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Evaluation of nucleic acid amplification testing (NAAT) in the early identification of HIV in high-risk persons in Fulton County, Georgia

Gupta, Neil (2014)
Master's Thesis (44 pages)
Committee Chair / Thesis Adviser: Sullivan, Patrick S
Committee Members: McKenna, Matthew (Fulton County Department of Health and Wellness);
Research Fields: Health Sciences, Public Health
Partnering Agencies: Georgia state or local health department ; CDC
Keywords: HIV; nucleic acid amplification testing; acute HIV infection; program evaluation
Program: Rollins School of Public Health, Epidemiology (Epidemiology)
Permanent url: http://pid.emory.edu/ark:/25593/g0v6w

Abstract

Background: Acute HIV infection (AHI) is characterized by rapid viral replication and lack of detectable antibodies in the early stages of infection. Because standard testing relies on antibody detection, failure to detect AHI when individuals are highly contagious is a missed opportunity for prevention. In 2012, the Fulton County Department of Health & Wellness (FCDHW) received funds to implement nucleic acid amplification testing (NAAT) to detect AHI among persons from high-morbidity zip codes in Metropolitan Atlanta. This report evaluates the outcomes and cost-effectiveness of the program after 12 months of implementation.

Methods: AHI was defined as a positive NAAT test in a patient with a negative HIV antibody test between August 2012 and January 2014. Process measures for testing, laboratory, and outreach were reviewed. A cost analysis was performed from the FCDHW program perspective to evaluate the incremental costs of conducting NAAT after rapid antibody testing. Using estimates from previous models, an AHI positivity rate ≥0.1% and program cost ≤$24,876 per new HIV infection were set as thresholds for cost-effectiveness.

Results: Eighty-six new HIV infections were detected by antibody testing alone. Among 4,686 NAAT tests conducted, 3 cases of AHI were identified (AHI positivity rate 0.06% [95% CI: 0.01 - 0.19]). The median turnaround time for NAAT results was 22 (15-35) days. No case successfully initiated antiretroviral therapy. The rate of AHI in men who have sex with men (MSM) was 0.69% [95% CI: 0.08-2.49], which was significantly higher than the overall AHI positivity rate (p=0.015). The estimated program cost per additional HIV infection identified by NAAT was $70,600.

Conclusions: The use of NAAT among individuals from high-morbidity zip codes improved HIV case identification by 3.5%; however, strong evidence for cost-effectiveness is lacking. Based on these data, future efforts should consider targeting NAAT to those with behaviors at highest risk for exposure to HIV (e.g., MSM), rather than targeting specific geographic areas. In addition, decreasing turnaround time for laboratory results and improving outreach to individuals with AHI will be critical in order to realize the full potential benefits of implementing NAAT in this setting.

Table of Contents

-- Background/ Literature Review -- -- 1 -- -- Methods -- -- 6 -- -- Results -- -- 12 -- -- Discussion -- -- 16 -- -- Summary -- -- 21 -- -- References -- -- 22 -- -- Tables -- -- 1: Nucleic acid amplification testing (NAAT) eligibility criteria -- -- 27 -- -- 2: Select variables used in the evaluation of a NAAT testing program -- -- 28 -- -- 3: NAAT test characteristics and results -- -- 29 -- -- 4: Demographics and risk factors of persons receiving NAAT -- -- 30 -- -- 5: Prevalence of acute HIV infection, by risk factor -- -- 31 -- -- 6: Demographics and risk factors of persons with acute HIV infection -- -- 32 -- -- Appendices -- -- A: Logic model -- -- 33 -- -- B: Cost analysis -- -- 34 -- -- C: HIV testing form -- -- 38 --

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