Harrell W. Chesson

Background: Updated estimates of the productivity losses per HIV infection due to premature HIV mortality are needed to help quantify the economic burden of HIV and inform cost-effectiveness analyses. Methods: We used the human capital approach to estimate the productivity loss due to HIV mortality per HIV infection in the United States, discounted to the time of HIV infection. We incorporated published data on age-specific annual productivity, life expectancy at HIV diagnosis, life-years lost from premature death among persons with HIV (PWH), the number of years from HIV infection to diagnosis, and the percentage of deaths in PWH attributable to HIV. For the base case, we used 2018 life expectancy data for all PWH in the United States. We also examined scenarios using life expectancy in 2010 and life expectancy for cohorts on antiretroviral therapy (ART). We conducted sensitivity analyses to understand the impact of key input parameters. Results: We estimated the base-case overall average productivity loss due to HIV mortality per HIV infection at $65,300 in 2022 US dollars. The base-case results showed a 45% decrease in the estimated productivity loss compared with the results when applying life expectancy data from 2010. Productivity loss was 83% lower for cohorts of PWH on ART compared with the base-case scenario. Results were sensitive to assumptions about percentage of deaths attributable to HIV and heterogeneity in age at death. Conclusion: This study provides valuable insights into the economic impact of HIV mortality, illustrating reductions in productivity losses over time due to advancements in treatments. Highlights: Updated estimates of productivity losses per HIV infection due to premature HIV mortality can help assess the total economic burden of HIV in the United States. This study estimates productivity losses per HIV infection for overall, by sex, and by varying ages of HIV infection. Advancement in treatment has contributed to a significant reduction in productivity losses due to premature HIV mortality in the United States over the past decade.

Background: Updated estimates of the productivity losses per HIV infection due to premature HIV mortality are needed to help quantify the economic burden of HIV and inform cost-effectiveness analyses. Methods: We used the human capital approach to estimate the productivity loss due to HIV mortality per HIV infection in the United States. We incorporated published data on age-specific annual productivity, life expectancy at HIV diagnosis, life years lost from premature death among persons with HIV (PWH), the number of years from HIV infection to diagnosis, and the percentage of deaths in PWH attributable to HIV. For the base case, we used 2018 life expectancy data for all PWH in the United States. We also examined scenarios using life expectancy in 2010 and life expectancy for cohorts on antiretroviral therapy (ART). We conducted sensitivity analyses to understand the impact of key input parameters. Results: We estimated the base case overall average productivity loss due to HIV mortality per HIV infection at $65,300 in 2022 US dollars. The base case results showed a 45% decrease in the estimated productivity loss compared to the results when applying life expectancy data from 2010. Productivity loss was 83% lower for cohorts of PWH on ART compared to the base case scenario. Results were sensitive to assumptions about percentage of deaths attributable to HIV and heterogeneity in age at death. Conclusion: This study provides valuable insights into the economic impact of HIV mortality, illustrating reductions in productivity losses over time due to advancements in treatments. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Funding: This work was done as regular official duties of the authors as employees of the Centers for Disease Control and Prevention. Conflicts of Interest: All authors report no conflicts of interest. Previous Presentation: Presented in part as a poster presentation at the ISPOR 2024 Conference, May 5-8, 2024, Atlanta, GA. Highlights: Updated estimates of productivity losses per HIV infection due to premature HIV mortality can help assess the total economic burden of HIV in the United States. This study estimates productivity losses per HIV infection for overall, by sex, and by varying ages of HIV infection. Advancement in treatment has contributed to significant reduction in productivity losses due to premature HIV mortality in the United States over the past decade.

Background: Limited estimates exist on the population-level impact of partner notification (PN) for gonorrhea, with uncertainty in the influence of local epidemiology on PN effectiveness. An ecologic study in New York found a 6% reduction in diagnoses with a 10% increase in PN coverage. We estimated gonorrhea incidence reductions via PN across different epidemiologic conditions to compare the effects with the prior finding and to understand key determinants of variation. Methods: We developed a stochastic network model of men who have sex with men and calibrated gonorrhea transmission dynamics to varied epidemiologic conditions. The population-level impact of increasing PN was summarized by incidence rate ratios (IRRs), and the relative importance of explanatory variables (including network density, baseline burden, and natural history parameters) was assessed via linear regression modeling of IRR and bootstrapping to evaluate uncertainty in estimation. Results: We estimated an IRR of 0.97 (95% range, 0.93–0.99) for a 10% relative increase in PN coverage, comparable to the IRR of 0.94 (0.91–0.97) identified in the empirical study. PN retained effectiveness under diverse epidemiologic conditions. In a univariate sensitivity analysis, the strongest influence on IRR came from parameters governing index case testing probability, with an IRR of 0.93 when testing was at its highest. Other factors, such as network density, baseline incidence, and various natural history parameters, had relatively minor effects on the IRR. We observed larger individual-level benefits from PN for individuals with higher numbers of partners. Conclusions: Our findings support prior population-level estimates of the impact of PN on gonorrhea incidence.

Background: This article describes an updated spreadsheet tool that sexually transmitted infection (STI) prevention programs in the United States can use to estimate the health and economic benefits of their STI and HIV prevention activities. Methods: The development of the updated tool, Sexually Transmitted Infection Costs (STIC) Figure 2.0, involved 2 main components. First, we revised the tool to be more useful and user-friendly based on feedback from focus groups and usability testing. Second, we updated the mathematical model behind the calculations by (1) revising the model to reflect current STI and HIV prevention activities in the United States, (2) updating the epidemiological and economic parameters in the model using the best available evidence, and (3) including ranges (not just point estimates) in the model output. To demonstrate the use of STIC Figure 2.0, we applied it to estimate the impact of a hypothetical prevention program, consistent with that of a health department or large STI clinic in a metropolitan area. Results: STIC Figure 2.0 incorporated new features, including an interactive user interface to explore findings and create customized charts for use in reports and presentations. The hypothetical example we analyzed illustrated how providing STI treatment to 2680 people and HIV prevention services to 325 people could avert 1253 adverse outcomes and save more than $2 million in medical costs and productivity costs. Conclusions: Although subject to important limitations, STIC Figure 2.0 allows state and local programs, including STI clinics, to calculate evidence-based estimates of the impact of their program activities.

In June 2019, the U.S. Advisory Committee on Immunization Practices recommended shared clinical decision making regarding potential human papillomavirus (HPV) vaccination of men and women aged 27 to 45 years ("mid-adults"). To examine the incremental cost-effectiveness ratios (ICERs) and number needed to vaccinate (NNV) to prevent 1 HPV-related cancer case of expanding HPV vaccination to subgroups of mid-adults at increased risk for HPV-related diseases in the United States. Individual-based transmission dynamic modeling of HPV transmission and associated diseases using HPV-ADVISE (Agent-based Dynamic model for VaccInation and Screening Evaluation). Published data. All U.S. mid-adults and higher-risk subgroups within this population. 100 years. Health care sector. Expanding 9-valent HPV vaccination to mid-adults and higher-risk subgroups. ICERs and NNVs. Expanding 9-valent HPV vaccination to all mid-adults, those with more lifetime partners, and those who have just separated was projected to cost an additional $2 005 000, $763 000, and $1 164 000 per quality-adjusted life-year (QALY) gained, respectively. The NNVs to prevent 1 additional HPV-related cancer case were 7670, 3190, and 5150, respectively, compared with 223 for vaccination of persons aged 9 to 26 years (vs. no vaccination). The mid-adult strategy with the lowest ICER and NNV was vaccinating infrequently screened mid-adult women who have just separated and have a higher number of lifetime sex partners (ICER, $86 000 per QALY gained; NNV, 470). Uncertainty about rate of new sex partners and natural history of HPV among mid-adults. Vaccination of mid-adults against HPV is substantially less cost-effective and produces higher NNVs than vaccination of persons younger than 26 years under all scenarios investigated. However, cost-effectiveness and NNV are projected to improve when higher-risk mid-adult subgroups are vaccinated, such as mid-adults with more sex partners and who have recently separated, and women who are underscreened. Centers for Disease Control and Prevention.

Background: Productivity costs of sexually transmitted infections (STIs) reflect the value of lost time due to STI morbidity and mortality, including time spent traveling to, waiting for, and receiving STI treatment. The purpose of this study was to provide updated estimates of the average lifetime productivity cost for chlamydia, gonorrhea, and syphilis, per incident infection. Methods: We adapted published decision tree models from recent studies of the lifetime medical costs of chlamydia, gonorrhea, and syphilis in the United States. For each possible outcome of infection, we applied productivity costs that we obtained based on published health economic studies. Productivity costs included the value of patient time spent to receive treatment for STIs and for related sequelae such as pelvic inflammatory disease in women. We used a human capital approach and included losses in market (paid) and nonmarket (unpaid) productivity. We conducted 1-way sensitivity analyses and probabilistic sensitivity analyses. Results: The average lifetime productivity cost per infection was $28 for chlamydia in men, $205 for chlamydia in women, $37 for gonorrhea in men, $212 for gonorrhea in women, and $411 for syphilis regardless of sex, in 2023 US dollars. The estimated lifetime productivity cost of these STIs acquired in the United States in 2018 was $795 million. Conclusions: These estimates of the lifetime productivity costs can help in quantifying the overall economic burden of STIs in the United States beyond just the medical cost burden and can inform cost-effectiveness analyses of STI prevention activities.

Context: Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house. Program: We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface. Implementation: The STI Prevention Allocation Consequences Estimator (“SPACE Monkey 2.0”) model will be publicly available as a free downloadable tool. Evaluation: In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype. Discussion: Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.