Estimating the National Cost of Treating People With HIV Disease: Patient, Payer, and Provider Data:

Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review

BACKGROUND

As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change.

OBJECTIVES

To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers.

METHODS

A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management.

RESULTS

22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996.

CONCLUSIONS

This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses.

DISCLOSURES

This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.

Limited spending: an analysis of correctional expenditures on antiretrovirals for HIV-infected prisoners

OBJECTIVE

Correctional facilities provide a critical opportunity to treat and manage human immunodeficiency virus (HIV) and HIV-related complications among inmates. Inmates bear a higher HIV burden than the general population, and many have never received HIV care prior to incarceration. The standard of care in the community and in corrections for the treatment of HIV is highly active antiretroviral therapy (HAART). This study evaluated U.S. correctional expenditures for antiretrovirals (ARVs) and compared them to the estimated need for ARVs among HIV-infected prisoners in the U.S. to treat this population successfully.

METHODS

The total number of HIV-infected prisoners in the United States was estimated using Bureau of Justice Statistics data. The National Sales Perspectives Audit, Combined Retail and Nonretail, July 1999 to December 2004 was used to estimate correctional ARV expenditures in 2004. Both measures were used to calculate treatment costs for ARV therapy.

RESULTS

The analysis demonstrates that, in 2004, total ARV sales represented only 29% of the total necessary to treat all HAART eligible inmates with known HIV infection.

CONCLUSION

There is a substantial unmet need for ARVs in correctional health care. Although many barriers exist to treating all eligible HIV-infected prisoners, treatment reduces costs associated with HIV-related complications and may encourage linkage to HIV care in the community. Treatment of all eligible HIV-infected inmates should be a public health priority.

[Economic and socio-behavioural issues related to highly active antiretroviral therapies for HIV infection: the contribution of social science research]

This article presents a synthesis of the main topics covered by social science research (SSR) on HIV/AIDS, since the advent of highly active antiretroviral therapies (HAART) in 1996. SSR has shown that non-adherence cannot be reliably <<predicted>> on the sole basis of a few a priori patient characteristics that clinicians could easily identify before initiation of HAART, and that a dynamic approach to adherence, continuously monitoring the impact of patients' subjective experience with HAART is needed. In relationship with the evolution of HIV infection toward a <<chronic disease>>, SSR has dealt with the impact of HAART on all aspects of patients' daily lives (from employment and professional status to sexuality). It has also emphasised the potential contradictions between the hopes generated by these cost-effective therapeutic advances, on the one hand, and the high social vulnerability of a growing proportion of people living with HIV-AIDS, on the other hand. Finally, SSR suggests recommendations for <<normalising>> AIDS public policies without losing the potential for innovations that the fight against this epidemic has introduced in health care and <<Social Security>> systems, as well as physician-patient's relationships.

The cost effectiveness of combination antiretroviral therapy for HIV disease

BACKGROUND

Combination antiretroviral therapy with a combination of three or more drugs has become the standard of care for patients with human immunodeficiency virus (HIV) infection in the United States. We estimated the clinical benefits and cost effectiveness of three-drug antiretroviral regimens.

METHODS

We developed a mathematical simulation model of HIV disease, using the CD4 cell count and HIV RNA level as predictors of the progression of disease. Outcome measures included life expectancy, life expectancy adjusted for the quality of life, lifetime direct medical costs, and cost effectiveness in dollars per quality-adjusted year of life gained. Clinical data were derived from major clinical trials, including the AIDS Clinical Trials Group 320 Study. Data on costs were based on the national AIDS Cost and Services Utilization Survey, with drug costs obtained from the Red Book.

RESULTS

For patients similar to those in the AIDS Clinical Trials Group 320 Study (mean CD4 cell count, 87 per cubic millimeter), life expectancy adjusted for the quality of life increased from 1.53 to 2.91 years, and per-person lifetime costs increased from $45,460 to $77,300 with three-drug therapy as compared with no therapy. The incremental cost per quality-adjusted year of life gained, as compared with no therapy, was $23,000. On the basis of additional data from other major studies, the cost-effectiveness ratio for three-drug therapy ranged from $13,000 to $23,000 per quality-adjusted year of life gained. The initial CD4 cell count and drug costs were the most important determinants of costs, clinical benefits, and cost effectiveness.

CONCLUSIONS

Treatment of HIV infection with a combination of three antiretroviral drugs is a cost-effective use of resources.

Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy

BACKGROUND

The introduction of expensive but very effective antiviral medications has led to questions about the effects on the total use of resources for the care of patients with human immunodeficiency virus (HIV) infection. We examined expenditures for the care of HIV-infected patients since the introduction of highly active antiretroviral therapy.

METHODS

We interviewed a random sample of 2864 patients who were representative of all American adults receiving care for HIV infection in early 1996, and followed them for up to 36 months. We estimated the average expenditure per patient per month on the basis of self-reported information about care received.

RESULTS

The mean expenditure was $1,792 per patient per month at base line, but it declined to $1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. Use of highly active antiretroviral therapy was independently associated with a reduction in expenditures. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from $20,300 per patient in 1996 to $18,300 in 1998. Expenditures among subgroups of patients varied by a factor of as much as three. Pharmaceutical costs were lowest and hospital costs highest among underserved groups, including blacks, women, and patients without private insurance.

CONCLUSIONS

The total cost of care for adults with HIV infection has declined since the introduction of highly active antiretroviral therapy. Expenditures have increased for medications but have declined for other services. However, there are large variations in expenditures across subgroups of patients.