Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies

BACKGROUND

Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels.

METHODOLOGY

We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment.

FINDINGS

Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally.

SIGNIFICANCE

With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

"It Makes You Feel Like Someone Cares" acceptability of a financial incentive intervention for HIV viral suppression in the HPTN 065 (TLC-Plus) study

BACKGROUND

HPTN 065 (TLC-Plus) evaluated the feasibility and effectiveness of providing quarterly $70 gift card financial incentives to HIV-infected patients on antiretroviral therapy (ART) to encourage ART adherence and viral suppression, and represents the largest study to-date of a financial incentive intervention for HIV viral suppression. A post-trial qualitative substudy was undertaken to examine acceptability of the financial incentives among those receiving and implementing the intervention.

METHODS

Between July and October 2013, semi-structured interviews were conducted with 72 patients and 12 investigators from 14 sites; three focus groups were conducted with 12 staff from 10 sites. Qualitative data collection elicited experiences with and attitudes about the intervention, including philosophical viewpoints and implementation experiences. Transcripts were analyzed in NVivo 10. Memos and matrices were developed to explore themes from different participant group perspectives.

RESULTS

Patients, investigators, and staff found the intervention highly acceptable, primarily due to the emotional benefits gained through giving or receiving the incentive. Feeling rewarded or cared for was a main value perceived by patients; this was closely tied to the financial benefit for some. Other factors influencing acceptability for all included perceived effectiveness and health-related benefits, philosophical concerns about the use of incentives for health behavior change, and implementation issues. The termination of the incentive at the end of the study was disappointing to participants and unexpected by some, but generally accepted.

CONCLUSION

Positive experiences with the financial incentive intervention and strategies used to facilitate implementation led to high acceptability of the intervention, despite some reluctance in principle to the use of incentives. The findings of this analysis provide encouraging evidence in support of the acceptability of a large-scale financial incentive intervention for HIV viral suppression in a clinical setting, and offer valuable lessons for future applications of similar interventions.

Understanding how domestic health policy is integrated into foreign policy in South Africa: a case for accelerating access to antiretroviral medicines

BACKGROUND

South Africa, as an emerging middle-income country, is becoming increasingly influential in global health diplomacy (GHD). However, little empirical research has been conducted to inform arguments for the integration of domestic health into foreign policy by state and non-state actors. This study seeks to address this knowledge gap. It takes the form of an empirical case study which analyses how South Africa integrates domestic health into its foreign policy, using the lens of access to antiretroviral (ARV) medicines.

OBJECTIVE

To explore state and non-state actors' perceptions regarding how domestic health policy is integrated into foreign policy. The ultimate goal of this study was to achieve better insights into the health and foreign policy processes at the national level.

METHODS

Employing qualitative approaches, we examined changes in the South African and global AIDS policy environment. Purposive sampling was used to select key informants, a sample of state and non-state actors who participated in in-depth interviews. Secondary data were collected through a systematic literature review of documents retrieved from five electronic databases, including review of key policy documents. Qualitative data were analysed for content. This content was coded, and the codes were collated into tentative categories and sub-categories using Atlas.ti v.7 software.

RESULTS

The findings of this work illustrate the interplay among social, political, economic and institutional conditions in determining the success of this integration process. Our study shows that a series of national and external developments, stakeholders, and advocacy efforts and collaboration created these integrative processes. South Africa's domestic HIV/AIDS constituencies, in partnership with the global advocacy movement, catalysed the mobilization of support for universal access to ARV treatment nationally and globally, and the promotion of access to healthcare as a human right.

CONCLUSIONS

Transnational networks may influence government's decision making by providing information and moving issues up the agenda.

What Is the Economic Burden of Subsidized HIV/AIDS Treatment Services on Patients in Nigeria and Is This Burden Catastrophic to Households?

Background

A gap in knowledge exists regarding the economic burden on households of subsidized anti-retroviral treatment (ART) programs in Nigeria. This is because patients also incur non-ART drug costs, which may constrain the delivery and utilisation of subsidized services.

Methods

An exit survey of adults (18+years) attending health facilities for HIV/AIDS treatment was conducted in three states in Nigeria (Adamawa, Akwa Ibom and Anambra). In the states, ART was fully subsidized but there were different payment modalities for other costs of treatment. Data was collected and analysed for direct and indirect costs of treatment of HIV/AIDS and co-morbidities’ during out-and in-patient visits. The levels of catastrophic health expenditure (CHE) were computed and disaggregated by state, socio-economic status (SES) and urban-rural location of the respondents. Catastrophic Health Expenditure (CHE) in this study measures the number of respondents whose monthly ART-related household expenditure (for in-patient and out-patient visits) as a proportion of monthly non-food expenditure was greater than 40% and 10% respectively.

Results

The average out-patient and in-patient direct costs were $5.49 and $122.10 respectively. Transportation cost was the highest non-medical cost and it was higher than most medical costs. The presence of co-morbidities contributed to household costs. All the costs were catastrophic to households at 10% and 40% thresholds in the three states, to varying degrees. The poorest SES quintile had the highest incidence of CHE for out-patient costs (p<0.0001). Rural dwellers incurred more CHE for all categories of costs compared to urban dwellers, but the costs were statistically significant for only outpatient costs.

Conclusion

ART subsidization is not enough to eliminate economic burden of treatment on HIV patients. Service decentralization to reduce travel costs, and subsidy on other components of HIV treatment services should be introduced to eliminate the persisting inequitable and high cost burden of ART services. Full inclusion of ART services within the benefit package of the National Health Insurance Scheme should be considered.

Evaluating the Usefulness of Compulsory Licensing in Developing Countries: A Comparative Study of Thai and Brazilian Experiences Regarding Access to Aids Treatments

While compulsory licensing (CL) is described in the TRIPS agreement as flexibility to protect public health by improving access to medicines in developing countries, a recent literature contends adversely that CL may harm public health. Therefore, this article intends to evaluate the usefulness of CL in the South through the prism of obligations and goals entrusted to patent holders (the effective and non-abusive exploitation of patents in order to achieve industrial and health developments) and in light of experiences in Thailand and Brazil regarding access to antiretroviral drugs. In this way, it shows that the obligations assigned to patent holders were better served by the recipients of CL and brought significant health and industrial benefits in the two high middle-income countries. In particular, CL allowed the scaling-up of free and universal access to antiretroviral drugs by assuring the financial sustainability of these public health programs endangered by monopolistic practices from patent holders.

Scaling Up HIV Treatment in Peru

Many countries with financial support for HIV treatment experience delays in scale-up because of bureaucratic, operational, and technical obstacles. The authors describe the Peruvian National HIV Program's response to such challenges. A team of consultants experienced in the scale-up of the Peruvian national program to treat multidrug-resistant tuberculosis worked with the national HIV program to identify and address key factors contributing to slow enrollment of HIV patients into the antiretroviral treatment program. The rate of enrollment into the antiretroviral treatment program increased from 124 patients/month in the first 9 months of the program to 226 patients/month in the last 7 months, an increase of 83%. This strategy achieved 38.5% coverage of the population in need. Effective programmatic expansion of the Peruvian National HIV Program was facilitated by a multidisciplinary collaboration in a systematized effort to overcome barriers to scale-up.

Cost-effectiveness of initial antiretroviral treatment administered as single vs. multiple tablet regimens with the same or different components

OBJECTIVE

To evaluate the efficiency of single-tablet regimens (STR) and multiple-tablet regimens (MTR) with exactly the same or different components.

METHODS

A study was conducted on HIV-1-infected antiretroviral-naïve patients from 6 Spanish or French centers, who were started on treatment with STR-Atripla^®, or the same components separately (MTR-SC), or a different MTR (MTR-Other). Effectiveness was measured as percentage of HIV-RNA <50copies/mL at 48 weeks (ITT). Efficiency was the ratio between costs (direct cost of antiretrovirals plus outpatient visits, hospital admissions, and resistance tests) and effectiveness.

RESULTS

The study included a total of 2773 patients (759 STR-Atripla^®, 483 MTR-SC, and 1531 MTR-Other). Median age was 37 years, 15% were HCV co-infected, 27% had a CD4+ count <200cells/μL, and 30% had viral load ≥100.000copies/mL. The duration of the assigned treatment was longer for STR-Atripla^® (P<.0001). Response rates (adjusted for CD4+ count, viral load, and clustered on hospitals) at 48 weeks were 76%, 74%, and 62%, respectively (P<.0001). Virological failure was more common in MTR patients (P=.0025), and interruptions due to intolerance with MTR-Other (P<.0001). Cost per responder at 48 weeks (efficiency) was €12,406 with STR-Atripla^®, €11,034 with MTR-SC (0.89 [0.82, 0.99] times lower), and €18,353 (1.48 [1.38, 1.61] times higher) with MTR-Other.

CONCLUSIONS

STR-Atripla^® and MTR-SC regimens showed similar effectiveness, but virological failure rate was lower with STR-Atripla. MTR-SC, considered less convenient, had a marginally better efficiency, mainly due to lower direct costs. MTR-Other regimens had both a worse effectiveness and efficiency. Similar efficiency analyses adjusting for baseline characteristics should be recommended for new STRs.

Aids, Empire, and Public Health Behaviorism

Much of the current health approach to designing HIV/AIDS interventions in resource-poor settings involves behavior-change initiatives, particularly those adopting education-based and “culturally competent” frameworks for the reduction of HIV-associated “risk behaviors.” This article reviews the evidence and social assumptions behind this approach to preventing HIV transmission, and argues that these approaches are often inadequate or misguided, particularly in their conflation of the concept of “culture” with social circumstances. By analyzing the socioeconomic circumstances that constrain individual agency, and by combining data from prevention literature with analyses of international trade agreements and the controversies over antiretroviral drug distribution, the author argues that the movement of capital and the maintenance of inequality are central to the problems associated with behavior-change initiatives and must be addressed through new paradigms in order to respond appropriately to the global AIDS pandemic. Hardt and Negri's paradigm of “Empire”—that is, examining the system through which social inequalities are maintained not only between countries but also within them—offers prospects for the design of new interventions and targets for public health workers and social movements.

Pharmaceutical Equivalence of Distributed Generic Antiretroviral (ARV) in Asian Settings: The Cross-Sectional Surveillance Study - PEDA Study

OBJECTIVES

Ensuring that medicines meet quality standards is mandatory for ensuring safety and efficacy. There have been occasional reports of substandard generic medicines, especially in resource-limiting settings where policies to control quality may be less rigorous. As HIV treatment in Thailand depends mostly on affordable generic antiretrovirals (ARV), we performed quality assurance testing of several generic ARV available from different sources in Thailand and a source from Vietnam.

METHODS

We sampled Tenofovir 300mg, Efavirenz 600mg and Lopinavir/ritonavir 200/50mg from 10 primary hospitals randomly selected from those participating in the National AIDS Program, 2 non-government organization ARV clinics, and 3 private drug stores. Quality of ARV was analyzed by blinded investigators at the Faculty of Pharmaceutical Science, Chulalongkorn University. The analysis included an identification test for drug molecules, a chemical composition assay to quantitate the active ingredients, a uniformity of mass test and a dissolution test to assess in-vitro drug release. Comparisons were made against the standards described in the WHO international pharmacopeia.

RESULTS

A total of 42 batches of ARV from 15 sources were sampled from January-March 2015. Among those generics, 23, 17, 1, and 1 were Thai-made, Indian-made, Vietnamese-made and Chinese-made, respectively. All sampled products, regardless of manufacturers or sources, met the International Pharmacopeia standards for composition assay, mass uniformity and dissolution. Although local regulations restrict ARV supply to hospitals and clinics, samples of ARV could be bought from private drug stores even without formal prescription.

CONCLUSION

Sampled generic ARVs distributed within Thailand and 1 Vietnamese pharmacy showed consistent quality. However some products were illegally supplied without prescription, highlighting the importance of dispensing ARV for treatment or prevention in facilities where continuity along the HIV treatment and care cascade is available.

Analysis of contemporary HIV/AIDS health care costs in Germany: Driving factors and distribution across antiretroviral therapy lines

To analyze contemporary costs of HIV health care and the cost distribution across lines of combination antiretroviral therapy (cART). To identify variations in expenditures with patient characteristics and to identify main cost determinants. To compute cost ratios between patients with varying characteristics.Empirical data on costs are collected in Germany within a 2-year prospective observational noninterventional multicenter study. The database contains information for 1154 HIV-infected patients from 8 medical centers.Means and standard deviations of the total costs are estimated for each cost fraction and across cART lines and regimens. The costs are regressed against various patient characteristics using a generalized linear model. Relative costs are calculated using the resultant coefficients.The average annual total costs (SD) per patient are &OV0556;22,231.03 (8786.13) with a maximum of &OV0556;83,970. cART medication is the major cost fraction (83.8%) with a mean of &OV0556;18,688.62 (5289.48). The major cost-driving factors are cART regimen, CD4-T cell count, cART drug resistance, and concomitant diseases. Viral load, pathology tests, and demographics have no significant impact. Standard non-nucleoside reverse transcriptase inhibitor-based regimens induce 28% lower total costs compared with standard PI/r regimens. Resistance to 3 or more antiretroviral classes induces a significant increase in costs.HIV treatment in Germany continues to be expensive. Majority of costs are attributable to cART. Main cost determinants are CD4-T cells count, comorbidity, genotypic antiviral resistance, and therapy regimen. Combinations of characteristics associated with higher expenditures enhance the increasing effect on the costs and induce high cost cases.

Measurement, "scriptural economies," and social justice: governing HIV/AIDS treatments by numbers in a fragile state, the Central African Republic (CAR)

Fragile states have been raising increasing concern among donors since the mid-2000s. The policies of the Global Fund to fight HIV/AIDS, Malaria, and Tuberculosis (GF) have not excluded fragile states, and this source has provided financing for these countries according to standardized procedures. They represent interesting cases for exploring the meaning and role of measurement in a globalized context. Measurement in the field of HIV/AIDS and its treatment has given rise to a private outsourcing of expertise and auditing, thereby creating a new form of value based on the social process of registration and the creation of realities produced by the intervention itself. These "scriptural economies" must be questioned in terms of the production of knowledge, but also in terms of social justice. Governing HIV/AIDS treatments by numbers in a fragile state is explored in this article through the experience of the Central African Republic (CAR) in terms of epidemiology and access to antiretroviral drugs. The unexpected effects of performance-based programs in this context underline the need for global health governance to be re-embedded into a social justice framework.

[Progress on China' s national free antiretroviral therapy strategy in 2002-2014]

OBJECTIVE

To analyze the progress and characteristics of China' s "Free AIDS treatment strategy" since the implementation of the national "four free and one care" policy against AIDS 12 years ago.

METHODS

Retrospective cohort study and cross-sectional analysis had been conducted in this study. 368 449 cases that had received the ' free antiviral therapy' from 2002 to 2014 were selected from the National Treatment Database. Data from the baseline (initial time of ART, CD(4) cell count, and antiretroviral regimen) and from the follow-up program (dates and status of follow-up, CD(4) cell counts) were gathered and analysed by SAS 9.3.

RESULTS

The number of cases that having received new treatment was increasing year by year, accounting for 75.4% of all the cases identified from 2010 to 2014. Constituent ratios of patients with baseline CD(4) cell count <200 cells/µl and clinical diagnosis of AIDS were decreasing from 81.0% in 2006 to 39.7 % in 2014. Status on drug optimization showed that: 3TC replaced DDI, EFV replaced NVP and TDF replaced D4T, making the utilization rates as 99.5%, 75.7%, and 60.6%, respectively, by 2014. Regions that were covered by the treatment accounted for 75.4% of all the counties/districts involved. The previous CDC-led AIDS treatment program and mode of management had been transferred to the hospital-based model. Proportion on the twice-CD(4)-testing model had been 75.2% since 2010, with the rate of virological detection increased from 70.8% in 2010 to 87.4% in 2014 and the virological unsuccessful testing rate decreased from 17.6% in 2010 to 11.8% in 2014. Among all the patients, the 1, 5 and 10 year survival rates appeared as 92.2%, 80.5% and 69.6%, respectively. For patients with baseline CD(4) cell counts as <50 cells/µl or >350 cells/µl, the corresponding survival rates showed as 81.6% , 69.9% , 60.9% and 97.9%, 89.8% , 81.0%, respectively.

CONCLUSION

China' s HIV/AIDS free antiretroviral therapy program appeared as a national treatment cohort which involved large number of participants, with new patients joining in, annually. Criterion on drug optimization and treatment were consistently following the recommendation and guidelines set by WHO. Management program on treatment had gradually turned to hospital-based, with follow-up and laboratory testing programs guaranteed, ended up with satisfactory treatment effects.

Impact and Cost-Effectiveness of Hypothetical Strategies to Enhance Retention in Care within HIV Treatment Programs in East Africa

OBJECTIVES

Attrition from care among HIV infected patients can lead to poor clinical outcomes. Our objective was to evaluate hypothetical interventions seeking to improve retention-in-care (RIC) for HIV-infected patients in East Africa, asking whether they could offer favorable value compared to earlier ART initiation.

METHODS

We used a micro-simulation model to analyze two RIC focused strategies within an East African HIV treatment program--"risk reduction," defined as intervention(s) that decrease the risk of attrition from care; and "outreach," defined as interventions that find patients and relink them with care. We compared this to earlier ART treatment as a measure of the potential health benefits forgone (e.g., opportunity cost).

RESULTS

Reducing attrition by 40% at an average cost of $10 per person remains a less efficient use of resources compared to ensuring full access to ART (cost- effectiveness ratio $1300 vs $3700) for ART eligible patients. An outreach intervention had limited clinical benefit in our simulation. If intervention costs are <$10 per person, however, an intervention able to achieve a 40% (or greater) reduction in attrition may be a cost-effective next implementation option following implementation of earlier ART treatment.

CONCLUSIONS

Our results suggest that programs should consider retention focused programs once they have already achieved high degrees of ART coverage among eligible patients. It is important that decision makers understand the epidemiology and associated outcomes of those patients who are classified as lost to follow up in their systems prior to implementation in order to achieve the highest value.

Mass HIV Treatment and Sex Disparities in Life Expectancy: Demographic Surveillance in Rural South Africa

BACKGROUND

Women have better patient outcomes in HIV care and treatment than men in sub-Saharan Africa. We assessed--at the population level--whether and to what extent mass HIV treatment is associated with changes in sex disparities in adult life expectancy, a summary metric of survival capturing mortality across the full cascade of HIV care. We also determined sex-specific trends in HIV mortality and the distribution of HIV-related deaths in men and women prior to and at each stage of the clinical cascade.

METHODS AND FINDINGS

Data were collected on all deaths occurring from 2001 to 2011 in a large population-based surveillance cohort (52,964 women and 45,688 men, ages 15 y and older) in rural KwaZulu-Natal, South Africa. Cause of death was ascertained by verbal autopsy (93% response rate). Demographic data were linked at the individual level to clinical records from the public sector HIV treatment and care program that serves the region. Annual rates of HIV-related mortality were assessed for men and women separately, and female-to-male rate ratios were estimated in exponential hazard models. Sex-specific trends in adult life expectancy and HIV-cause-deleted adult life expectancy were calculated. The proportions of HIV deaths that accrued to men and women at different stages in the HIV cascade of care were estimated annually. Following the beginning of HIV treatment scale-up in 2004, HIV mortality declined among both men and women. Female adult life expectancy increased from 51.3 y (95% CI 49.7, 52.8) in 2003 to 64.5 y (95% CI 62.7, 66.4) in 2011, a gain of 13.2 y. Male adult life expectancy increased from 46.9 y (95% CI 45.6, 48.2) in 2003 to 55.9 y (95% CI 54.3, 57.5) in 2011, a gain of 9.0 y. The gap between female and male adult life expectancy doubled, from 4.4 y in 2003 to 8.6 y in 2011, a difference of 4.3 y (95% CI 0.9, 7.6). For women, HIV mortality declined from 1.60 deaths per 100 person-years (95% CI 1.46, 1.75) in 2003 to 0.56 per 100 person-years (95% CI 0.48, 0.65) in 2011. For men, HIV-related mortality declined from 1.71 per 100 person-years (95% CI 1.55, 1.88) to 0.76 per 100 person-years (95% CI 0.67, 0.87) in the same period. The female-to-male rate ratio for HIV mortality declined from 0.93 (95% CI 0.82-1.07) in 2003 to 0.73 (95% CI 0.60-0.89) in 2011, a statistically significant decline (p = 0.046). In 2011, 57% and 41% of HIV-related deaths occurred among men and women, respectively, who had never sought care for HIV in spite of the widespread availability of free HIV treatment. The results presented here come from a poor rural setting in southern Africa with high HIV prevalence and high HIV treatment coverage; broader generalizability is unknown. Additionally, factors other than HIV treatment scale-up may have influenced population mortality trends.

CONCLUSIONS

Mass HIV treatment has been accompanied by faster declines in HIV mortality among women than men and a growing female-male disparity in adult life expectancy at the population level. In 2011, over half of male HIV deaths occurred in men who had never sought clinical HIV care. Interventions to increase HIV testing and linkage to care among men are urgently needed.

An update on integrase inhibitors: new opportunities for a personalized therapy? The NEXTaim Project

Thanks to the development of antiretroviral agents to control HIV replication, HIV infection has turned from a fatal disease into a treatable chronic infection. The present work collects the opinions of several experts on the efficacy and safety of recently approved second generation of integrase inhibitors and, in particular, on the role of this new class of drugs in antiretroviral therapy. The availability of new therapeutic options represents an opportunity to ameliorate the efficacy of cART in controlling HIV replication also within viral reservoirs. The personalization of the treatment driven mainly by the management of comorbidities, HIV-HCV co-infections and aging, will be easier with antiretroviral drugs without drug-drug interactions and with a better toxicity and tolerability profile. Future assessment of economic impact for the introduction of new innovative drugs in the field of antiretroviral therapy will likely need some degree of adjustment of the evaluation criteria of costs and benefit which are currently based almost exclusively on morbidity and mortality.

Enhancing the benefits of antiretroviral therapy in Vietnam: towards ending AIDS

Vietnam has a concentrated HIV epidemic, with the highest HIV prevalence being observed among people who inject drugs (PWID). Based on its experience scaling-up robust HIV interventions, Vietnam aims to further strengthen its response by harnessing the preventive benefits of antiretroviral therapy (ART). Mathematical modelling suggests that prioritizing key populations for earlier access to ART, combined with other prevention interventions, may have significant impact on the epidemic, cost-effectively reducing new HIV infections and deaths. Pilot studies are being conducted to assess feasibility and acceptability of expansion of HIV testing and counselling (HTC) and early ART among key populations and to demonstrate innovative service delivery models to address challenges in uptake of services across the care cascade. Earlier access of key populations to combination prevention interventions, combined with sustained political commitment and supportive environment for key populations, are essential for maximum impact of ART on the HIV epidemic in Vietnam.

[Study on economic burden caused by antiretroviral treatment for people living with HIV/AIDS and influencing factors in Nanjing]

OBJECTIVE

To understand the economic burden caused by antiretroviral treatment for people living with HIV/AIDS and influencing factors in Nanjing.

METHODS

People living with HIV/AIDS were divided into two groups, HIV infected patients and AIDS patients. The data about their direct medical expenditure, direct non-medical expenditure and indirect economic loss in the past year were collected. Univariate and multivariate analysis were conducted to identify the potential influencing factors.

RESULTS

The median of direct medical expenditure and total costs for 133 HIV infected patients were 1,200 yuan RMB and 1,972 yuan RMB respectively. The median of direct medical expenditure and total costs for 145 AIDS patients were 1 060 yuan RMB and 2 826 yuan RMB respectively. The differences in direct medical expenditure and total costs between HIV infected patients and AIDS patients showed no statistical significance. The results from univariate analysis indicated that the sample source influenced total costs significantly. Multivariate analysis showed that onset time and CD level were negatively correlated with direct medical expenditure. The patients infected through heterosexual contact had more direct medical expenditure than those infected through homosexual contact. The patients receiving HIV test in hospitals had more direct medical expenditure than those receiving volunteer counseling and testing.

CONCLUSION

Further efforts should be made to expand HIV testing and treatment coverage in order to detect HIV infections as early as possible. Early antiretroviral treatment should be given to HIV infected patients to maintain their immunity and reduce their medical expenditure.

The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations

The diversion of antiretroviral medications (ARVs) has implications for the integrity and success of HIV care, however little is known about the ARV illicit market. This paper aimed to identify the motivations for buying illicit ARVs and to describe market dynamics. Semi-structured interviews (n = 44) were conducted with substance-involved individuals living with HIV who have a history of purchasing ARVs on the street. Grounded theory was used to code and analyze interviews. Motivations for buying ARVs on the illicit market were: to repurchase ARVs after having diverted them for money or drugs; having limited access or low quality health care; to replace lost or ruined ARVs; and to buy a back-up stock of ARVs. This study identified various structural barriers to HIV treatment and ARV adherence that incentivized ARV diversion. Findings highlight the need to improve patient-provider relationships, ensure continuity of care, and integrate services to engage and retain high-needs populations.

The lifetime medical cost savings from preventing HIV in the United States

OBJECTIVE

Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States.

METHODS

We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD).

RESULTS

The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided.

CONCLUSIONS

The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment.

Cost effectiveness of option B plus for prevention of mother-to-child transmission of HIV in resource-limited countries: evidence from Kumasi, Ghana

BACKGROUND

Achieving the goal of eliminating mother-to-child HIV transmission (MTCT) necessitates increased access to antiretroviral therapy (ART) for HIV-infected pregnant women. Option B provides ART through pregnancy and breastfeeding, whereas Option B+ recommends continuous ART regardless of CD4 count, thus potentially reducing MTCT during future pregnancies. Our objective was to compare maternal and pediatric health outcomes and cost-effectiveness of Option B+ versus Option B in Ghana.

METHODS

A decision-analytic model was developed to simulate HIV progression in mothers and transmission (in utero, during birth, or through breastfeeding) to current and all future children. Clinical parameters, including antenatal care access and fertility rates, were estimated from a retrospective review of 817 medical records at two hospitals in Ghana. Additional parameters were obtained from published literature. Modeled outcomes include HIV infections averted among newborn children, quality-adjusted life-years (QALYs), and cost-effectiveness ratios.

RESULTS

HIV-infected women in Ghana have a lifetime average of 2.3 children (SD 1.3). Projected maternal life expectancy under Option B+ is 16.1 years, versus 16.0 years with Option B, yielding a gain of 0.1 maternal QALYs and 3.2 additional QALYs per child. Despite higher initial ART costs, Option B+ costs $785/QALY gained, a value considered very cost-effective by World Health Organization benchmarks. Widespread implementation of Option B+ in Ghana could theoretically prevent up to 668 HIV infections among children annually. Cost-effectiveness estimates remained favorable over robust sensitivity analyses.

CONCLUSIONS

Although more expensive than Option B, Option B+ substantially reduces MTCT in future pregnancies, increases both maternal and pediatric QALYs, and is a cost-effective use of limited resources in Ghana.

Healthcare costs associated with antiretroviral adherence among medicaid patients

BACKGROUND

The relationship of antiretroviral therapy (ART) adherence to total healthcare expenditures for Medicaid-insured people living with HIV or AIDS (PLWHA) is not well understood, especially among asymptomatic HIV-positive patients.

OBJECTIVE

This study examined Medicaid-insured HIV-positive and AIDS-diagnosed patient groups to determine the association of ART adherence to mean monthly total healthcare expenditures in the 24-month measurement period, controlling for demographic, geographic, insurance, and clinical factors. The present study extends the existing literature by analyzing the relationship of ART adherence to total healthcare costs for asymptomatic HIV-positive patients separately from those patients with AIDS-defining conditions.

METHODS

This retrospective study utilized claims data from Florida Medicaid claims from July 2006 through June 2011. All patients (n = 502) were HIV-positive, aged 18-64 years, non-pregnant, and ART naïve for at least 12 months prior to the measurement period. Each patient was categorized, based on medication possession ratios, as adherent (≥90 %) or non-adherent (<90 %), and were divided into two groups: HIV positive (n = 232) and AIDS diagnosed (n = 270). Generalized linear models predicted the mean monthly total expenditures for the non-adherence group versus the adherence group.

RESULTS

For the HIV-positive group, the adjusted mean monthly expenditures for the non-adherent group were US$1,291; the adherent group adjusted mean monthly expenditures were US$1,926. The HIV-positive non-adherent group adjusted mean monthly expenditures were significantly less than the adherent group (-40 %, p < 0.001). However, for the AIDS-diagnosed group, there was not a statistically significant association of ART adherence to total healthcare expenditures (p = 0.29).

CONCLUSION

The results show that the relationship of ART adherence to healthcare costs is more complex than previously reported.