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

Socio-demographic and psycho-social determinants of HIV late presentation in Germany - results from the FindHIV study

Delayed HIV diagnosis at advanced stages of disease remains common (33%-64%). This analysis of the multi-center FindHIV study including newly diagnosed HIV-infected adults in Germany, focused on the potential role of socio-demographic and psychological factors on late diagnosis (formerly "late presentation", AIDS diagnosis or CD4 cells <350/µL). These data were collected from patient profiles, physician-patient interviews and questionnaires. Participating centers (n = 40) represented the diverse health care settings in HIV care and geographic regions. Of 706 newly diagnosed adults (92% male, median age 39 years) between 2019 and 2020, 55% (388/706) were diagnosed late with a median CD4 cell count of 147/µL; 20% (142/706) presented with AIDS. From the physicians' perspective, earlier diagnosis would have been possible in 45% of participants (late versus non-late presentation 58% versus 29%). The most common physician-perceived reason was an underestimated risk for HIV infection by the patient (37%). In multivariable logistic regression analysis, older age, sexual contacts with both sexes as possible route of HIV transmission, being married, and a poor level of knowledge about HIV treatment were found to be associated with a significantly elevated risk for late presentation. Education, employment status, sexual relations, migration background and personality traits were not.Trial registration: German Clinical Trials Register (DRKS00016351).

Optimization of HIV testing services in Germany using HIV indicator diseases: study protocol of the HeLP study

BACKGROUND

Despite the potentially accompanying negative clinical, epidemiologic, and health economic effects, a large proportion of persons living with the human immunodeficiency virus (HIV) are diagnosed late. Internationally, numerous diseases are known to be HIV indicator diseases. Adequate HIV testing in the presence of HIV indicator diseases could help to diagnose unknown HIV infections earlier. The objective of the HeLP study is to validate published HIV indicator diseases for the German setting and to identify guidelines in terms of these indicator diseases in order to reduce knowledge gaps and increase HIV testing when HIV indicator diseases are diagnosed.

METHODS

A mixed methods approach is used. In a first step, published HIV indicator diseases will be identified in a systematic literature review and subsequently discussed with clinical experts regarding their relevance for the German setting. For the validation of selected indicator diseases different data sets (two cohort studies, namely HIV-1 seroconverter study & ClinSurv-HIV, and statutory health insurance routine data) will be analyzed. Sensitivity analyses using different time periods will be performed. Guidelines of HIV indicator diseases validated in the HeLP study will be reviewed for mentioning HIV and for HIV testing recommendations. In addition, semi-standardized interviews (followed by a free discussion) with guideline creators will identify reasons why HIV testing recommendations were (not) included. Subsequently, a random sample of physicians in medical practices will be surveyed to identify how familiar physicians are with HIV testing recommendations in guidelines and, if so, which barriers are seen to perform the recommended tests in everyday care.

DISCUSSION

The HeLP-study adopts the challenge to validate published HIV indicator diseases for the German setting and has the potential to close a knowledge gap regarding this objective. This has the potential to improve targeted HIV testing for patients with HIV indicator diseases and consequently lead to earlier HIV diagnosis.

TRIAL REGISTRATION

DRKS00028743.

Healthcare Resource Consumption and Related Costs in Patients on Antiretroviral Therapies: Findings from Real-World Data in Italy

This real-world analysis conducted on administrative databases of a sample of Italian healthcare entities was aimed at describing the role of therapeutic pathways and drug utilization in terms of adherence, persistence, and therapy discontinuation in HIV-infected patients under antiretroviral therapies (ART) and Tenofovir Alafenamide (TAF)-based regimens on healthcare resource consumption and related direct healthcare costs. Between 2015 and 2019, adults (≥18 years) prescribed with TAF-based therapies were identified and characterized in the year prior to the first prescription (index-date) for TAF-based therapies and followed-up until the end of data availability. Overall, 2658 ART-treated patients were included, 1198 of which were under a TAF-based regimen. TAF-based therapies were associated with elevated percentages of adherence (83.3% patients with proportion of days covered, PDC > 95% and 90.6% with PDC > 85%) and persistence (78.5%). The discontinuation rate was low in TAF-treated patients, ranging from 3.3% in TAF-switchers to 5% in naïve. Persistent patients had lower overall mean annual healthcare expenditures (EUR 11,106 in persistent vs. EUR 12,380 in non-persistent, p = 0.005), and this trend was statistically significant also for costs related to HIV hospitalizations. These findings suggest that a better therapeutic management of HIV infection might result in positive clinical and economic outcomes.

[How do generic quotas work? An analysis using HIV infection as an example]

Hintergrund

Die Steuerungsinstrumente der Arzneimittelversorgung in der gesetzlichen Krankenversicherung (GKV) sind schon länger Bestandteil der gesundheitspolitischen Reformdebatte. Über die Jahre hat sich eine Gemengelage sehr verschiedener Werkzeuge herausgebildet, die zumeist auf eine Kontrolle der Arzneimittelausgaben zielen. Die Instrumente der regionalen Verordnungssteuerung fokussieren vor allem auf eine Verhaltenssteuerung des verordnenden Arztes. Zu erwähnen ist nicht zuletzt der verstärkte Einsatz von indikationsbezogenen Quoten, vorrangig Leitsubstanzen und/oder Generika/Biosimilars. Diese gibt es mittlerweile auch im Bereich des Humanen Immundefizienz-Virus (HIV), etwa die seit 2020 in Bayern und Berlin eingeführten Generikaquoten für HIV-Therapeutika.

Zielstellung

Ziel des vorliegenden Beitrages ist es, auf Grundlage von GKV-Apothekenabrechnungsdaten das Potenzial sowie Grenzen von Generikaquotenlösungen in der HIV-Versorgung zu analysieren und Handlungsempfehlungen zu skizzieren.

Ergebnisse

Es zeigte sich, dass das Quotenpotenzial für Generika im patentfreien Bereich in der HIV-Versorgung bereits weitgehend ausgeschöpft wird. Dieser Umstand ist vor allem darauf zurückzuführen, dass die HIV-Verordner den Austausch durch Verzicht auf Aut-idem-Kreuze auf dem Kassenrezept unterstützen.

Diskussion

Das steuerungspolitische Optimum ist fast erreicht. Dies ist auf das geeignete Instrumentarium zurückzuführen, das aus dem Rahmenvertrag zur Arzneimittelversorgung und einer leitliniengerechten Wirkstoffverordnung durch den Arzt besteht – in Verbindung mit dem AMNOG(Arzneimittelmarktneuordnungsgesetz)-Verfahren und Festbeträgen. Leitlinienkonformität und (existierende) Eintablettenregime müssen beibehalten werden, damit die gute Versorgungsqualität gewährleistet bleibt.

Understanding and avoiding late presentation for HIV diagnosis - study protocol of a trial using mixed methods (FindHIV)

Many patients infected with HIV are diagnosed at an advanced stage of illness. These late presenters are individuals with a CD4 cell count of less than 350 cells/µL and/or an AIDS defining disease at initial HIV diagnosis. Purpose of FindHIV is to develop and distribute a questionnaire/scoring system aimed at a reduction in late presentation. FindHIV uses a mixed methods approach. In a first step, primary data of patients were collected. Inclusion criteria were: age ≥ 18 years, cognitive ability and language skills to participate in the study, initial HIV diagnosis within the past 6 months, and patient informed consent. Descriptive methods and regression models are used to identify: (1) patient characteristics associated with late presentation and (2) contacts to the healthcare system with indicator diseases that did not lead to HIV testing. Secondly, a questionnaire/scoring system is created by an expert panel. Afterwards the questionnaire/scoring system is to be disseminated. The greatest challenge was in reaching an adequate sample size. Another risk may be a recall bias. Nevertheless, FindHIV is devised as an in-depth study of the phenomenon of late presentation with potential to significantly improve HIV detection.