Antiretroviral therapy and health care utilization: a study of privately insured men and women with HIV disease

Detection of Patient HIV-1 Drug Resistance Mutations in Russia’s Northwestern Federal District in Patients with Treatment Failure

Highly active antiretroviral therapy (HAART) is currently a combination of three (less frequently four) antiretroviral drugs; these target pathways involved in various stages of HIV replication in the body. Treatment failure is a problem facing doctors and patients using HAART. The most common cause of therapeutic failure is the development of HIV drug resistance. The emergence of resistance is associated with processes involving mutation occurring in the viral genome under the influence of evolutionary factors. Sequencing reactions were performed using the AmpliSens HIV Resist-Seq. Assembly of consensus sequences from fragments obtained during sequencing was carried out using Unipro UGENE softwar. Isolate genotyping was performed using the MEGA-X software with the Neighbor-joining algorithm. According to the analysis, 72.05% of patients had at least one significant mutation associated with drug resistance for the corresponding viral subtype. HIV-1 A6 remains the predominant HIV-1 genetic variant in Russia’s Northwestern Federal District. Among samples with drug resistance mutations, in all cases, mutations associated with pharmacological resistance to two or three drug groups were found. Given the high incidence of resistance mutations in patients on ineffective ART, surveillance of HIV-1 drug resistance, in both ART-receiving and ART-naive individuals, appears necessary. A lack of vigilance and control measures may lead to the spread of primary ART-resistant HIV strains.

Social Determinants of Health and Retention in HIV Care Among Recently Incarcerated Women Living with HIV in Canada

Women living with HIV (WLWH) are over-represented in corrections in Canada, yet little is known about women's experiences post-release. We used CHIWOS cross-sectional data from WLWH to estimate associations between social determinants of health and HIV-related care outcomes among WLWH with recent (within past year) or ever (before past year) incarceration experience. Lifetime incarceration prevalence was 36.9% (6.5% recent; 30.4% ever), with significant differences by province of residence (British Columbia: 10% recent; 52% ever; Ontario: 5%; 24%; Quebec: 6%; 22%; p < 0.001). In adjusted multinomial logistic regression analyses, compared with never incarcerated, recent incarceration was associated with Indigenous ancestry, lower annual income (< $20,000 CAD), unstable housing, current sex work, injection drug use (IDU), and sub-optimal antiretroviral therapy (ART) adherence, while ever incarceration was associated with current sex work, IDU, and experiencing adulthood violence. Our findings have implications regarding supports needed by WLWH in the post-release period, including ART adherence and achieving health and social goals.

Using information on ART costs and benefits to mobilise resources - comparing different methods and contexts

Sustaining HIV and AIDS responses depends on a mix of donor, government and private funders. Their decisions about investing in HIV treatment may be informed by various types of economic evaluations, which may be more or less useful for different contexts. This paper benchmarks methods against each other. Epidemiological and demographic impacts of HIV and antiretroviral therapy (ART) from 1996-2015 were quantified using country- specific spectrum files. The study compared societal benefits of ART using the full income (FI) methodology with "conventional" benefit, utility and effectiveness estimates produced with the same data. The FI estimates suggested $3.50 in benefits per dollar spent on ART globally, 2.6 times larger than productivity-related measures of benefits, of $1.33 in benefits per dollar. Higher benefit-cost ratios are mainly because FI reflects value of life beyond what people produce at work and in non-working age groups, and allocates the future stream of benefits in the year that death is avoided. ART costs were 0.78 times per capita GDP per quality-adjusted life-years gained globally. FI benefit-cost ratios are considerably higher in upper- and lower-middle-income countries than in low- or high-income countries. Productivity-based benefits also exceeded costs in all but one region but had smaller ratios and different regional patterns. Per capita GDP per quality-adjusted life-years ratios were below 1.2 for all regions and country income bands, suggesting cost effectiveness. The fact that FI returns of ART are higher than productivity returns, helps to quantify developmental benefits of interventions that directly extend life and its quality, arguably the objective of development. They provide an important argument to increase budget allocations to health sectors for ART scale-up, and not just reallocate existing health resources. Benchmarking FI returns against cost per quality- adjusted life-years may allow comparison to other "cost effective" health interventions. However, caution should be taken in extrapolations between measures, because they produce different rankings across country categories.

Demographic and Health Services Characteristics Associated With Testing for Sexually Transmitted Infections Among a Commercially Insured Population of HIV-Positive Patients

BACKGROUND

Presence of a sexually transmitted infection (STI) can increase the likelihood of HIV transmission, and current treatment guidelines indicate that HIV-positive persons should be screened yearly for STIs. Therefore, we examined recent insurance claims data to determine whether private insurance beneficiaries who are HIV-positive were receiving recommended STI testing.

METHODS

We used data from the 2011 and 2012 MarketScan data sets, a longitudinal population-based database that collects claims from commercially insured persons in private insurance and is conducted by Truven Health Analytics. Over a 13-month period, we calculated rates of testing for chlamydia, gonorrhea, and syphilis among an HIV-positive population and determined the factors that contributed to differences in testing rates.

RESULTS

Overall testing rates were 22.2% for chlamydia, 21.9% for gonorrhea, and 51.1% for syphilis. Significant predictors of STI testing were sex, age, type of health plan, engagement with the health care system, and geographic location. Most notably, persons receiving viral load testing were more likely to receive testing for chlamydia [odds ratio (OR): 1.72; 95% confidence interval (CI): 1.63 to 1.81], gonorrhea (OR: 1.72; 95% CI: 1.64 to 1.81), and syphilis (OR: 3.38; 95% CI: 3.25 to 3.53) compared with persons not receiving viral load testing.

DISCUSSION

Not all commercially insured HIV-positive patients are receiving recommended testing for STIs. Presence of STIs could affect the transmission of HIV and has deleterious effects on health outcomes of the patients. Targeted efforts based on demographics, health plan type, and other quality-of-care measures could help identify populations for whom testing rates for STIs among HIV-positive persons could be improved.

Sex differences in benzodiazepine use in the HIV-infected population

In the HIV-infected population there is a high prevalence of psychiatric disorders, conditions that often coexist with drug and alcohol dependence. Symptoms associated with psychiatric disorders are frequently managed with benzodiazepines, a class of medication often abused. We examined whether HIV-infected patients were more likely to fill a benzodiazepine prescription than their uninfected counterparts using a privately insured, nationally representative sample receiving clinical care between January 2007 and December 2009. Odds ratios (OR) and 95% confidence intervals (CI) to quantify the likelihood of receiving a benzodiazepine were calculated using multivariate logistic regression models. We examined the presence of interaction between HIV infection and sex using backwards elimination and by comparing stratum-specific OR to identify clinically meaningful differences. Overall, 323,796 beneficiaries were included in the sample, of which 723 were HIV infected. Bivariate analyses showed that compared to the uninfected sample, HIV-infected patients were more likely to have filled a benzodiazepine prescription (24% vs. 19%) during the study period. HIV-infected patients were also more likely to be male (80% vs. 44%), black (21% vs. 7%) and have a diagnosis of depression (12% vs. 8%) or insomnia (6% vs. 3%) than were uninfected patients. Adjusted for other covariates, HIV infection was associated with an increase (OR): 1.68, 95% CI: 1.39, 2.02) in the likelihood of filling a benzodiazepine prescription. When stratified by sex, HIV-infected males were more likely (OR: 1.68, 95% CI: 1.05, 2.67) than uninfected males to fill a benzodiazepine prescription while there was no observed difference in the likelihood of filling a benzodiazepine prescription between HIV-infected and uninfected females (OR: 1.12, 95% CI: 0.73, 1.70). Our findings suggest that HIV-infected patients, particularly HIV-infected males, are more likely to fill benzodiazepine prescriptions than their uninfected counterparts, highlighting the need for further research to investigate reasons for these observed differences.

Systemic barriers to health care access for U.S. women with HIV: the role of cost and insurance

Lack of access to health care has particularly brutal consequences for low-income U.S. women with HIV who, without regular and consistent primary care, including treatment with highly active antiretroviral therapy (HAART), are less likely to live long and well with HIV. This article explores barriers to basic health care encountered by a sample of 55 HIV-infected women from urban and rural Wisconsin who participated in a longitudinal, qualitative study. In a series of 10 in-depth, story-eliciting interviews over a two-year period, each woman explained in detail what it was like for her to obtain health care since becoming infected. Conveying women's subjective experiences of trying to get the care they needed, their stories highlight serious institutional impediments to health care and provide a discomfiting glimpse of the systemic forces that limit access to health itself. Findings convey how the extraordinarily high cost of U.S. health care, the unpredictable and disjointed array of out-of-pocket costs, and the complex and obfuscated intricacies of health insurance impeded women's access. They lived a paradoxical reality: having an illness they feared, needing treatment for long-term survival, and being unable to meet its costs. Each woman's story reflects deep fissures in the U.S. health care system.

Cost-effectiveness estimates for antenatal HIV testing in the Netherlands

This paper provides an estimation of the lifetime health-care cost of HIV-infected children and an update of the cost-effectiveness of universal HIV-screening of pregnant women in Amsterdam (The Netherlands). During 2003-2005, we collected data concerning the prevalence of newly diagnosed HIV-infected pregnant women in Amsterdam. Also, data on resource utilization and HAART regimen for HIV-infected children was gathered from a national registry. Using Kaplan-Meier survival analysis, we estimated the life-expectancy of a vertically HIV-infected child at 19 years, with the corresponding lifetime health-care costs of 179,974 Euros. HIV-screening of pregnant women could prevent 2.4 HIV transmissions annually in Amsterdam, based on an estimated prevalence of nine yet undiagnosed HIV-positive pregnant women per 10,000 pregnancies. We show that universal HIV screening during pregnancy generates significant net cost savings and health benefits in most situations. Universal antenatal HIV screening is justified in Amsterdam from a health-economic point of view.

Predictors of post-release primary care utilization among HIV-positive prison inmates: a pilot study

The primary aims of this exploratory pilot study were (1) to determine the proportion of a sample of HIV-positive inmates utilizing primary care after recent release, and (2) to identify variables associated with utilization of primary care at the time of a post-release interview. Sixty HIV-positive, male and female state prison inmates were interviewed approximately three months prior to release, and 30 were interviewed again between seven and 21 days after release. Variables associated with having utilized primary care at the time of a post-release interview (chi(2) p-values < 0.20) included: taking anti-HIV medications at the time of release, no alcohol use since release, living in the same place as before incarceration and rating of housing situation as 'comfortable' or 'very comfortable'. For exploratory purposes, these variables were entered into a logistic regression model. The model correctly classified 80% of cases overall. Future studies are required to ascertain whether these results would obtain with a statistically adequate sample size.

Gender differences in quality of HIV care in Ryan White CARE Act-funded clinics

BACKGROUND

Women with HIV infection have lagged behind men in receipt of critical health care, but it is not known if those disparities are due in part to where women receive care. We examined differences in care received by HIV-infected women and men in a national sample of Ryan White CARE Act-funded clinics and explored the influence of clinic characteristics on care quality.

METHODS

Record review was done on a sample of 9,015 patients who received care at 69 CARE Act-funded HIV primary care clinics that participated in a quality improvement study. Outcome measures studied were highly active antiretroviral therapy (HAART) use, HIV viral suppression, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, screening, and other disease prevention efforts.

RESULTS

Women were less likely than men to receive HAART (78% versus 82%, p < .001), receive PCP prophylaxis (65% versus 75%, p < .0001), or have their hepatitis C virus status known (87% versus 88%, p = .02) despite being seen more regularly (69% versus 66%, p = .04). Sites serving high percentages of women delivered similar or better care for both men and women than other sites. Although sites serving a higher percent of women had more support services such as case management and onsite obstetrician-gynecologists and provided Pap smears at higher rates, women at such sites remained less likely than men to receive important HIV care including HAART and PCP prophylaxis.

CONCLUSIONS

The gap in the quality of care provided to HIV-infected men and women in critical areas persists, and is not explained by the types of sites where men and women receive care.

Development of a capitation scale for IDF career soldiers in Israel

The Israeli National Health Insurance Law allocates a national healthcare budget to the sickness funds, which provide medical care to civilian population. Medical care for members of the IDF is financed through the budget of the Ministry of Defense and is not included in the national healthcare budget. Benefits provided to soldiers serving in the permanent forces are far more extensive than those provided to civilians. Because of no co-payments, poor management, and the cost-based budget, military healthcare costs in Israel are expected to exceed civilian healthcare costs, adjusting for age and sex. The present paper derives age- and sex-based capitation rates for military personnel, and compares military and civilian age-based expenditure and capitation rates. The study population comprised career soldiers and civilians aged 21-54 years. Expenses of career soldiers were calculated to provide information on the financial costs of medical services for each age group in 2003. Overall expenses for women were higher than for men in all age groups. As anticipated, the older the group, the higher the total expenditure for both men and women. In-patient care represented a higher percentage of the total costs for men (28.3%) than for women (22.1%). Emergency room care was higher for women in the 22-24 age group but comparable to that of men in higher age groups. Specialist visits represented a significantly higher percentage of the total costs for women than for men in the 22-24 and 25-34 age groups (by 6% and 15%, respectively). The difference decreased to 13% in the 35-44 age groups and, in the 45-54 age group, the difference for men was 14% higher than for women. Military costs were similar to civilian costs in the 22-24 age groups, higher in the following two groups, and lower in the 45-54 age group. Like in other organizations, military healthcare services might benefit from outsourcing. The inequality in medical services to soldiers and civilians, the over-use of the military healthcare system, and the decrease of standards and budgetary resources will compel the establishment of more creative means of providing these services through contracts and agreements, perhaps through the civilian sickness funds.

Updated estimates of healthcare utilization and costs among perinatally HIV-infected children

OBJECTIVES

This study examined changes in healthcare use among perinatally HIV-infected children and developed new estimates of expected lifetime treatment costs.

METHODS

The study analyzed longitudinal medical record data from the Pediatric Spectrum of Disease study on perinatally HIV-infected children enrolled in 6 US sites during 1995 and 2001 for enrollee characteristics including healthcare utilization. For the year 2001, costs were assigned to hospitalization, HIV-related drug usage, and laboratory testing. To estimate lifetime treatment costs based on those categories, median survival times of 9, 15, and 25 years were assumed and average annual healthcare utilization costs were applied to each year of survival.

RESULTS

From 1995 to 2001, hospitalization rates fell from 0.67 per child-year to 0.23 per child-year (P < 0.05). In 2001, the average cost of healthcare utilization per child was $12,663, including $2164 for hospitalization, $9505 for HIV-related drugs, and $994 for laboratory tests. The discounted lifetime treatment cost, based on those 3 cost categories, was $113,476 for 9 years of survival, $151,849 for 15 years, and $228,155 for 25 years.

CONCLUSIONS

Hospitalizations among perinatally HIV-infected children decreased significantly from 1995 to 2001. Compared with previously published estimates, lifetime treatment costs for children perinatally infected with HIV have remained relatively stable. However, as years of survival increase for this population, lifetime costs also are likely to increase.

Economic models of antiretroviral therapy: searching for the optimal strategy

The diffusion of protease inhibitors and non-nucleoside reverse transcriptase inhibitors in the US in 1996 and 1997 reduced the number of deaths attributable to HIV disease and changed the way we think about the illness. Today, HIV disease may be deemed a fairly expensive chronic condition rather than an intolerably expensive fatal illness. Although most studies have found that patients receiving new drug therapies are hospitalised less frequently than patients who received early drug therapies, it is unclear whether the diffusion of new drug therapies has increased or decreased the annual cost of care. However, it is evident that the diffusion of new drug therapies has increased the lifetime cost of care. Analysts rely on models to simulate the course and cost of HIV disease. This study reviews the evolution of these models, paying particular attention to how these models estimate the cost of care. The primary findings of this review are that the economic data used in these models are often too imprecise to accurately identify the cost of each disease stage and are almost always outdated. Moreover, it was found that estimates of drug costs in these models may not accurately reflect actual expenditures.

Inappropriate drug combinations among privately insured patients with HIV disease

OBJECTIVE

The objective of this study was to examine inappropriate drug combinations among privately insured patients with HIV disease.

DATA

Data were obtained from the MarketScan Commercial Claims and Encounter Database for the years 1999 and 2000.

METHODS

Each of the 2110 person-years of data examined in this study represents the claims experience of an enrollee with HIV disease who filled an antiretroviral medication prescription in either 1999 or 2000 for a protease inhibitor or nonnucleoside reverse transcription inhibitor. This study compares the claims experience of patients with HIV who filled a prescription for an inappropriate drug combination as specified in guidelines jointly issued by the U.S. Department of Health and Human Services and the Henry J. Kaiser Family Foundation with the claims experience of patients who did not.

RESULTS

An inappropriate drug combination was found in approximately 2% of the person-years of data, and persons who experienced an inappropriate drug combination had higher claims costs. One half of all of the inappropriate drug combinations involved a single lipid-lowering agent (simvastatin). Protease inhibitors decrease the activity of the enzyme that metabolizes simvastatin, and high concentrations of simvastatin have been associated with muscle damage. We found that patients who received protease inhibitors and simvastatin were more likely to experience muscle damage.

CONCLUSION

Persons with HIV have compromised immune systems and often take many medications. Thus, the risk and consequences of medication errors are severe, and both providers and patients should carefully monitor drug regimens to ensure that they are both safe and efficacious.