Resource utilization and direct costs of pediatric HIV in Italy

This multicenter, prospective, observational study assessed the global economic impact of HIV care in a large cohort of HIV-infected children and adolescents in Italy. Three pediatric departments of reference participated on a voluntary basis. Centers were asked to enroll all their children during the period April 2010-March 2011. At enrollment, a pediatrician completed a questionnaire for each patient, including the type of service at access (outpatient consultation or day hospital), laboratory tests, instrumental examinations, specialists' consultations, antiretroviral therapy and opportunistic illness prophylaxis. Eligible patients had a confirmed diagnosis of HIV infection caused by direct vertical maternal-fetal transmission, their age ranging from 0 to 24 years. Since patients routinely have quarterly check-ups in all three centers, we adopted a three-month time horizon. Health-care services were priced using outpatient and inpatient tariffs. Drug costs were calculated by multiplying the daily dose by the public price for each active ingredient. A total of 142 patients were enrolled. More than half the patients were female and the mean age was 14 years, with no significant differences by center. There were substantial differences in health-care management among the three centers, particularly as regards the type of access. One center enrolled the majority of its patients in day-hospital and prescribed a large number of clinical tests, while children accessed another center almost exclusively through outpatient consultation. Drug therapy was the main cost component and was very similar in all three centers. The day-hospital was the second highest cost component, much higher than outpatient consultation (including examinations), leading to significant differences between total costs per center. These findings suggest that a recommendation to the Italian National Health Service would be to use more outpatient consultation for patients' access in order to increase their efficiency in treating pediatric HIV infection.

Antiretroviral Therapy in the??Real World

OBJECTIVE AND METHODS

The aim of our study was to analyse retrospectively the nature and frequency of antiretroviral prescriptions for 990 HIV-infected patients followed at our outpatient centre in Bologna, Italy, from January 2003 to March 2004. The main focus of the study was to identify the most commonly prescribed combinations and their related expenses, in order to identify the most competitive treatment regimens with regard to costs. Prescriptions were given directly to patients at monthly intervals, and drug treatment adherence data was stored in an electronic database. Antiretroviral regimens administered for the longest period to each patient during the 15 months of the study were selected for the study. All patients treated for <9 consecutive months and/or with treatment adherence levels <90% were excluded. Physicians assessed antiretroviral therapy at least quarterly according to efficacy and safety criteria, but not in terms of pharmacoeconomic considerations. Direct pharmacy expenses were obtained for the 24 most commonly used therapeutic regimens, covering 80.1% of patients.

RESULTS

The zidovudine-lamivudine-efavirenz combination proved to be the most prescribed combination (7.3%), followed by zidovudine-lamivudine- nevirapine (7.1%), lamivudine-stavudine (6.2%), zidovudine-lamivudine- lopinavir-ritonavir (5.2%), didanosine-stavudine-lopinavir-ritonavir (4.8%), and lamivudine-stavudine-nevirapine (4.7%). Anti-HIV combinations varied from a minimum yearly cost of euro3895.6 for lamivudine-stavudine to euro9422.8 for the zidovudine-lamivudine-lopinavir-ritonavir combination (+241.9%) [year of costing 2003]. There was a significant difference between the two first-line regimens for antiretroviral-naive subjects, with lopinavir-ritonavir-based combinations costing more than euro9000 per patient/year compared with efavirenz-containing combinations, which were 28% less expensive. Mean daily costs varied substantially, from a minimum of euro10.7 per day for lamivudine-stavudine to a maximum of euro25.8 per day (+241.1%) for zidovudine-lamivudine-lopinavir-ritonavir. Regimens based on non-nucleoside reverse transcriptase inhibitors (NNRTIs) were less costly than most of those including protease inhibitors (PIs). The increased expense of each combination was compared with the cheapest therapeutic selection (lamivudine-stavudine), and costs of all triple combinations were also compared. Regimens based on NNRTIs accounted for 29.3% of our cohort (nevirapine-containing therapies 15.1%, and efavirenz-based ones 14.2%), while PIs were used in the majority of cases (37.3%), with lopinavir-ritonavir as the leading combination (13.6% of patients), followed by nelfinavir (9.9%) and indinavir (9.2%). When drug-related costs were examined, dual nucleoside analogues showed the lowest expense (euro10.7-euro11.6 per day), while triple nucleoside/nucleotide analogue combinations cost nearly twice as much (euro18.5-euro20.4 per day). Among the NNRTIs, there were comparable costs for nevirapine-based combinations (euro18.3-euro18.7 per day), while efavirenz-including regimens were 10% more costly (euro19.2-euro20.l per day). A very broad range of combinations and related costs were found with PIs, but apart from indinavir and saquinavir combinations (euro15.7-euro21.7 per day), all other regimens had a higher daily cost (from euro22.0 per day for ritonavir-based regimens to euro23.4-euro24.3 per day for nelfinavir combinations, and up to euro24.9-euro25.8 per day with lopinavir-ritonavir). When considering nelfinavir- and lopinavir-containing combinations, the difference compared with NNRTI-based regimens varied from 41% when nevirapine- and lopinavir-ritonavir were compared, to 11.6% when efavirenz and nelfinavir were compared.

CONCLUSIONS

Investigations that link prescribing patterns and related costs in the setting of HIV disease therapy are needed to improve patient management and help with the planning of healthcare resource allocation.

A Comparison of the Therapeutic Plan Costs in the Treatment of HIV-Positive Patients

OBJECTIVE

To determine the cost of each therapeutic protocol (TP) used for HIV-positive patients and to identify the most frequently adopted one by relating it to the cost and by identifying the drug (drugs) that is more competitive in relation to expense.

SETTING

Infectious Disease Department and Hospital Pharmacy, Ospedale Maggiore, Bologna, Italy. The department treats approximately 600 outpatients with HIV infection each year.

PATIENTS AND METHODS

464 patients with HIV infection were examined every 3 months and clinicians judged whether the treatment (usually consisting of three drugs) was to be continued or changed according to its effectiveness, availability and possible new treatment options. The study also ascertained the cost of antiretroviral drugs within the period 1 January 2001-30 April 2002, and identified the most commonly used therapeutic protocols, the relevant daily cost and the frequency of use in all patients. The cost of the various protocols (most TPs were grouped in the most frequently used 15 regimens) was considered only at the end of the study, in order to define the percentage differences in cost. Importantly, from the beginning, this aspect was not a primary factor in drug choice.

RESULTS

The antiretroviral drug cost was 4 448 186 Euro (euro) in 2001 and euro1 536 984 in the first 4 months of 2002, with an increase of 3.5% compared with the same period in 2001. In the 16 months under consideration, 55.21% of the cost was associated with nucleoside reverse transcriptase inhibitors (NRTI), 25.97% with protease inhibitors (PI) and 18.83% with non-nucleoside reverse transcriptase inhibitors (NNRTI). Among the 464 TPs considered, 331 (71.33%) were distributed among 15 prevalent TPs. The least expensive TP (euro9.95/day; time of costing 1 January 2001-30 April 2002) comprised two drugs (stavudine and lamivudine) and showed a cost differential of +euro16.74 (+62.70%) compared with the most expensive one (zidovudine, lamivudine, lopinavir and ritonavir). The most used TP (zidovudine, lamivudine and nevirapine) covered 61 cases (13.1%) with a daily cost of euro19.61 (time of costing 1 January 2001-30 April 2002).

CONCLUSIONS

This study demonstrated that, starting with decisions that take into account the efficacy of the therapy and the compliance of the patients, and choosing ethical protocols agreed upon with the patients, it is possible to reduce the costs of the TPs. Of the 464 TPs examined, NNRTIs were used in 46.7% of the cases and a PI in 39.6% (16.1% of the latter drug group was boosted with ritonavir). Only 7% of TPs used two drugs (NRTIs). The two less expensive TPs comprised two drugs only (NRTIs). Among the three-drug TPs with a lower cost, the drug pattern was two NRTIs and one NNRTI. The remaining TPs included a PI as a third drug and demonstrated a cost increase greater than 50% with respect to the less expensive treatment.