-3 and C-4) includes cost estimates for a program. Table C-3 provides estimates of the counseling, testing, and partner notification costs per 1,000 HIV-positive individuals identified and, using the state of New Jersey as an example, estimates of total counseling and testing costs if all HIV-infected individuals in the state were identified. Table C-4 presents rough estimates of the costs of medical surveillance, prophylaxis, and treatment per 1,000 HIV-positive individuals identified across four different treatment categories (based on CD4+ cell counts). Also using New Jersey as an example, it provides estimates of the costs of early medical intervention for all HIV-infected individuals in the state. These tables are by no means comprehensive, nor do they provide definitive cost estimates. State policymakers may find the cost estimates per 1,000 HIV-positive individuals (see Tables C-3a and C-4a) helpful in calculating the potential costs of a screening program for their state. They can estimate the number of HIV-infected childbearing women in their state and apply the cost figures per 1,000 HIV-positive individuals to arrive at an approximation of prenatal screening program costs.
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HIV Screening of Pregnant Women and Newborns Part 1: Cost Estimates Per Intervention Counseling and Testing Cost estimates for counseling and testing are provided by the Centers for Disease Control (March 1990). Estimates for the costs associated with HIV testing and counseling were prepared by the Division of Sexually Transmitted Diseases, based on a survey of approximately 15 states providing these services. The estimates include personnel fringe benefits and current overhead rates. Laboratory cost estimates were prepared by the Public Health Practice Program Office, based on a routinely conducted CDC survey of state health department laboratories and selected private laboratories. Table C-1 Cost Estimates Per Intervention: Counseling and Testing Item HIV (-) HIV (+) Assumptions LABORATORY Kit (ELISA) S1.75 (1x) $ 5.25 (3x) Lab time 0.43 1.28 $21,428 average lab tech annual salary; 50,400 tests/year Personnel fringe benefits 0.11 0.33 25.5% Overhead 1.15 3.43 50% of labor and kits Subtotal 3.44 10.29 Kit (Western Blot) 20.00 Lab time 2.48 8,640 tests/year Personnel fringe benefits 0.63 Overhead 11.56 Subtotal 34.67 COUNSELING Pretest: 15 minutes counseling plus 15 minutes preparation and processing Counselor $ 6.78 $ 6.78 $26,029 (average annual salary) Supervisor 1.36 1.36 $31,229 (average annual salary) Clerical 0.78 0.78 $17,986 (average annual salary) Personnel fringe benefits 2.27 2.27 25.5% Overhead 4.48 4.48 40% of personnel Subtotal 15.67 15.67
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HIV Screening of Pregnant Women and Newborns Item HIV (-) HIV (+) Assumptions Posttest: HIV (-): 30 minutes counseling plus 15 minutes processing HIV (+): 90 minutes counseling plus 15 minutes processing Time 15.67 (30 min.) 47.01 (90 min.) 7.84 (15 min.) 7.84 (15 min.) Total 42.62 115.48 PARTNER NOTIFICATION Time 1 Partner Notified $ 24.41 2 hrs., $23,430 (average annual salary for disease intervention specialist) Personnel fringe benefits 6.22 Overhead 12.25 40% of personnel Subtotal 42.88 Total 158.36 Medical Surveillance, Prophylaxis, and Treatment Cost estimates are given for four treatment categories of asymptomatic HIV infection: 1 CD4+ cells > 500 Medical monitoring 2 CD4+ cells 200-500 Treatment with zidovudine 3 CD4+ cells < 200 Treatment with zidovudine, prophylaxis with trimethoprim-sulfamethoxazole 4 CD4+ cells < 200 Treatment with zidovudine, prophylaxis with aerosolized pentamidine Three sources of cost estimates were used: P. S. Arno, D. Shenson, N. F. Siegel, P. Franks, and P. R. Lee, "Economic and Policy Implications of Early Intervention in HIV Disease," Journal of the American Medical Association 262(1989):1493-1498. The authors distinguish two treatment categories for purposes of cost estimation: 1 (CD4+ cells > 500), and 2-4 (CD4+ cells < 500).
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HIV Screening of Pregnant Women and Newborns The cost estimates reproduced in Table C-2 are mid-range figures from this paper. New Jersey Department of Health (NJ DOH): (a) Department of Health document prepared for the Office of Management and Budget, Department of the Treasury, State of New Jersey: Plan for Early Intervention Services for HIV-Infected Persons, June 1989; (b) Department of Health letter to Donald S. Goldman, member of the National Commission on AIDS, reporting on initial implementation and preliminary costs of the state early intervention plan, prepared by Christine Grant, J.D., M.B.A., Deputy Commissioner of Health, January 18, 1990. The New Jersey Department of Health specifies services and provides cost estimates for each of the four treatment categories, which are summarized in Table C-2. The source for the department's estimates is Jersey City Medical Center reported costs for the first three months (October-December 1989) of the New Jersey early intervention (TAP) program. AIDS Service, The Johns Hopkins School of Medicine and The Johns Hopkins Hospital (Baltimore, Md.); information provided by Mark D. Smith, M.D., Associate Director, AIDS Service, August 1990. The Johns Hopkins cost estimates are for services provided in accordance with National Institute of Allergy and Infectious Diseases treatment recommendations, which are summarized in Table C-2. The source of the AIDS Service cost estimates is per-item charges applied to the treatment protocol. The amount of actual reimbursement received by health services providers depends on the payer; Medicaid, Blue Cross, and commercial insurers each pay varying proportions of these charges. Note: All estimates include the cost of pharmaceuticals when indicated for that treatment category, pharmaceuticals represent the predominant cost factor in treatment categories 2, 3, and 4.
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HIV Screening of Pregnant Women and Newborns TABLE C-2 Cost Estimates Per Intervention: Medical Surveillance, Prophylaxis, and Treatment Source for Cost Estimate Annual Servicesa Annual Coat Treatment Category 1: CD4+ Cells > 500 (1) Arno et al. 4 physician visits, 4 CD4 panels, 4 counseling visits $ 854 (2) NJ DOH Physician visits: initial, 1-2 wk. follow-up, then every 4 mos.; x-ray and lab includes VDRL, PPD, CBC with differential, platelets, CD4, HBsAg/Ab, gonococcal culture, Pap smear, chlamydia; case mgmt., nutrition, assess., educ./counseling each visit (visits every 4-8 wks. if CD4 count drops) 1,676 (3) Johns Hopkins Physician visits: initial, 1-2 wk. follow-up, then every 3-6 mos. with CD4; initial lab includes CBC with differential, CD4, HBsAg/Ab, RPR, PPD, influenza, pneumococcal, hepatitis B virus vaccine 775 Treatment Category 2: CD4+ Cells 200 - 500, with Zidovudine (1) Arno et al. 6-12 physician visits; 6-12 counseling visits; 6-12 CD4 panels 9,637b (2) NJ DOH As for Category 1, plus: physician visits every 2 wks. for 3 mos., then every 1-2 mos.; zidovudine; lab includes CBC with differential, hematocrit, CD4, platelets every visit 6,146 (3) Johns Hopkins As for Category 1, plus: physician visits every month for 3 mos., then every 3 mos. with CBC with differential, CD4; zidovudine 3,620
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HIV Screening of Pregnant Women and Newborns Source for Cost Estimate Annual Servicesa Annual Cost Treatment Category 3: CD4+ Cells < 200, with Zidovudine + trimethoprim-sulfamethoxazole (TMP-SMX) (1) Arno et al. 6-12 physician visits; 6-12 counseling visits; 6-12 CD4 panels 9,637b (2) NJ DOH As for Category 2, plus: physician visits every 2 wks. for 2 mos., then every 1-2 mos.; TMP-SMX; lab includes creatinine 6,097 (3) Johns Hopkins As for Category 2, plus: physician visits every 2-3 mos. with CBC, SMA-12; TMP-SMX 3,736 Treatment Category 4: CD4+ Cells < 200, with zidovudine + aerosolized pentamidine (1) Arno et al. 6-12 physician visits; 6-12 counseling visits; 6-12 CD4 panels 9,637b (2) NJ DOH As for Category 2, plus: physician visits every 3 mos.; pentamidine every month; CD4 tests every 6 mos. 7,304 (3) Johns Hopkins As for Category 2, plus: physician visits every 2-3 mos. with CBC, SMA-12; pentamidine every month 6,532 a VDRL, a serologic test for syphilis; PPD, purified protein derivative, a skin test for tuberculosis; CBC, complete blood count; HBsAg, hepatitis B surface antigen; HBAb, hepatitis B antibody; RPR, a serologic test for syphilis; SMA-12, 12 blood chemistry tests. b This figure also includes costs of zidovudine therapy and primary PCP prophylaxis with aerosolized pentamidine or trimethoprim-sulfamethoxazole.
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HIV Screening of Pregnant Women and Newborns Part 2: Program Cost Estimates TABLE C-3a Program Cost Estimates per 1,000 Infected Persons Detected: Counseling and Testing (using CDC cost estimates) Cost per 1,000 HIV (+) Persons Detected Counseling and testing for HIV (+) individuals (1,000 x $115) $115,000 Partner notification for 1 contact per HIV (+) index case (1,000 x $43) 43,000 Counseling and testing for HIV (-) individualsa (7,333 x $43) 315,319 Total 473,319 TABLE C-3b Program Cost Estimates for One State: Counseling and Testing (using CDC cost estimate) Cost in One State: New Jerseyb Counseling and testing for all HIV (+) individuals (70,000 x $115) $ 8,050,000 Partner notification for 1 contact per HIV (+) index case (70,000 x $43) 3,010,000 Counseling and testing for HIV (-) individualsa (513,300 x $43) 22,071,900 Total 33,031,900 a The ratio of HIV (-) individuals tested to HIV (+) individuals varies greatly by background infection rates, intensity of outreach and testing efforts, and other factors. As a greater proportion of HIV (+) individuals in one area are identified, the number of HIV (-) tests required to find each HIV (+) individual will increase. In New Jersey in 1988-1989, that ratio in publicly funded testing programs was 100:12. Using this ratio, a total of 8,333 individuals would have to be tested to identify 1,000 HIV (+) individuals, yielding 7,333 HIV (-) individuals. b population of the state = 7.8 million; estimated number of HIV-infected individuals = 70,000.
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HIV Screening of Pregnant Women and Newborns TABLE C-4a Program Cost Estimates: Annual Costs per 1,000 HIV (+) Patients by Treatment Category (using New Jersey Department of Health and Johns Hopkins cost estimates) for Medical Surveillance, Prophylaxis, and Treatment New Jersey Dept. of Health Johns Hopkins Treatment Categorya Number of Patients/1,000 Patientsb Annual Cost/patient Total Annual Cost/Patient Total 1 500 $1,6% $ 838,000 $ 775 $ 387,500 2 300 6,146 1,843,800 3,620 1,086,000 3 150 6,097 914,550 3,736 560,400 4 50 7,304 365,200 6,532 326,600 Total (1,000) 3,961,550 2,360,500 a Treatment categories: 1, CD4+ cells >500-medical monitoring; 2, CD4+ cells 200-500-treatment with zidovudine; 3, CD4+ cells < 200-treatment with zidovudine, prophylaxis with trimethoprim-sulfamethoxazole; 4, CD4+ cells < 200-treatment with zidovudine, prophylaxis with aerosolized pentamidine. b Distribution of HIV (+) individuals among treatment categories. This proportion is derived from the New Jersey data but is consistent with the Johns Hopkins AIDS Service experience for all adult patients. HIV (+) women may be disproportionately represented in the earlier treatment categories. TABLE C-4b Program Cost Estimates: Annual Costs for All HIV (+) Individuals in New Jersey (using New Jersey Department of Health and Johns Hopkins cost estimates) for Medical Surveillance, Prophylaxis, and Treatment New Jersey Dept. of Health Johns Hopkins Treatment Category Total Patients Annual Cost/Patient Total (in millions) Annual Cost/Patient Total (in millions) 1 35,000 $1,676 $ 58,660 $ 775 $ 27,125 2 21,000 6,146 129,066 3,620 76,020 3 10,500 6,097 64,019 3,736 39,228 4 3,500 7,304 25,564 6,532 22,862 Total 70,000 277,309 165,235
Representative terms from entire chapter: