Estimating the national cost of treating people with HIV disease: patient, payer, and provider data

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.

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 of Care for HIV-Infected Patients with Co-Occurring Substance Use Disorder or Psychiatric Disease: Report from a Large, Integrated Health Plan

Background. The costs of providing care to HIV-infected (HIV+) patients with co-occurring diagnoses of substance use (SU) disorder or psychiatric disease (PD) are not well documented. It is our objective to evaluate costs in these HIV+ patients receiving care in a large health plan. Methods. We conducted a retrospective cohort study from 1995 to 2010 to compare costs of healthcare in HIV+ patients with and without co-occurring SU disorder and/or PD diagnoses. Estimates of proportional differences in costs (rate ratios) were obtained from repeated measures generalized linear regression. Models were stratified by cost category (e.g., inpatient, outpatient). Results. Mean total healthcare costs per patient per year were higher in HIV+ patients diagnosed with SU disorder or PD compared to HIV+ patients without these comorbid conditions. After controlling for confounders, total mean costs remained significantly higher in patients diagnosed with SU disorder (RR = 1.24, 95% CI = 1.18-1.31) or PD (RR = 1.19, 95% CI = 1.15-1.24). Mean outpatient care costs were significantly greater in patients with both SU disorder and PD (RR = 1.52, 95% CI = 1.41-1.64). Conclusions. Given these higher expenditures in the care of HIV+ patients with comorbid SU disorder and/or PD, greater efforts to facilitate SU disorder or PD treatment initiation and persistence could provide substantial savings.

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

OBJECTIVES

The aims of this study were to estimate the expenditure for HIV-care in Germany and to identify variables associated with resource use.

DESIGN/SETTING

We performed an 18-month prospective multi-center study in an HIV specialized ambulatory care setting from 2006 to 2009.

SUBJECTS, PARTICIPANTS

Patients were eligible for study participation if they (1) were HIV-positive, (2) were ≥ 18 years of age, (3) provided written consent and (4) were not enrolled in another clinical study; 518 patients from 17 centers were included.

MAIN OUTCOME MEASURES

Health care costs were estimated following a micro-costing approach from two perspectives: (1) costs incurred to society in general, and (2) costs incurred to statutory health insurance. Data were obtained using questionnaires. Several empirical models for identifying the relationship between health care costs and independent variables, including age, gender, route of transmission and CD4 cell count at baseline, were developed.

RESULTS

Average annual health care costs were <euro>23,298 per patient from the societal perspective and <euro>19,103 from the statutory health insurance perspective. Most expenses are caused by antiretroviral medication (80 % of the total and 89 % of direct costs), while hospital costs represented 7 % of total expenditure. A statistically significant association was found between health care costs and clinical variables, with higher CD4 count and female gender generating lower costs, while increased antiretroviral experience and injection drug use led to higher expenditures (P < 0.05).

CONCLUSIONS

Expenditures for HIV-infection are driven mainly by drug costs. We identified several clinical variables influencing the costs of HIV-treatment. This information could assist policymakers when allocating limited health care resources to HIV care.

Contemporary costs of HIV healthcare in the HAART era

BACKGROUND

The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.

METHODS

We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.

RESULTS

Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.

CONCLUSION

HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Early and late direct costs in a Southern African antiretroviral treatment programme: a retrospective cohort analysis

BACKGROUND

There is a paucity of data on the health care costs of antiretroviral therapy (ART) programmes in Africa. Our objectives were to describe the direct heath care costs and establish the cost drivers over time in an HIV managed care programme in Southern Africa.

METHODS/FINDINGS

We analysed the direct costs of treating HIV-infected adults enrolled in the managed care programme from 3 years before starting non-nucleoside reverse transcriptase inhibitor-based ART up to 5 years afterwards. The CD4 cell count criterion for starting ART was <350 cells/microl. We explored associations between variables and mean total costs over time using a generalised linear model with a log-link function and a gamma distribution. Our cohort consisted of 10,735 patients (59.4% women) with 594,497 mo of follow up data (50.9% of months on ART). Median baseline CD4+ cell count and viral load were 125 cells/microl and 5.16 log(10) copies/ml respectively. There was a peak in costs in the period around ART initiation (from 4 mo before until 4 mo after starting ART) driven largely by hospitalisation, following which costs plateaued for 5 years. The variables associated with changes in mean total costs varied with time. Key early associations with higher costs were low baseline CD4+ cell count, high baseline HIV viral load, and shorter duration in HIV care prior to starting ART; whilst later associations with higher costs were lower ART adherence, switching to protease inhibitor-based ART, and starting ART at an older age.

CONCLUSIONS

Drivers of mean total costs changed considerably over time. Starting ART at higher CD4 counts or longer pre-ART care should reduce early costs. Monitoring ART adherence and interventions to improve it should reduce later costs. Cost models of ART should take into account these time-dependent cost drivers, and include costs before starting ART. Please see later in the article for the Editors' Summary.

Trends and responsiveness in national resource allocation for needed HIV services: a five year (1996-2000) analysis

A recent study conducted by the Institute of Medicine concluded that there are approximately 1,200 to 1,400 avoidable deaths per year in the U.S. among people living with HIV (PLWH) who do not have health insurance (Institute of Medicine, 2002). The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed by the U.S. Congress in 1990 to provide funding for community-based HIV care services for uninsured and underinsured PLWH--the only Federal program to provide such funding. There is substantial local autonomy in the allocation of CARE Act funds, with planning processes that take place in both States and metropolitan areas. The purpose of this study is to examine trends in the allocation of such funds from 1996 through 2000, the first five years during which effective antiretroviral medications were available for HIV. The study also considers whether these trends were responsive to the evolving modalities of care and the service needs of a changing population of PLWH.

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.

The cost of care for patients with HIV from the provider economic perspective

Health care costs for HIV infection are often reported from the economic perspective of third party payors and little data exist to show how total costs are distributed across specific health service categories. We used a retrospective cohort design to measure total medical costs for 1 year in a randomly selected sample of 280 patients treated for HIV infection at an urban health care facility. Inpatient and outpatient costs were measured from the economic perspective of the health care provider. Hospital costs included ward, ancillary, and procedure costs. Ambulatory included medications, primary and specialty care, case management, ancillary, and behavioral comorbidity treatment costs. The mean total was $20,114 per patient, of which $6,322 was for inpatient and $13,842 was for ambulatory services. Specific ambulatory costs were: medications, $9,257; primary, specialty and ancillary services, $3,470; and behavioral comorbidity treatment, $1,111. The mean annual outpatient ancillary cost was $841. Over 30% of the total service cost was for building and administrative overhead and approximately 25% of both hospital and clinic costs were for ancillary services. Independent predictors of high cost were CD4 counts, Medicaid eligibility, and behavorial comorbidities. Our outpatient costs were higher, with less variation than previously reported. Increasingly, there has been a shift of HIV care from hospital to ambulatory settings. We postulate that reimbursement rates have not captured the recent flourishing of ambulatory care. If reimbursement is not commensurate with outpatient advances, providers may be paradoxically underreimbursed for improving care.

CD4-guided scheduled treatment interruptions compared with continuous therapy for patients infected with HIV-1: results of the Staccato randomised trial

BACKGROUND

Stopping antiretroviral therapy in patients with HIV-1 infection can reduce costs and side-effects, but carries the risk of increased immune suppression and emergence of resistance.

METHODS

430 patients with CD4-positive T-lymphocyte (CD4) counts greater than 350 cells per muL, and viral load less than 50 copies per mL were randomised to continued therapy (n=146) or scheduled treatment interruptions (n=284). Median time on randomised treatment was 21.9 months (range 16.4-25.3). Primary endpoints were proportion of patients with viral load less than 50 copies per mL at the end of the trial, and amount of drugs used. Analysis was intention-to-treat. This study is registered at ClinicalTrials.gov with the identifier NCT00113126.

FINDINGS

Drug savings in the scheduled treatment interruption group, compared with continuous treatment, amounted to 61.5%. 257 of 284 (90.5%) patients in the scheduled treatment interruption group reached a viral load less than 50 copies per mL, compared with 134 of 146 (91.8%) in the continued treatment group (difference 1.3%, 95% CI-4.3 to 6.9, p=0.90). No AIDS-defining events occurred. Diarrhoea and neuropathy were more frequent with continuous treatment; candidiasis was more frequent with scheduled treatment interruption. Ten patients (2.3%) had resistance mutations, with no significant differences between groups.

INTERPRETATION

Drug savings with scheduled treatment interruption were substantial, and no evidence of increased treatment resistance emerged. Treatment-related adverse events were more frequent with continuous treatment, but low CD4 counts and minor manifestations of HIV infection were more frequent with scheduled treatment interruption.

Distribution of health care expenditures for HIV-infected patients

BACKGROUND

Health care expenditures for persons infected with human immunodeficiency virus (HIV) in the United State determined on the basis of actual health care use have not been reported in the era of highly active antiretroviral therapy.

METHODS

Patients receiving primary care at the University of Alabama at Birmingham HIV clinic were included in the study. All encounters (except emergency room visits) that occurred within the University of Alabama at Birmingham Hospital System from 1 March 2000 to 1 March 2001 were analyzed. Medication expenditures were determined on the basis of 2001 average wholesale price. Hospitalization expenditures were determined on the basis of 2001 Medicare diagnostic related group reimbursement rates. Clinic expenditures were determined on the basis of 2001 Medicare current procedural terminology reimbursement rates.

RESULTS

Among the 635 patients, total annual expenditures for patients with CD4+ cell counts <50 cells/microL (36,533 dollars per patient) were 2.6-times greater than total annual expenditures for patients with CD4+ cell counts > or =350 cells/microL (13,885 dollars per patient), primarily because of increased expenditures for nonantiretroviral medication and hospitalization. Expenditures for highly active antiretroviral therapy were relatively constant at approximately 10,500 dollars per patient per year across CD4+ cell count strata. Outpatient expenditures were 1558 dollars per patient per year; however, the clinic and physician component of these expenditures represented only 359 dollars per patient per year, or 2% of annual expenses. Health care expenditures for patients with HIV infection increased substantially for those with more-advanced disease and were driven predominantly by medication costs (which accounted for 71%-84% of annual expenses).

CONCLUSIONS

Physician reimbursements, even with 100% billing and collections, are inadequate to support the activities of most clinics providing HIV care. These findings have important implications for the continued support of HIV treatment programs in the United States.

Economic costs to business of the HIV/AIDS epidemic

HIV infection is a devastating disease for individuals and society. The economic burden of employees with HIV infection is a matter of increasing concern for employers. The purpose of this paper was to conduct a comprehensive review of published studies which measured/estimated economic costs incurred by HIV-infected employees, and evaluate the potential economic impact of the HIV/AIDS epidemic on business in different countries. This review finds a conceptual consensus in the literature that suggests that the HIV/AIDS epidemic has a potentially sizable economic cost to business, primarily due to increased costs for employment-based insurance premiums, welfare benefits, lost productivity, new hiring and training, and a downsized economy and labour market. Based on published data in the US, accounting for the first three major cost items, in 2002 an HIV-infected worker would cost an employer in the US an estimated 37,320 US dollars for asymptomatic individuals and 50,374 US dollars for symptomatic individuals per person-year. However, this review found little consistent empirical data in the literature regarding the scale of disease costs specific to businesses in different settings. In addition, the current literature offers little guidance in terms of well designed, validated, and easily replicated analytical frameworks for conducting a comprehensive cost analysis from a business perspective. Future research is needed to improve both the theoretical modelling and empirical work in assessing the full economic impact of the HIV/ADIS epidemic on patients, businesses and society at large.

Twenty years of therapy for HIV-1 infection

Antiretroviral therapy, where available, has transformed HIV-1 disease into a treatable and somewhat chronic infection. This article summarizes the accomplishments thus far and what lies ahead in our struggle to improve the treatment of, and possibly eliminate, HIV-1 infection.

Lifetime Cost of HIV Care in France during the Era of Highly Active Antiretroviral Therapy

Objective

To estimate the treatment and health care costs of HIV infection or AIDS in France during the era of highly active antiretroviral therapy (HAART).

Design

We used a clinical database of HIV-infected patients to calculate the resource use and cost of care for different stages of HIV infection. Costs were incorporated into a computer-based, probabilistic simulation model of the natural history and treatment of HIV infection to estimate the lifetime cost of treating patients with HIV disease.

Setting

A northern France HIV clinical cohort.

Participants

1232 HIV-infected patients followed from January 1994 through July 1998.

Results

In the absence of an AIDS-defining event, the average total cost of care ranged from 670 euros (1 euro=US $1.19) per person-month in the highest CD4 stratum (>500/μl) to 1060 euros per person-month in the lowest CD4 stratum (≤50/μl). The mean cost of care was estimated at 3370 euros per person-month during the initial months around the occurrence of an AIDS-defining event; at 1750 euros per person-month during the period spanning from 2 months after the diagnosis of specific AIDS-defining event to 1 month prior to death; and at 13 010 euros per person-month in the final month prior to death. If clinical management of HIV infection began at a CD4 cell count of 378/μl, as in this cohort, the discounted lifetime cost of treating an HIV-infected French patient was estimated at 214 000 euros. The undiscounted costs were 309 000 euros over a projected life expectancy of 16.4 years.

Conclusion

The cost of HIV disease varies widely depending upon the stage of illness. These estimates of stage-specific and lifetime costs of HIV care will assist health policy planners in assessing the burden of disease in the era of HAART and projecting future resource requirements.

HIV chemotherapy

The use of chemotherapy to suppress replication of the human immunodeficiency virus (HIV) has transformed the face of AIDS in the developed world. Pronounced reductions in illness and death have been achieved and healthcare utilization has diminished. HIV therapy has also provided many new insights into the pathogenesis and the viral and cellular dynamics of HIV infection. But challenges remain. Treatment does not suppress HIV replication in all patients, and the emergence of drug-resistant virus hinders subsequent treatment. Chronic therapy can also result in toxicity. These challenges prompt the search for new drugs and new therapeutic strategies to control chronic viral replication.