Daniel M. Keller, PhD

November 01, 2011

November 1, 2011 (Boston, Massachusetts) — Patients presenting late with HIV incur significantly higher healthcare costs, Maria Martinez-Colubi, MD, from the Ramón y Cajal Hospital in Madrid, Spain, told delegates here at the 13th European AIDS Conference of the European AIDS Clinical Society (EACS).

Dr. Martinez-Colubi said much of the difference is attributable to increased hospital admissions, but drug costs are also higher for individuals coming in late. In a survey conducted in September 2007, 38% of new patients with HIV in Spain presented late.

She also reported that for the individual, delayed HIV diagnosis (DD) increases the risk for HIV-related morbidity and mortality, as well as serious non-AIDS events, and predicts a poor response to therapy. For the community, there is an increased risk for transmission of HIV and increased healthcare costs.

This prospective cohort study involved 426 HIV-infected individuals who had never been treated with highly active antiretroviral therapy and who came to a single tertiary care hospital in Madrid between 2004 and 2009. DD was defined as having a CD4 lymphocyte count less than 350 cells/μL and/or an AIDS-defining illness on presentation. Those patients with a CD4 count of 350 cells/μL or greater at HIV diagnosis were considered as having early diagnosis (ED).

Of the 426 patients, 266 (62%) presented with DD. With a mean follow-up of 38.5 ± 20.5 months, the researchers calculated total patient costs/month of follow-up for both DD and ED patients, which included costs of outpatient hospital visits, hospital admissions, and highly active antiretroviral therapy medications.

The DD patients had a mean age of 38 years, 78.6% were men, 37.2% were men who had sex with men, 38.0% were infected through heterosexual transmission, 17.7% were intravenous drug users, and 7.1% had other or unknown modes of transmission. Most (69.9%) were from Western Europe, with some Latin Americans (18.4%) and some Africans (10.5%). More than half (55.6%) had no schooling or had attended only primary school.

Predictors of DD

The researchers found that being older than 40 years, being heterosexual, having an unknown mode of HIV transmission, and having no schooling were all predictors of having a DD. An unknown mode of transmission was the strongest predictor of DD, with a 7.5-fold increased DD risk.

Table. Factors Associated With DD

  Odds Ratio by Multivariate Analysis (95% Confidence Interval)
Older than 40 years 1.05 (1.02 - 1.07)
Heterosexual 1.04 (1.02 - 1.07)
Unknown mode of transmission 7.5 (1.68 - 33.60)
No schooling 1.93 (1.03 - 3.60)

Table courtesy of Dr. Martinez-Colubi.

Costs of DD

After adjustment for patient characteristics, the mean monthly cost associated with DD was €1302 compared with €290 for ED, resulting in a mean excess monthly cost for DD of €1012 (95% confidence interval, €322 - €1703; P = .004).

"The difference in total costs likely are attributable to differences in HIV-related hospital care, and this means that it was 17 times higher for late presenters," Dr. Martinez-Colubi said. "Breaking down this difference in total cost...shows that all of the different costs are statistically higher in late presenters except [out]patient consults."

Calculating costs based only on the number of patients treated (as opposed to diagnosed) in each category (DD, n = 235/266; ED, n = 58/160), antiretroviral therapy cost €687/month for DD patients vs €587/month for ED patients. ED patients began antiretroviral therapy an average of 12.1 months from inclusion in the study compared with DD patients, who started an average of 2.8 months from inclusion.

Monthly costs also differed greatly, depending on immune status at inclusion: €290 for CD4 counts greater than 350 cells/μL, €657 for CD4 counts of 200 to 350 cells/μL, and €1699 for CD4 counts less than 200 cells/μL.

Dr. Martinez-Colubi summarized that up to one third of all patients with HIV seen at her hospital were late presenters, and that late presentation was associated with older age, a lower educational level, and heterosexual or unknown categories of HIV transmission.

Healthcare costs for these DD patients are significantly increased. "Although much of this difference may be attributed to hospital admissions, drug cost per patient treated is also higher in late presenters," she said. "For all of these [reasons,] avoiding late diagnosis would improve the prognosis of HIV-infected patients and significantly reduce direct costs."

Session moderator Georg Behrens, MD, professor of Immunology at Hanover Medical School in Germany, commented to Medscape Medical News that the increased cost for antiretroviral therapy in the DD group "was mainly driven by [protease inhibitor]–based regimens, and that was a 10% difference, translating into a €100/month increased cost. You can either say we want to diagnose them earlier, but you could also question, 'Isn't it feasible also to use cheaper treatments in this situation and thereby save the costs?' "

Dr. Behrens said that not only ED is needed but also access to care and drugs. "It's very important to follow-up that those people that were diagnosed with HIV get access to care. Even though we have very good systems in Europe...we need to see that." He noted that some groups of individuals do not routinely see doctors, and that it was only circumstantial if they are tested and diagnosed. "If we really want to transfer the benefits of HIV therapy, we need to follow-up these patients," Dr. Behrens advised.

He said the main impediments to implementing such a system are that such groups are often difficult to contact, to get into care, and to follow-up. Furthermore, their adherence to antiretroviral therapy regimens is often impaired, so the success of HIV treatment in these groups may be lower than for other infected groups.

He praised the study for contributing to the data on diagnosis and attendant costs. "It's nice to see that different countries have different cohorts and different approaches, and that the statistical and mathematical approaches are getting more solid, and that there is more discussion on it."

Dr. Behrens thinks it is hard to get physicians outside of the specific field of HIV management to do patient screening. "So we've got to talk to gynecologists, dermatologists, and so on and to make them aware of these data, and then to convince them to consider HIV testing in that situation," he said. "It's a long, long way to go still."

Disclosure information for Dr. Martinez-Colubi was not available. Dr. Behrens, who was not involved in the study, has disclosed no relevant financial relationships.

13th European AIDS Conference of the European AIDS Clinical Society (EACS): Abstract PS8/7. Presented on October 14, 2011.

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