Estimated Lifetime HIV-Related Medical Costs in the United States

Projecting the Potential Clinical and Economic Impact of Human Immunodeficiency Virus Prevention Resource Reallocation in Tennessee

BACKGROUND

In 2023, Tennessee replaced $6.2 M in US Centers for Disease Control and Prevention (CDC) human immunodeficiency virus (HIV) prevention funding with state funds to redirect support away from men who have sex with men (MSM), transgender women (TGW), and heterosexual Black women (HSBW) and to prioritize instead first responders (FR), pregnant people (PP), and survivors of sex trafficking (SST).

METHODS

We used a simulation model of HIV disease to compare the clinical impact of Current, the present allocation of condoms, preexposure prophylaxis (PrEP), and HIV testing to CDC priority risk groups (MSM/TGW/HSBW); with Reallocation, funding instead increased HIV testing and linkage of Tennessee-determined priority populations (FR/PP/SST). Key model inputs included baseline condom use (45%-49%), PrEP provision (0.1%-8%), HIV testing frequency (every 2.5-4.8 years), and 30-day HIV care linkage (57%-65%). We assumed Reallocation would reduce condom use (-4%), PrEP provision (-26%), and HIV testing (-47%) in MSM/TGW/HSBW, whereas it would increase HIV testing among FR (+47%) and HIV care linkage (to 100%/90%) among PP/SST.

RESULTS

Reallocation would lead to 166 additional HIV transmissions, 190 additional deaths, and 843 life-years lost over 10 years. HIV testing reductions were most influential in sensitivity analysis; even a 24% reduction would result in 287 more deaths compared to Current. With pessimistic assumptions, we projected 1359 additional HIV transmissions, 712 additional deaths, and 2778 life-years lost over 10 years.

CONCLUSIONS

Redirecting HIV prevention funding in Tennessee would greatly harm CDC priority populations while conferring minimal benefits to new priority populations.

Cost and Activity Analysis of Patient Navigation for Persons With HIV: Comparing Health Department and Health Clinic Delivered Interventions

BACKGROUND

Housing and employment are key factors in the health and well-being of people with HIV (PWH). Patient navigation programs to improve housing and employment show success in achieving viral suppression. Replicating patient navigation interventions to improve population health is needed. Understanding costs associated with patient navigation is a key next step. Therefore, the purpose of this study is to describe the costs associated with delivering patient navigator interventions in two different organizations to improve housing and employment for PWH.

METHODS

We conducted a cost analysis of two models of patient navigation. Costs were collected from two sites' payroll, invoices, contracts, and receipts. Pre-implementation and implementation costs and utilization of service costs are presented. Potential reimbursement costs were calculated based on salaries from the Department of Labor.

RESULTS

The health clinic's pre-implementation costs were higher ($169,133) than the health department's ($22,018). However, costs of patient navigation during the 2-year intervention were similar between health clinic and health department ($264,985 and $232,923, respectively). The health clinic reported more total time spent with clients (16,013.7 hours) than the health department (1,883.8 hours). The costs per additional person suppressed were $20,632 versus $37,810 for the health department and health clinic, respectively, which are lower than the average lifetime cost of HIV treatment.

DISCUSSION

Replicability and scalability of a patient navigation intervention are possible in both health clinic and health department settings. Each site had specific costs, client needs, and other factors that required adaptations to successfully implement the intervention. Future programs should consider tailoring costs to site-specific factors to improve outcomes. Policymakers and public health officials should consider using these results to improve planning and investment in HIV treatment and prevention interventions.

An Interactive Modeling Tool for Projecting the Health and Direct Medical Cost Impact of Changes in the Sexually Transmitted Diseases Prevention Program Budgets

CONTEXT

Estimating the return on investment for public health services, tailored to the state level, is critical for demonstrating their value and making resource allocation decisions. However, many health departments have limited staff capacity and expertise to conduct economic analyses in-house.

PROGRAM

We developed a user-friendly, interactive Excel-based spreadsheet model that health departments can use to estimate the impact of increases or decreases in sexually transmitted infection (STI) prevention funding on the incidence and direct medical costs of chlamydia, gonorrhea, syphilis, and STI-attributable HIV infections. Users tailor results to their jurisdictions by entering the size of their population served; the number of annual STI diagnoses; their prior annual funding amount; and their anticipated new funding amount. The interface was developed using human-centered design principles, including focus groups with 15 model users to collect feedback on an earlier model version and a usability study on the prototype with 6 model users to finalize the interface.

IMPLEMENTATION

The STI Prevention Allocation Consequences Estimator ("SPACE Monkey 2.0") model will be publicly available as a free downloadable tool.

EVALUATION

In the usability testing of the prototype, participants provided overall positive feedback. They appreciated the clear interpretations, outcomes expressed as direct medical costs, functionalities to interact with the output and copy charts into external applications, visualization designs, and accessible information about the model's assumptions and limitations. Participants provided positive responses to a 10-item usability evaluation survey regarding their experiences with the prototype.

DISCUSSION

Modeling tools that synthesize literature-based estimates and are developed with human-centered design principles have the potential to make evidence-based estimates of budget changes widely accessible to health departments.

Frontal cortical volume deficits as enduring evidence of childhood abuse in community adults with AUD and HIV infection comorbidity

Background

Childhood abuse is an underappreciated source of stress, associated with adverse mental and physical health consequences. Childhood abuse has been directly associated with risky behavior thereby increasing the likelihood of alcohol misuse and risk of HIV infection, conditions associated with brain structural and functional deficits. Here, we examined the neural and behavioral correlates of childhood trauma history in alcohol use disorder (AUD), HIV infection (HIV), and their comorbidity (AUD+HIV).

Methods

Occurrence of childhood trauma was evaluated by retrospective interview. Cortical (frontal, temporal, parietal, and occipital), subcortical (hippocampus, amygdala), and regional frontal volumes were derived from structural MRI, adjusted for intracranial volume and age. Test scores of executive functioning, attention/working memory, verbal/visual learning, verbal/visual memory, and motor speed functional domains were standardized on age and education of a laboratory control group.

Results

History of childhood abuse was associated with smaller frontal lobe volumes regardless of diagnosis. For frontal subregional volumes, history of childhood abuse was selectively associated with smaller orbitofrontal and supplementary motor volumes. In participants with a child abuse history, poorer verbal/visual memory performance was associated with smaller orbitofrontal and frontal middle volumes, whereas in those without childhood abuse, poorer verbal/visual memory performance was associated with smaller orbitofrontal, frontal superior, and supplemental motor volumes.

Conclusions

Taken together, these results comport with and extend the findings that childhood abuse is associated with brain and behavioral sequelae in AUD, HIV, and AUD+HIV comorbidity. Further, these findings suggest that sequelae of abuse in childhood may be best conceptualized as a spectrum disorder as significant deficits may be present in those who may not meet criteria for a formal trauma-related diagnosis yet may be suffering enduring stress effects on brain structural and functional health.

Weathering the Storm: Syringe Services Program Laws and Human Immunodeficiency Virus During the COVID-19 Pandemic

BACKGROUND

Syringe services programs (SSPs) are community-based prevention programs that provide a range of harm reduction services to persons who inject drugs. Despite their benefits, SSP laws vary across the United States. Little is known regarding how legislation surrounding SSPs may have influenced HIV transmission over the COVID-19 pandemic, a period in which drug use increased. This study examined associations between state SSP laws and HIV transmission among the Medicaid population before and after the COVID-19 pandemic.

METHODS

State-by-month counts of new HIV diagnoses among the Medicaid population were produced using administrative claims data from the Transformed Medicaid Statistical Information System from 2019 to 2020. Data on SSP laws were collected from the Prescription Drug Abuse Policy System. Associations between state SSP laws and HIV transmission before and after the start of the COVID-19 pandemic were evaluated using an event study design, controlling for the implementation of COVID-19 nonpharmaceutical interventions and state and time fixed effects.

RESULTS

State laws allowing the operation of SSPs were associated with 0.54 (P = 0.044) to 1.18 (P = 0.001) fewer new monthly HIV diagnoses per 100,000 Medicaid enrollees relative to states without such laws in place during the 9 months after the start of the COVID-19 pandemic. The largest effects manifested for population subgroups disproportionately affected by HIV, such as male and non-Hispanic Black Medicaid enrollees.

CONCLUSION

Less restrictive laws on SSPs may have helped mitigate HIV transmission among the Medicaid population throughout the COVID-19 pandemic. Policymakers can consider implementing less restrictive SSP laws to mitigate HIV transmission resulting from future increases in injection drug use.

DISCLAIMER

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

The impact of pet ownership on healthcare access and utilization among people with HIV

Though bonds with pets can be health-promoting for people with HIV (PWH), recent studies indicate that owning pets may complicate healthcare access, especially for those with fewer economic resources, poorer social support, and a strong human-animal bond. In this study, we make a case for considering pets to be an important element of the social environment that can influence healthcare access and utilization among PWH. Pet-owning PWH (n = 204) were recruited at healthcare and community sites throughout Florida as part of a larger survey study (the “Florida Cohort”). We developed a 12-item index of pet-related barriers to healthcare, which was designed to assess whether the participants experienced or anticipated any barriers to accessing and/or utilizing timely healthcare or health-related services due to pet caregiving or concerns about pet welfare. We estimated a series of regression models (negative binomial, logistic regression) to assess the effects of comfort from companion animals, human social support, healthcare needs, and sociodemographic characteristics on 1) the total number of pet-related healthcare barriers endorsed, 2) previously experienced pet-related healthcare barriers, and 3) anticipated pet-related healthcare barriers. Thirty-six percent of the sample reported at least one experienced or anticipated pet-related barrier to their healthcare; 17% reported previous healthcare barriers and 31% anticipated future healthcare barriers. Greater comfort from companion animals, greater healthcare needs, and poorer social support were associated with a greater probability of experiencing or anticipating any pet-related healthcare barriers. Those who identified racially as Black were less likely to anticipate future healthcare barriers than those who were White. Income was associated with pet-related healthcare barriers in all models. Given the importance of health maintenance for PWH and previous research suggesting pets may be an important emotional support for this population, social safety net programs and community partnerships that support multispecies families are strongly recommended.

Factors Associated with Antiretroviral Therapy Adherence Among a Community-Based Sample of Sexual Minority Older Adults with HIV

Older sexual minorities (e.g., gay, bisexual) living with HIV are at risk for poor HIV outcomes due to their frequent experience with both psychosocial challenges and structural barriers to care. This study utilized a stochastic search variable selection (SVSS) approach to explore potential psychosocial and structural factors associated with HIV-related health outcomes among a community-based sample of older sexual minorities (N = 150) in South Florida, an U.S. HIV-epidemic epicenter. After SVSS, a forward entry regression approach suggested unstable housing, illicit substance use, current nicotine use, and depression were all associated with poorer ART adherence among older sexual minority adults living with HIV. No associations between potential correlates and biological measures of HIV disease severity were observed. Findings highlight a need to focus on multiple levels of intervention that target a combination of psychosocial and structural factors to improve HIV-care outcomes among older sexual minorities and achieve Ending the HIV Epidemic goals.

Longitudinal Associations of Psychiatric Risk Factors with Non-psychiatric Hospitalization in a Large Cohort of People Living with HIV in New York City

Hospitalizations among people living with HIV (PLWH) are frequent and costly. This study examined the association between psychiatric, HIV-related, and demographic factors and hospitalization rates among PLWH using data from the Einstein-Rockefeller-City University of New York Center for AIDS Research Clinical Cohort Database. Of the 10,215 PLWH included in the sample, 45% had at least one non-psychiatric hospitalization between 2009 and 2018, with significant risk factors including prior psychiatric outpatient visits, depression, or alcohol-related disorder diagnoses, female sex, older age, CD4 count < 500 cells/uL, and detectable viral load. Additionally, 14% had an HIV-related hospitalization, with significant risk factors including prior psychiatric outpatient visits, alcohol- and substance-related disorder diagnoses, female sex, older age, CD4 count < 500 cells/uL, and detectable viral load. The study emphasizes the need for tailored interventions, including integrated treatment and comprehensive case management, for PLWH with comorbid psychiatric disorders, women, and older adults.

Influence of childhood trauma, HIV infection, alcohol use disorder, and resilience on health-related quality of life in adulthood

Experience of childhood trauma, especially physical, emotional, and sexual abuse, carries a risk for developing alcohol use disorder (AUD) and engaging in risky behaviors that can result in HIV infection. AUD and HIV are associated with compromised self-reported health-related quality of life (HRQoL) possibly intersecting with childhood trauma. To determine whether poor HRQoL is heightened by AUD, HIV, their comorbidity (AUD + HIV), number of trauma events, or poor resilience, 108 AUD, 45 HIV, 52 AUD + HIV, and 67 controls completed the SF-21 HRQoL, Brief Resilience Scale (BRS), Ego Resiliency Scale (ER-89), and an interview about childhood trauma. Of the 272 participants, 116 reported a trauma history before age 18. Participants had a blood draw, AUDIT questionnaire, and interview about lifetime alcohol consumption. AUD, HIV, and AUD + HIV had lower scores on HRQoL and resilience composite comprising the BRS and ER-89 than controls. Greater resilience was a significant predictor of better quality of life in all groups. HRQoL was differentially moderated in AUD and HIV: more childhood traumas predicted poorer quality of life in AUD and controls, whereas higher T-lymphocyte count contributed to better quality of life in HIV. This study is novel in revealing a detrimental impact on HRQoL from AUD, HIV, and their comorbidity, with differential negative contribution from trauma and beneficial effect of resilience to quality of life. Channeling positive effects of resilience and reducing the incidence and negative impact of childhood trauma may have beneficial effects on health-related quality of life in adulthood independent of diagnosis.

Economic Burden of Cancer for the First Five Years after Cancer Diagnosis in Patients with Human Immunodeficiency Virus in Korea

This study aimed to estimate the medical cost of cancer in the first five years of diagnosis and in the final six months before death in people who developed cancer after human immunodeficiency virus (HIV) infection in Korea. The study utilized the Korea National Health Insurance Service-National Health Information Database (NHIS-NHID). Among 16,671 patients diagnosed with HIV infection from 2004 to 2020 in Korea, we identified 757 patients newly diagnosed with cancer after HIV diagnosis. The medical costs for 60 months after diagnosis and the last six months before death were calculated from 2006 to 2020. The mean annual medical cost due to cancer in HIV-infected people with cancer was higher for acquired immunodeficiency syndrome (AIDS)-defining cancers (48,242 USD) than for non-AIDS-defining cancers (24,338 USD), particularly non-Hodgkin's lymphoma (53,007 USD), for the first year of cancer diagnosis. Approximately 25% of the cost for the first year was disbursed during the first month of cancer diagnosis. From the second year, the mean annual medical cost due to cancer was significantly reduced. The total medical cost was higher for non-AIDS-defining cancers, reflecting their higher incidence rates despite lower mean medical costs. The mean monthly total medical cost per HIV-infected person who died after cancer diagnosis increased closer to the time of death. The estimated burden of medical costs in patients with HIV in the present study may be an important index for defining healthcare policies in HIV patients in whom the cancer-related burden is expected to increase.

Closing the gaps in the continuum of depression care for persons with HIV: modeling the impact on viral suppression in the United States

OBJECTIVE

Depression is prevalent among persons with HIV (PWH) and is associated with poorer adherence and lack of viral load suppression (VLS). When treated for depression, PWH are more likely to stay in HIV care and adhere to medications; however, for many PWH, depression is not adequately diagnosed or treated. We adapted Progression and Transmission of HIV (PATH 3.0), a U.S. agent-based dynamic stochastic simulation model, by incorporating a continuum of depression care and estimating the impact on VLS of an enhanced depression diagnosis and care scenario (EDC).

METHODS

We compared EDC - whereby every PWH is assessed for depression, gets treatment if diagnosed, and of those, half achieve remission - to a status quo scenario (SQ) on VLS. Based on published findings, assumptions for SQ were: 34.7% depressed, 45% diagnosed, 55.3% treated and 33% of treated achieving remission. Compared to PWH without depression, we assumed the probability of being non-virally suppressed increased by 1.57 times for PWH with depression (PWH-D), and by 0.95 times for PWH with remitted depression.

RESULTS

There was an average increase of 14.6% (11.5-18.5) in the proportion of PWH-D who achieved VLS in EDC compared to SQ. Among all PWH, there was a 4.7% (3.4-6.0) increase in the proportion who achieved VLS in EDC compared to SQ.

CONCLUSIONS

Fully diagnosing and adequately treating depression would improve health and quality of life for a substantial proportion of PWH-D and result in a nearly 5% increase in expected rates of VLS in the United States, supporting national prevention goals.

The Antiviral Compound PSP Inhibits HIV-1 Entry via PKR-Dependent Activation in Monocytic Cells

Actin depolymerization factor (ADF) cofilin-1 is a key cytoskeleton component that serves to lessen cortical actin. HIV-1 manipulates cofilin-1 regulation as a pre- and post-entry requisite. Disruption of ADF signaling is associated with denial of entry. The unfolded protein response (UPR) marker Inositol-Requiring Enzyme-1α (IRE1α) and interferon-induced protein (IFN-IP) double-stranded RNA- activated protein kinase (PKR) are reported to overlap with actin components. In our published findings, Coriolus versicolor bioactive extract polysaccharide peptide (PSP) has demonstrated anti-HIV replicative properties in THP1 monocytic cells. However, its involvement towards viral infectivity has not been elucidated before. In the present study, we examined the roles of PKR and IRE1α in cofilin-1 phosphorylation and its HIV-1 restrictive roles in THP1. HIV-1 p24 antigen was measured through infected supernatant to determine PSP's restrictive potential. Quantitative proteomics was performed to analyze cytoskeletal and UPR regulators. PKR, IRE1α, and cofilin-1 biomarkers were measured through immunoblots. Validation of key proteome markers was done through RT-qPCR. PKR/IRE1α inhibitors were used to validate viral entry and cofilin-1 phosphorylation through Western blots. Our findings show that PSP treatment before infection leads to an overall lower infectivity. Additionally, PKR and IRE1α show to be key regulators in cofilin-1 phosphorylation and viral restriction.

Evaluating the efficacy of an online, family-based intervention to promote adolescent sexual health: a study protocol for a randomized controlled trial

BACKGROUND

Adolescents in the U.S. experience significant negative sexual health outcomes, representing a public health priority in the U.S. Research shows that while parents play an influential role in shaping adolescent sexual behavior, surprisingly few programs engage parents in existing programming. Moreover, most efficacious parent-based programs focus on young adolescents, and few utilize delivery mechanisms that facilitate broad reach and scale-up. To address these gaps, we propose to test the efficacy of an online-delivered, parent-based intervention adapted to address both younger and older adolescent sexual risk behavior.

METHODS

In this parallel, two-arm, superiority randomized controlled trial (RCT), we propose to evaluate Families Talking Together Plus (FTT+), an adaptation of an existing and efficacious FTT parent-based intervention, in shaping sexual risk behavior among adolescents aged 12-17 and delivered via a teleconferencing application (e.g., Zoom). The study population will include n=750 parent-adolescent dyads recruited from public housing developments in the Bronx, New York. Adolescents will be eligible if they are between the ages of 12 and 17 years of age, self-report as Latino and/or Black, have a parent or primary caregiver, and are South Bronx residents. Parent-adolescent dyads will complete a baseline survey, after which they will be assigned to either the FTT+ intervention condition (n=375) or the passive control condition (n=375) in a 1:1 allocation ratio. Parents and adolescents in each condition will complete follow-up assessments 3 and 9 months post-baseline. The primary outcomes will include sexual debut and ever sex, and the secondary outcomes will include the frequency of sex acts, number of lifetime sexual partners, number of unprotected sex acts, and linkage to health and educational/vocational services in the community. We will utilize intent-to-treat analyses of 9-month outcomes and single degree of freedom contrasts comparing the intervention to the control group for primary and secondary outcomes.

DISCUSSION

The proposed evaluation and analysis of the FTT+ intervention will address gaps in the current cadre of parent-based programs. If efficacious, FTT+ would represent a model for scale-up and adoption of parent-based approaches designed to address adolescent sexual health in the U.S.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04731649. Registered on February 1, 2021.

Severely Restricting Abortion Threatens Equitable Health Outcomes for People With Human Immunodeficiency Virus

Equitable access to abortion is a critical component of reproductive care. Women with human immunodeficiency virus (HIV) in the United States are disproportionately Black and will be disproportionately affected by abortion bans following the Supreme Court's decision to overturn Roe v Wade. We argue that this decision is directly in conflict with the National HIV/AIDS Strategies and Centers for Disease Control and Prevention's goals to eliminate perinatal HIV transmission.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

A new mixed agent-based network and compartmental simulation framework for joint modeling of related infectious diseases- application to sexually transmitted infections

Background

A model that jointly simulates infectious diseases with common modes of transmission can serve as a decision-analytic tool to identify optimal intervention combinations for overall disease prevention. In the United States, sexually transmitted infections (STIs) are a huge economic burden, with a large fraction of the burden attributed to HIV. Data also show interactions between HIV and other sexually transmitted infections (STIs), such as higher risk of acquisition and progression of co-infections among persons with HIV compared to persons without. However, given the wide range in prevalence and incidence burdens of STIs, current compartmental or agent-based network simulation methods alone are insufficient or computationally burdensome for joint disease modeling. Further, causal factors for higher risk of coinfection could be both behavioral (i.e., compounding effects of individual behaviors, network structures, and care behaviors) and biological (i.e., presence of one disease can biologically increase the risk of another). However, the data on the fraction attributed to each are limited.

Methods

We present a new mixed agent-based compartmental (MAC) framework for jointly modeling STIs. It uses a combination of a new agent-based evolving network modeling (ABENM) technique for lower-prevalence diseases and compartmental modeling for higher-prevalence diseases. As a demonstration, we applied MAC to simulate lower-prevalence HIV in the United States and a higher-prevalence hypothetical Disease 2, using a range of transmission and progression rates to generate burdens replicative of the wide range of STIs. We simulated sexual transmissions among heterosexual males, heterosexual females, and men who have sex with men (men only and men and women). Setting the biological risk of co-infection to zero, we conducted numerical analyses to evaluate the influence of behavioral factors alone on disease dynamics.

Results

The contribution of behavioral factors to risk of coinfection was sensitive to disease burden, care access, and population heterogeneity and mixing. The contribution of behavioral factors was generally lower than observed risk of coinfections for the range of hypothetical prevalence studied here, suggesting potential role of biological factors, that should be investigated further specific to an STI.

Conclusions

The purpose of this study is to present a new simulation technique for jointly modeling infectious diseases that have common modes of transmission but varying epidemiological features. The numerical analysis serves as proof-of-concept for the application to STIs. Interactions between diseases are influenced by behavioral factors, are sensitive to care access and population features, and are likely exacerbated by biological factors. Social and economic conditions are among key drivers of behaviors that increase STI transmission, and thus, structural interventions are a key part of behavioral interventions. Joint modeling of diseases helps comprehensively simulate behavioral and biological factors of disease interactions to evaluate the true impact of common structural interventions on overall disease prevention. The new simulation framework is especially suited to simulate behavior as a function of social determinants, and further, to identify optimal combinations of common structural and disease-specific interventions.

Assessing the individual benefits of reducing HIV diagnosis delay and increasing adherence to HIV care and treatment

We used an agent-based simulation model (Progression and Transmission of HIV) to follow for 20 years a cohort of persons in the United States infected with HIV in 2015. We assessed the benefits of reducing the delay between HIV infection and diagnosis and increasing adherence to HIV care and treatment on the percent of persons surviving 20 years after infection, average annual HIV transmission rates, and time spent virally suppressed. We examined average diagnosis delays of 1.0-7.0 years, monthly care drop-out rates of 5% to 0.1%, and combinations of these strategies. The percent of the cohort surviving the first 20 years of infection varied from 70.8% to 77.5%, and the annual transmission risk, from 1.5 to 5.2 HIV transmissions per 100 person-years. Thus, individuals can enhance their survival and reduce their risk of transmission to partners by frequent testing for HIV and adhering to care and treatment.

Cost of non‐communicable diseases in people living with HIV in the Central Denmark Region

OBJECTIVE

To estimate the economic burden of non-communicable diseases (NCDs) in people living with HIV (PLWH) in Denmark.

METHODS

We conducted a cohort study using population-based Danish medical registries including all adult residents of the Central Denmark Region registered with a first-time HIV-diagnosis during the period 2006-2017. For each PLWH, we matched 10 persons without HIV from the background population by birth year, sex and municipality of residence. Information on healthcare utilization and costs for the PLWH and non-HIV cohorts was retrieved from register data. For each cohort, we estimated the annual costs for major disease categories (HIV care, other somatic care, and psychiatric care) in the period from 3 years before to 9 years after diagnosis/matching date.

RESULTS

We identified 407 PLWH and 4070 persons from the background population. The total healthcare costs during the study period were approximately three times higher for PLWH compared to the non-HIV cohort (€76 198 vs. €23 692). Average annual cost of hospital care, primary care and selected prescription medicine was estimated to be €6987 per year in the years after the diagnosis compared to €2083 per year in the non-HIV cohort. In PLWH, the cost of NCDs and psychiatric care was approximately two times higher than the cost of HIV care.

CONCLUSION

PLWH have higher healthcare costs stemming from three areas: excess cost due to the HIV infection, the treatment of NCDs, and psychiatric care.

Are Unequal Policies in Pre-Exposure Prophylaxis Uptake Needed to Improve Equality? An Examination Among Men Who Have Sex with Men in Los Angeles County

Racial and ethnic minority men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Los Angeles County (LAC), an important epicenter in the battle to end HIV. We examine tradeoffs between effectiveness and equality of pre-exposure prophylaxis (PrEP) allocation strategies among different racial and ethnic groups of MSM in LAC and provide a framework for quantitatively evaluating disparities in HIV outcomes. To do this, we developed a microsimulation model of HIV among MSM in LAC using county epidemic surveillance and survey data to capture demographic trends and subgroup-specific partnership patterns, disease progression, patterns of PrEP use, and patterns for viral suppression. We limit analysis to MSM, who bear most of the burden of HIV/AIDS in LAC. We simulated interventions where 3000, 6000, or 9000 PrEP prescriptions are provided annually in addition to current levels, following different allocation scenarios to each racial/ethnic group (Black, Hispanic, or White). We estimated cumulative infections averted and measures of equality, after 15 years (2021-2035), relative to base case (no intervention). By comparing allocation strategies on the health equality impact plane, we find that, of the policies evaluated, targeting PrEP preferentially to Black individuals would result in the largest reductions in incidence and disparities across the equality measures we considered. This result was consistent over a range of PrEP coverage levels, demonstrating that there are "win-win" PrEP allocation strategies that do not require a tradeoff between equality and efficiency.

Cost-Effectiveness Analysis of Standardized Clinical Nutrition Diagnosis and Treatment Pathway in Patients with Pulmonary Infection

Objective

From the perspective of economics, this study discusses the value of establishing a standardized clinical nutrition diagnosis and treatment pathway in the diagnosis and treatment of pulmonary infection and provides a reference for optimizing the diagnosis and treatment pathway of pulmonary infection.

Methods

The patients who received the nutrition diagnosis and treatment pathway intervention in 2017 were counted as the routine group and were subdivided into the conventional intervention group (C1) and conventional control group (C2) according to whether the standardized nutrition therapy was applied or not. The patients who received the nutrition diagnosis and treatment pathway intervention in 2020 were counted as the experimental group and were subdivided into the experimental intervention group (T1) and the experimental control group (T2) according to whether standardized intervention was applied or not. The total hospitalization expenses, average daily hospitalization cost, nutrition support expenses, plasma albumin before and after nutrition support, readmission, and other indicators of all patients were recorded and compared. The cost-effectiveness ratio (CER), incremental cost-effectiveness ratio (ICER), and cost-effectiveness threshold for cost-effectiveness analysis were adopted.

Results

Compared with the C2 group, the C1 group had higher total hospitalization expenses, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Compared with the T2 group, the T1 group had higher total hospitalization cost, average daily hospitalization expenses, nutritional support expenses, and plasma albumin improvement rate and lower readmission rate (P < 0.001). Taking the improvement rate of plasma albumin as the effect index, compared with the C1 group, the T1 group has less investment cost and better effect, and the ICER is negative (below the cost-effect threshold). And taking the readmission rate as the effective index, compared with the C1 group, the T1 group invested less cost and had a better effect, and the ICER was negative (below the cost-effect threshold).

Conclusion

For the patients with pulmonary infection, whether the improvement rate of plasma albumin or the readmission rate is used as the impact index, the standardized nutrition diagnosis and treatment pathway in 2020 is more economical than the nonstandardized nutrition diagnosis and treatment pathway.

The shifting age distribution of people with HIV using antiretroviral therapy in the United States

OBJECTIVE

To project the future age distribution of people with HIV using antiretroviral therapy (ART) in the United States, under expected trends in HIV diagnosis and survival (baseline scenario) and achieving the ending the HIV epidemic (EHE) goals of a 75% reduction in HIV diagnoses from 2020 to 2025 and sustaining levels to 2030 (EHE75% scenario).

DESIGN

An agent-based simulation model with mathematical functions estimated from North American AIDS Cohort Collaboration on Research and Design data and parameters from the US Centers for Disease Control and Prevention's annual HIV surveillance reports.

METHODS

The PEARL (ProjEcting Age, MultimoRbidity, and PoLypharmacy in adults with HIV) model simulated individuals in 15 subgroups of sex-and-HIV acquisition risk and race/ethnicity. Simulation outcomes from the baseline scenario are compared with outcomes from the EHE75% scenario.

RESULTS

Under the baseline scenario, PEARL projects a substantial increase in number of ART-users over time, reaching a population of 909 638 [95% uncertainty range (UR): 878 449-946 513] by 2030. The overall median age increased from 50 years in 2020 to 52 years in 2030, with 23% of ART-users age ≥65 years in 2030. Under the EHE75% scenario, the projected number of ART-users was 718 348 [703 044-737 817] (median age = 56 years) in 2030, with a 70% relative reduction in ART-users <30 years and a 4% relative reduction in ART-users age ≥65 years compared to baseline, and persistent heterogeneities in projected numbers by sex-and-HIV acquisition risk group and race/ethnicity.

CONCLUSIONS

It is critical to prepare healthcare systems to meet the impending demand of the US population aging with HIV.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

The Estimated Direct Lifetime Medical Costs of Sexually Transmitted Infections Acquired in the United States in 2018

BACKGROUND

We estimated the lifetime medical costs attributable to sexually transmitted infections (STIs) acquired in 2018, including sexually acquired human immunodeficiency virus (HIV).

METHODS

We estimated the lifetime medical costs of infections acquired in 2018 in the United States for 8 STIs: chlamydia, gonorrhea, trichomoniasis, syphilis, genital herpes, human papillomavirus (HPV), hepatitis B, and HIV. We limited our analysis to lifetime medical costs incurred for treatment of STIs and for treatment of related sequelae; we did not include other costs, such as STI prevention. For each STI, except HPV, we calculated the lifetime medical cost by multiplying the estimated number of incident infections in 2018 by the estimated lifetime cost per infection. For HPV, we calculated the lifetime cost based on the projected lifetime incidence of health outcomes attributed to HPV infections acquired in 2018. Future costs were discounted at 3% annually.

RESULTS

Incident STIs in 2018 imposed an estimated $15.9 billion (25th-75th percentile: $14.9-16.9 billion) in discounted, lifetime direct medical costs (2019 US dollars). Most of this cost was due to sexually acquired HIV ($13.7 billion) and HPV ($0.8 billion). STIs in women accounted for about one fourth of the cost of incident STIs when including HIV, but about three fourths when excluding HIV. STIs among 15- to 24-year-olds accounted for $4.2 billion (26%) of the cost of incident STIs.

CONCLUSIONS

Incident STIs continue to impose a considerable lifetime medical cost burden in the United States. These results can inform health economic analyses to promote the use of cost-effective STI prevention interventions to reduce this burden.

The Estimated Number and Lifetime Medical Cost of HIV Infections Attributable to Sexually Transmitted Infections Acquired in the United States in 2018: A Compilation of Published Modeling Results

BACKGROUND

The purpose of this study was to estimate the number and lifetime medical cost of HIV infections attributable to incident sexually transmitted infections (STIs) in the United States in 2018.

METHODS

We combined data from published models regarding the number or percentage of HIV infections attributable to STIs with updated estimates of the lifetime medical cost per HIV infection. We used 2 distinct calculation methods. Our first calculation used recent estimates of the percentage of HIV infections in men who have sex with men (MSM) attributable to gonorrhea and chlamydia. Our second calculation, based on older studies, used estimates of the expected number of STI-attributable HIV infections per new STI infection, for gonorrhea, chlamydia, syphilis, and trichomoniasis.

RESULTS

Our first calculation method suggested that 2489 (25th-75th percentiles, 1895-3000) HIV infections in 2018 among MSM could be attributed to gonorrhea and chlamydia, at an estimated lifetime medical cost of $1.05 billion (25th-75th percentiles, $0.79-$1.26 billion). Our second calculation method suggested that 2349 (25th-75th percentiles, 1948-2744) HIV infections in the general population (including MSM) could be attributed to chlamydia, gonorrhea, syphilis, and trichomoniasis acquired in 2018, at an estimated lifetime medical cost of $0.99 billion (25th-75th percentiles, $0.80-$1.16 billion).

CONCLUSIONS

Despite ambiguity regarding the degree to which STIs affect HIV transmission, our combination of data from published STI/HIV transmission models and an HIV lifetime medical cost model can help to quantify the estimated burden of STI-attributable HIV infections in the United States.