Abstract and Introduction
Background: The economic consequences of a missed opportunity for HIV testing at an earlier stage of infection within a healthcare setting are poorly described.
Methods: For all newly diagnosed HIV patients followed at the Southern Alberta HIV/AIDS Clinic (SAC), Calgary, Canada, between 1 April 2011 and 1 April 2016, all clinical encounters occurring < 3 years prior to diagnosis within the region were obtained. The direct costs of HIV care after diagnosis to 31 March 2019 were determined from a payers’ perspective and reported as mean cost per patient per month (PPPM) in 2019 Canadian dollars (CDN$). Patients with no encounters for 3 years prior to diagnosis were compared with patients with encounters, with special attention to patients with HIV clinical indicator conditions (HCICs).
Results: Of 388 patients, 60% had one or more prior encounter without HIV testing; 14% had been treated for an HCIC. Females, older patients and heterosexuals were more likely to have prior encounters. At diagnosis, patients with previous encounters presented with lower CD4 counts and higher rates of AIDS. The mean PPPM costs for patients with any prior encounter or for an HCIC-based encounter were 16% and 33% higher, respectively, than for patients with no prior encounters. While mean PPPM costs for antiretroviral drugs and outpatient visits were slightly higher, in-patient costs were 10 times higher for people with HIV who had a previous HCIC encounter vs. those with no encounters (CDN$316 vs. $31, respectively).
Conclusions: Any healthcare visit, especially for an HCIC, represents relatively easy opportunities for HIV testing. Not testing can result in poorer health and higher costs. Targeted clinical testing and novel interventions to correct overlooked testing opportunities within healthcare settings may be an easy way to implement cost savings.
As part of the UNAIDS 90-90-90 initiative to eliminate HIV transmission, substantial effort has focused on addressing the first ’90’ and increasing HIV testing for ‘at risk’, ‘hard to reach’, and ‘vulnerable’ populations.[1–5] While enhanced community-based HIV testing attracts much attention,[6,7] an often overlooked opportunity for expanded HIV testing and diagnosis exists within the healthcare system itself.[8–10] Multiple guidelines promote routine and widespread HIV testing at clinical encounters, yet studies have shown that a majority of patients reported one or more healthcare visit in the years immediately prior to their diagnosis without being offered or tested for HIV infection.[11–18] Such ‘missed’ or ‘overlooked’ opportunities for testing within healthcare may contribute to a significant number of new diagnoses presenting ‘late’ (i.e. CD4 < 350 cells/μL) during the course of their HIV infection.[19–21]
Any clinical encounter potentially represents a relatively easy opportunity for HIV testing in that patients attending these encounters are neither ‘hard to reach’ nor are they declining to engage in healthcare; in fact they are already within a clinical setting where HIV testing should be offered. Lack of testing within healthcare, especially when risk or presence of an HIV clinical indicator condition (HCIC) is present, represents a significant oversight in providing quality healthcare. HIV clinical indicator conditions are those that are more common in undiagnosed people with HIV (PWH) than in the general population and may be indicative of underlying yet undiagnosed HIV infection. Despite decades-old recommendations for routine or targeted testing at clinical encounters, challenges in implementation remain. While patients are often offered testing when presenting for care with conditions related to sexual behaviours (e.g. men having sex with men) or being in an ‘at risk’ population (e.g. people who inject drugs), those presenting with other healthcare concerns may be overlooked for testing if they are not seen to be within an obvious at-risk population (e.g. older women or men). Despite guidelines and traditional educational programmes aimed at achieving the rates of HIV diagnoses needed to meet the UNAIDS 90-90-90 objectives, many populations are struggling to reach 90% of people with HIV who know their status (i.e. are diagnosed). A missed opportunity for testing at a clinical encounter may lead to presentation with lower CD4 counts, worse health outcomes, and higher direct costs of care.[24–27] Enhanced targeted in-care-based HIV testing at clinical encounters has the potential to diagnose individuals at higher CD4 counts and thereby to manage healthcare costs better.
We characterized and quantified healthcare encounters in the 3 years prior to HIV diagnosis for newly diagnosed PWH in southern Alberta, Canada. We examined the impact of missed opportunities for HIV testing on clinical health and on the cost to the healthcare system. By comparing patients with no prior clinical encounters with those with one or more encounters, we examined the effect that not testing for HIV (i.e. ‘missed opportunity’) has on clinical health and on the financial impact to the healthcare system.