Cost of HIV and determinants of health care costs in HIV-positive patients in Germany: results of the DAGNÄ K3A Study

Determinants and economic burden of HIV/AIDS in Iran: a prospective study

BACKGROUND

Since the start of the AIDS outbreak, the human immunodeficiency virus (HIV) has infected about 84.2 million people, and approximately 40.1 million people have died due to AIDS-related diseases. So, this study aims to provide a comprehensive population-based description of patient costs and the economic burden of HIV/AIDS in Iran.

METHODS

The study population of this cross-sectional cost-of-illness study consisted of HIV-infected patients who were receiving services in Mashhad and were under the supervision of BIDCC. There are four BIDCC centers in Mashhad, we considered all patients referred to these centers. Costs data were evaluated from a social perspective with a bottom-up approach and as a prevalence based. The data from 157 individuals were included in the study. For collecting data on direct and indirect costs belonging to patients and their families, a questionnaire was developed. Also, the Demographic characteristic of participants and the stage of the disease and Transmission category were analyzed.

RESULTS

In this study, 57.32 of the subjects were Male. The majority of participants in this study were in the age group 30-59 years (n = 124,78.98%). Based on where the patients live, the majority of patients have lived in the urban region (n = 144, 91.72%). The most common way to transmit this disease is through unprotected sex (30.57%) and then Infected spouse (28.03%), and then injecting drugs (21.02%). The highest cost of this disease is attributed to medicine (10339.32 $ for 6 months), after medicine, the cost of tests was 9101.22 $.

CONCLUSION

It seems that to reduce costs for patients with disease HIV/AIDS, the focus should be on diagnostic tests and care. Early diagnosis and rapid initiation of antiviral treatments can be effective in preventing serious and debilitating diseases.

A 10-year economic analysis of HIV management in Greece: evidence of efficient resource allocation

OBJECTIVE

Human Immunodeficiency Virus (HIV) prevalence has substantially increased over the years, leading to increased direct medical costs. The aim of the present study was to assess the long-term cost of HIV care in Greece incurred over the last decade.

METHODS

In order to assess the long-term cost of HIV care, a cost analysis was undertaken for three discrete time points (which reflect major changes in the HIV treatment paradigm), incorporating the evolution of the cost of pharmaceuticals, hospitalization, primary care visits and diagnostic tests. The cost per life year gained (LYG) was also estimated.

RESULTS

Total cost of HIV care increased by 57% over the last decade (€53.7 million in 2010 vs €84.5 million in 2019), which can be mainly attributed to a 107% (5084 in 2010 vs. 10,523 in 2019) increase observed in the number of people living with HIV (PLWH) under care. As a result, the cost per person on treatment has decreased by 24.0% (€10,567 in 2010 vs €8032 in 2019). Lifetime cost was lower and life expectancy higher in 2019 compared to 2010, leading to a - €711 cost per LYG, suggesting that the current treatment paradigm produces better health outcomes at a lower cost compared to a decade ago, implying that resources are used in a more efficient way.

CONCLUSION

The paper presents some evidence towards the direction that HIV management in Greece can be considered efficient in both clinical and financial terms, as it offers measurable clinical outcomes at well-controlled, almost inelastic spending.

Cost-savings and potential cost-savings through the distribution of generic antiretroviral drugs within the statutory health insurance market of Germany between January 2017 and June 2019

Abstract

Background

Recent patent losses for antiretroviral drugs (ARV) have led to the debate of cost-saving through the replacement of patented drugs with generic drugs. The split of recommended single-tablet regimens (STR) into their single substance partners is one of the considerations mentioned in said debate. Particularly, generic tenofovir disoproxil/emtricitabine (TDF/FTC) is expected to hold untapped cost-saving potential, which may curb increasing overall expenditures for combined antiretroviral therapy (cART) within the statutory health insurance (SHI) of Germany.

Methods

Data of ARV reimbursed by the SHI were used to describe the trends of defined daily doses (DDD) as well as the revenue within the German ARV market. They were also used to determine the cost-savings of moving to generic drugs. The time period observed was between January 2017 and June 2019. The potential cost-savings were determined with following assumption in mind: the maximum possible use of generic ARV, including 1) the split of STR and replacing all substance partners with generic ones, and 2) replacing patented tenofovir alafenamide/emtricitabine (TAF/FTC) with generic TDF/FTC.

Results

Throughout the observation period, the DDD of generic ARV increased nearly five-fold while their revenue increased more than four-fold. Total cost-saving showed a sharp increase over the same period, with generic TDF/FTC accounting for a share of around 70%. The largest potential cost-saving could have been achieved through replacing patented TAF/FTC with generic TDF/FTC, peaking at nearly 10% of total revenue, but showing decreasing trends in general.

Conclusion

The progressive distribution of generic ARV ensured increasing cost-savings_, but consequently curbed the potential cost-savings. Unique price reductions of generic TDF/FTC have played a pivotal role for these effects. In any case, substituting with generic ARV should not fail to adhere to the treatment guidelines and continue to consider the medical requirements for the treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07390-4.

Costs and mortality associated with HIV: a machine learning analysis of the French national health insurance database

BACKGROUND

The objective is to characterise the economic burden to the healthcare system of people living with HIV (PLWHIV) in France and to help decision makers in identifying risk factors associated with high-cost and high mortality profiles.

DESIGN AND METHODS

The study is a retrospective analysis of PLWHIV identified in the French National Health Insurance database (SNDS). All PLWHIV present in the database in 2013 were identified.  All healthcare resource consumption from 2008 to 2015 inclusive was documented and costed (for 2013 to 2015) from the perspective of public health insurance. High-cost and high mortality patient profiles were identified by a machine learning algorithm.

RESULTS

In 2013, 96,423 PLWHIV were identified in the SNDS database, including 3,373 incident cases. Overall, 3,224 PLWHIV died during the three-year follow-up period (mean annual mortality rate: 1.1%). The mean annual per capita cost incurred by PLWHIV was € 14,223, corresponding to a total management cost of HIV of € 1,370 million in 2013. The largest contribution came from the cost of antiretroviral medication (M€ 870; 63%) followed by hospitalisation (M€ 154; 11%). The costs incurred in the year preceding death were considerably higher. Four specific patient profiles were identified for under/over-expressing these costs, suggesting ways to reduce them.

CONCLUSIONS

Even though current therapeutic regimens provide excellent virological control in most patients, PLWHIV have excess mortality. Other factors such as comorbidities, lifestyle factors and screening for cancer and cardiovascular disease, need to be targeted in order to lower the mortality and cost associated with HIV infection.

Intersectoral costs of sexually transmitted infections (STIs) and HIV: a systematic review of cost-of-illness (COI) studies

Background

Sexually transmitted infections (STIs) and HIV can generate costs both within and outside the health sector (i.e. intersectoral costs). This systematic review aims (i) to explore the intersectoral costs associated with STIs and HIV considered in cost-of-illness (COI) studies, (ii) to categorise and analyse these costs according to cost sectors, and (iii) to illustrate the impact of intersectoral costs on the total cost burden.

Methods

Medline (PubMed), EMBASE (Ovid), Web of Science, CINAHL, PsycINFO, EconLit and NHS EED were searched between 2009 and 2019. Key search terms included terms for cost-of-illness, cost analysis and all terms for STIs including specific infections. Studies were included that assessed intersectoral costs. A standardised data extraction form was adopted. A cost component table was established based on pre-defined sector-specific classification schemes. Cost results for intersectoral costs were recorded. The quality of studies was assessed using a modified version of the CHEC-list.

Results

75 COI studies were considered for title/abstract screening. Only six studies were available in full-text and eligible for data extraction and narrative synthesis. Intersectoral costs were captured in the following sectors: Patient & family, Informal care and Productivity (Paid Labour). Patient & family costs were addressed in four studies, including patient out-of-pocket payments/co-payments and travel costs. Informal care costs including unpaid (home) care support by family/friends and other caregiver costs were considered in three studies. All six studies estimated productivity costs for paid labour including costs in terms of absenteeism, disability, cease-to-work, presenteeism and premature death. Intersectoral costs largely contributed to the total economic cost burden of STIs and HIV. The quality assessment revealed methodological differences.

Conclusions

It is evident that intersectoral costs associated with STIs and HIV are substantial. If relevant intersectoral costs are not included in cost analyses the total cost burden of STIs and HIV to society is severely underestimated. Therefore, intersectoral costs need to be addressed in order to ensure the total economic burden of STIs and HIV on society is assessed, and communicated to policy/decision-makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07147-z.

Cost of Human Immunodeficiency Virus (HIV) and Determinants of Healthcare Costs in HIV-Infected Treatment-Naive Patients Initiated on Antiretroviral Therapy in Germany: Experiences of the PROPHET Study

OBJECTIVES

The purpose of the prospective clinical and pharmacoeconomic outcomes study of different first-line antiretroviral treatment strategies (PROPHET) was to examine the healthcare costs of human immunodeficiency virus (HIV)-infected persons in Germany treated with different antiretroviral therapy (ART) strategies and to identify variables associated with high costs.

METHODS

The setting was a 24-month prospective multicenter observational cohort study in a German HIV-specialized care setting from 2014 to 2017. A microcosting approach was used for the estimation of healthcare costs. Data were obtained via electronic case report forms. The costs were calculated from both the societal and the statutory health insurance perspective. Regression models were performed that took into consideration the impact of several independent variables.

RESULTS

Four hundred thirty-four patients from 24 centers throughout Germany were included. Average annual healthcare costs were €20 118 (standard deviation [SD] €6451) per patient from the societal perspective (n = 336) and €17 306 (SD €4106) from the statutory health insurance perspective (n = 292). Expenditures for the ART medication had the highest impact. Total costs declined in the second year of therapy. There was a significant association between the amount of total cost and clinical or therapeutic variables from both perspectives; a diagnosis of acquired immune deficiency syndrome (AIDS) led to higher costs as well as the chosen ART strategy. Age also increased cost from the statutory health insurance perspective.

CONCLUSIONS

The main cost driver of the healthcare costs for HIV-positive patients was antiretroviral drug expenses. Further variables that influenced the costs were identified. The results provide a detailed overview of the resource use of patients in the PROPHET cohort.

Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058

BackgroundPre-exposure prophylaxis (PrEP) is a highly effective HIV prevention strategy for men-who-have-sex-with-men (MSM). The high cost of PrEP has until recently been a primary barrier to its use. In 2017, generic PrEP became available, reducing the costs by 90%.AimOur objective was to assess cost-effectiveness and costs of introducing PrEP in Germany.MethodsWe calibrated a deterministic mathematical model to the human immunodeficiency virus (HIV) epidemic among MSM in Germany. PrEP was targeted to 30% of high-risk MSM. It was assumed that PrEP reduces the risk of HIV infection by 85%. Costs were calculated from a healthcare payer perspective using a 40-year time horizon starting in 2018.ResultsPrEP can avert 21,000 infections (interquartile range (IQR): 16,000-27,000) in the short run (after 2 years scale-up and 10 years full implementation). HIV care is predicted to cost EUR 36.2 billion (IQR: 32.4-40.4 billion) over the coming 40 years. PrEP can increase costs by at most EUR 150 million within the first decade after introduction. Ten years after introduction, PrEP can become cost-saving, accumulating to savings of HIV-related costs of EUR 5.1 billion (IQR: 3.5-6.9 billion) after 40 years. In a sensitivity analysis, PrEP remained cost-saving even at a 70% price reduction of antiretroviral drug treatment and a lower effectiveness of PrEP.ConclusionIntroduction of PrEP in Germany is predicted to result in substantial health benefits because of reductions in HIV infections. Short-term financial investments in providing PrEP will result in substantial cost-savings in the long term.

Treatment cost of HIV/AIDS in Turkey

Purpose

The purpose of this study is to estimate the average cost of treatment and investigate the related parameters of HIV/AIDS among patients based on their annual treatment regime during the 2017 in Izmir.

Design/methodology/approach

The average annual direct cost of an HIV patient's treatment was estimated for 2017 at four university hospitals in a retrospective study in Izmir, Turkey. Inclusion criteria included confirmed HIV infection, age = 18 years, visited one of the hospitals at least three times a year and with at least one CD4+ T cell count. The average annual treatment cost per patient was calculated using accounting data for 527 patients from the hospitals' electronic databases.

Findings

The mean treatment cost per patient was US$4,381.93. Costs for treatment and care were statistically significantly higher (US$5,970.55) for patients with CD4+ T cell counts of fewer than 200 cells/mm3 than for other patients with CD4+ T cell counts above 200 cells/mm3. The mean treatment cost for patients who were 50 years old or older (US$4,904.24) was statistically significantly higher than for those younger than 50 years (US$4,216.10). The mean treatment cost for female patients (US$4,624.92) was higher than that of male patients ($US4,339.72), although the difference was not statistically significant. The main cost driver was antiretroviral treatment (US$3,852.38 per patient), accounting for almost 88% of all costs. However, the high burden of antiretroviral treatment cost is counterbalanced by relatively low care and hospitalization costs in Turkey.

Originality/value

The paper contributes to the literature by providing average annual treatment cost of an HIV-infected patient in Turkey by using a comprehensive bottom up approach. Moreover, cost drivers of HIV treatment are investigated.

Cost-effectiveness of increased HIV testing among MSM in The Netherlands

OBJECTIVES

To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands.

METHODS

Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective.

RESULTS

A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27 900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36 700/QALY gained. Both were not cost-effective, with a &OV0556;20 000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving.

CONCLUSION

Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.

A Cost-of-Illness Study of Patients with HIV/AIDS in Bogotá, Colombia

BACKGROUND

In 2014, 0.3% of the total population in Colombia was living with HIV/AIDS. The data currently available regarding the costs of these patients are very limited.

OBJECTIVES

To estimate the societal costs of patients with HIV/AIDS in Bogotá, Colombia.

METHODS

This study is a quantitative, cross-sectional cost-of-illness study. Costs were assessed with a prevalence-based, bottom-up approach. The data of 124 patients were collected from their medical records in a Bogotá hospital and a questionnaire was developed to measure other health care costs, as well as patient and family costs. Subgroup analyses were performed according to sex, age, Centers for Disease Control and Prevention classification, and CD4 count (cluster of differentiation 4).

RESULTS

The mean annual cost per patient with HIV/AIDS was estimated at $11,505 ± 18,658 (2014 US dollars). The larger part was attributable to drug costs (a mean annual cost of $8,616, 75% of the total), whereas productivity costs represented a mean annual cost of $1,044 (10%). Total costs per patient were estimated for a CD4 count of 500 or more, 200 to 499, and less than 200 cells/µl at $13,116, $9,077, and $10,741, respectively (all values in 2014 US dollars).

CONCLUSIONS

HIV/AIDS represents a high societal burden in Colombia. In comparison with the gross domestic product per capita of $7,904 in 2014, the mean annual cost per patient with HIV/AIDS was 40% higher, estimated at $11,505. The largest part of the HIV/AIDS costs was attributed to drugs, followed by productivity costs. Using extrapolation, the total cost of HIV/AIDS for the Colombian society would be $1.431 billion.

The burden of chronic diseases and cost-of-care in subjects with HIV infection in a Health District of Northern Italy over a 12-year period compared to that of the general population

Background

The increase in life expectancy of HIV-infected patients has driven increased costs due to life-long HIV treatment and concurrent age-related comorbidities. This population-based study aimed to investigate the burden of chronic diseases and health costs for HIV⁺ subjects compared to the general population living in Brescia Local health Agency (LHA) over a 12-year period.

Methods

LHA database recorded diagnoses, deaths, drug prescriptions and health resource utilization for all residents during 2003–2014. We estimated HIV prevalence and incidence, HIV-related mortality as well as prevalence of chronic diseases in HIV⁺ subjects. Observed/expected ratio of chronic diseases was calculated by indirect standardization with the general population as reference. Direct cost of HIV care and determinants were estimates across the period.

Results

HIV prevalence increased from 220 to 307 per 100 000 person-years while incidence decreased from 16.1 to 10.8 per 100 000 person-years from 2003 to 2014. Prevalence of most comorbidities increased over time but it reduced significantly (annual mean change − 0.7 %) when adjusting for age and gender. Observed to expected ratio for each chronic disease in HIV⁺ subjects decreased over time. Cost of HIV⁺ cures increased (+25 %) mainly due to cost for drugs (+50 %) but it stabilized in recent years. CD4⁺ cell count at the time of diagnosis was an important predictor of cost for HIV management.

Conclusions

Expenditures for HIV-infection are driven mainly by drugs cost and they have increased overtime. However, our findings suggest that spending on public health for HIV care can improve prognosis of HIV-infected patients, reduce transmission of HIV infection and reduce the global burden of chronic diseases, leading to a reduction of HIV global cost in the medium-long time.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3804-4) contains supplementary material, which is available to authorized users.

Utilisation patterns and cost of hospital care for people living with HIV in Ireland in 2012: a single-centre study

Data on the pattern and cost of health service use by HIV patients are required for evaluations of the cost-effectiveness of new drugs and technologies as well as being essential for service planning. The aim of this study was to identify the utilisation patterns and cost of hospital care for HIV patients in a single centre in Ireland in 2012. Data on the frequency and non-drug costs of all hospital resources used by HIV patients were extracted from a hospital activity-based costing system. Cost data were analysed using a generalised linear model. A total of 328 patients, 3672 patient months, were included in this study. Patients had a mean of 4.4 scheduled infectious disease outpatient appointments per patient year; 37% of patients also used another outpatient service, 15% in-patient services, 4% day-case service and 18% emergency department services in 2012. Patients with very advanced HIV disease continue to incur a disproportionate amount of the total cost of providing care. This study provides baseline utilisation and cost data for use of both infectious-disease and non-infectious disease hospital services and will be useful for service planning in light of the likely increases in resource demands.

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.

A Regional Drug and Therapeutics Committee-led Intervention to Reduce the Hospital Costs of Expensive HIV Drugs

In 2009, the regional Drug and Therapeutics Committee (DTC) began a series of meetings with lead specialists in infectious diseases. The role of the DTC was to engage clinicians and ensure commitment to prescribing the least expensive drugs among the clinically equivalent HAARTs (highly active antiretroviral therapy). DTC also led implementation of a national guideline. This study analyses the impact of this process on HAART consumption and expenditure. The HAART consumption and expenditure (2009-2013) was compared to forecasts produced by exponential smoothing (2004-2009). Abrupt switches between drug regimens coincided with the DTC-led meetings. Overall, HAART consumption rose 16%, while price per defined daily dose (DDD) fell 11% and the 2013 expenditure decreased 23%. The consumption of drugs addressed by the guideline rose 48%. Still, the 2013 expenditure was 41.5 million DKK (5.5 million €) (27%) lower than expected, reflecting a fall in price per DDD that coincided with the intervention. The consumption of drugs not addressed by the guideline rose 8.3%, while price per DDD fell 8.5% and the 2013 expenditure was 26.8 million DKK (3.6 million €) (19%) lower than expected. Despite a steadily increasing consumption, significant cost savings followed this DTC-led intervention. This multifaceted approach might be applicable to changing the prescribing of other expensive drug classes.

Resource utilisation and cost of ambulatory HIV care in a regional HIV centre in Ireland: a micro-costing study

Background

It is anticipated that demands on ambulatory HIV services will increase in coming years as a consequence of the increased life expectancy of HIV patients on highly active anti-retroviral therapy (HAART). Accurate cost data are needed to enable evidence based policy decisions be made about new models of service delivery, new technologies and new medications.

Methods

A micro-costing study was carried out in an HIV outpatient clinic in a single regional centre in the south of Ireland. The costs of individual appointment types were estimated based on staff grade and time. Hospital resources used by HIV patients who attended the ambulatory care service in 2012 were identified and extracted from existing hospital systems. Associations between patient characteristics and costs per patient month, in 2012 euros, were examined using univariate and multivariate analyses.

Results

The average cost of providing ambulatory HIV care was found to be €973 (95% confidence interval €938 - €1008) per patient month in 2012. Sensitivity analysis, varying the base-case staff time estimates by 20% and diagnostic testing costs by 60%, estimated the average cost to vary from a low of €927 per patient month to a high of €1019 per patient month. The vast majority of costs were due to the cost of HAART. Women were found to have significantly higher HAART costs per patient month while patients over 50 years of age had significantly lower HAART costs using multivariate analysis.

Conclusions

This study provides the estimated cost of ambulatory care in a regional HIV centre in Ireland. These data are valuable for planning services at a local level, and the identification of patient factors, such as age and gender, associated with resource use is of interest both nationally and internationally for the long-term planning of HIV care provision.

Cost of HAART in Italy: multicentric evaluation and determinants from a large HIV outpatient cohort

Background

As HIV infection turned into a chronic treatable disease, now ranking as one of the most costly in medicine, long-term sustainability of highly active antiretroviral treatment (HAART) expenses became a major issue, especially in countries with universal access to care. Identification of determinants of higher HAART costs may therefore help in controlling costs of care, while keeping high levels of retention in care and viral suppression.

Methods

With this aim, we enrolled a large multicentric sample of consecutive unselected human immunodeficiency virus (HIV) patients followed at five sites of care in Italy, and evaluated annual individual HAART costs in relation to a number of sociodemographic, clinical, and laboratory variables.

Results

We enrolled 2,044 patients, including 1,902 on HAART. Mean HAART costs were €9,377±€3,501 (range 782–29,852) per year, with remarkable site-based differences, possibly related to the different composition of local assisted populations. Percentages of patients on viral suppression were homogeneously high across all study sites. The factors identified by cross-validation were line of HAART, diagnosis of acquired immune deficiency syndrome, current CD4 T-cell count, and detectable HIV viremia >50 copies/mL. In the final multivariable model, HAART costs were independently directly associated with more advanced HAART line (P<0.001) and inversely correlated with current CD4 T-cell count (P=0.024). Site of care held independent prediction of higher costs, with marked control of expenses at sites 2 (P=0.001) and 5 (P<0.001).

Conclusion

Higher costs of HAART were strongly associated with previous treatment failures, detectable HIV viremia, and lower CD4 T-cell count at the time of evaluation, with no correlation at all with sex, age, hepatitis C virus coinfection, and nadir CD4 T-cell counts. Newer drugs, which are typically those associated with high prices, at the time of the analysis were still prevalently prescribed to rescue and maintain viral suppression in patients with more complex treatment history. Further analyses of the contribution of the single drug/regimen to the estimated cost are warranted.

Estimation of the Direct Cost of HIV-Infected Patients in Greece on an Annual Basis

OBJECTIVE

HIV infection is currently regarded as a global chronic disease. The purpose of this study was to assess the direct cost of illness per patient per year in Greece.

METHODS

A retrospective study for the estimation of the direct cost of HIV infection was performed from the third-party payer perspective. Data from 447 patients monitored in a general hospital of Athens were collected from their medical records. The survey involved all services and treatments that patients (stratified into three health states according to the number of CD4 cells/ml as defined by the Centers for Disease Control and Prevention classification system for HIV infection) received in 1 year, as well as demographic data.

RESULTS

The annual direct cost per patient was calculated at €6859 ± €4699. Antiretroviral therapy cost was estimated at €5741, while the annual cost of providing health care services regardless of health state was computed at €1118, with laboratory investigation and imaging studies representing €924 (13.5%), outpatient visits €34 (0.5%), and hospitalization €160 (2.3%) of total cost, respectively. Overall, direct cost per patient was found to increase as the CD4 T lymphocytes decreased, leading to prolonged hospitalization and an increase in the number of laboratory tests. Direct cost for patients with more than 500 CD4 cells/μl was estimated at €6067, whereas for those with 200 to 499 cells/μl and less than 200 cells/μl, it was assessed at €6857 and €7654, respectively.

CONCLUSIONS

The direct cost of HIV infection per patient increased as CD4 T lymphocytes decreased. The largest part of expenses was attributed to antiretroviral therapy, followed by laboratory tests/imaging studies, hospitalization, and finally outpatient visits.

Direct treatment costs of HIV/AIDS in Portugal

OBJECTIVE To analyze the direct medical costs of HIV/AIDS in Portugal from the perspective of the National Health Service. METHODS A retrospective analysis of medical records was conducted for 150 patients from five specialized centers in Portugal in 2008. Data on utilization of medical resources during 12 months and patients’ characteristics were collected. A unit cost was applied to each care component using official sources and accounting data from National Health Service hospitals. RESULTS The average cost of treatment was 14,277 €/patient/year. The main cost-driver was antiretroviral treatment (€ 9,598), followed by hospitalization costs (€ 1,323). Treatment costs increased with the severity of disease from € 11,901 (> 500 CD4 cells/µl) to € 23,351 (CD4 count ≤ 50 cells/ µl). Cost progression was mainly due to the increase in hospitalization costs, while antiretroviral treatment costs remained stable over disease stages. CONCLUSIONS The high burden related to antiretroviral treatment is counterbalanced by relatively low hospitalization costs, which, however, increase with severity of disease. The relatively modest progression of total costs highlights that alternative public health strategies that do not affect transmission of disease may only have a limited impact on expenditure, since treatment costs are largely dominated by constant antiretroviral treatment costs.

The prevalence of transmitted resistance to first-generation non-nucleoside reverse transcriptase inhibitors and its potential economic impact in HIV-infected patients

Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based highly active antiretroviral therapy (HAART) including efavirenz is recommended as a 1^st-line treatment choice in international HIV guidelines, and it is one of the most common components of initial therapy. Resistance to 1^st-generation NNRTIs is found among treated and untreated HIV-infected individuals creating a subpopulation of HIV-infected individuals in whom efavirenz is not fully effective. This analysis reviewed published articles and conference abstracts to examine the prevalence of 1^st-generation NNRTI resistance in Europe, the United States (US), and Canada and to identify published evidence of the economic consequences of resistance. The reported prevalence of NNRTI resistance was generally higher in US/Canada than in Europe and increased in both regions from their introduction in the late 1990s until the early 2000s. The most recent time-based trends suggest that NNRTI-resistance prevalence may be stable or decreasing. These estimates of resistance may be understated as resistance estimates using ultra-sensitive genotypic testing methods, which identify low-frequency mutations undetected by standard testing methods, showed increased prevalence of resistance by more than two-fold. No studies were identified that explicitly investigated the costs of drug resistance. Rather, most studies reported costs of treatment change, failure, or disease progression. Among those studies, annual HIV medical costs of those infected with HIV increased 1) as CD4 cells decreased, driven in part by hospitalization at lower CD4 cell counts; 2) for treatment changes, and 3) for each virologic failure. The possible erosion of efficacy or of therapy choices through resistance transmission or selection, even when present with low frequency, may become a barrier to the use of 1^st-generation NNRTIs and the increased costs associated with regimen failure and disease progression underlie the importance of identification of treatment resistance to ensure optimal initial therapy choice and regimen succession.

30 Years on Selected Issues in the Prevention of HIV among Persons Who Inject Drugs

After 30 years of extensive research on human immunodeficiency virus (HIV) among persons who inject drugs (PWID), we now have a good understanding of the critical issues involved. Following the discovery of HIV in 1981, epidemics among PWID were noted in many countries, and consensus recommendations for interventions for reducing injection related HIV transmission have been developed. While high-income countries have continued to develop and implement new Harm Reduction programs, most low-/middle-income countries have implemented Harm Reduction at very low levels. Modeling of combined prevention programming including needle exchange (NSP) and antiretroviral therapy (ARV) suggests that NSP be given the highest priority. Future HIV prevention programming should continue to provide Harm Reduction programs for PWID coupled with interventions aimed at reducing sexual transmission. As HIV continues to spread in low- and middle-income countries, it is important to achieve and maintain high coverage of Harm Reduction programs in these locations. As PWID almost always experience multiple health problems, it will be important to address these multiple problems within a comprehensive approach grounded in a human rights perspective.