Better HIV Care Could Save Lives, Billions in Health Costs

Nicola M. Parry, DVM

November 02, 2015

Improved efforts to link and retain HIV-positive individuals in care, along with increased screening for HIV, could reduce the incidence of HIV infection and deaths from AIDS in the United States by more than 50% during the next 20 years, a new computational model shows.

Maunank Shah, MD, PhD, an assistant professor of medicine at the Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues published the results of their study online September 11 in Clinical Infectious Diseases.

"[W]hile continued HIV screening in high-risk groups is extremely important, our model suggests that you get the most bang for your buck targeting retention in care," Dr Shah said in a university news release. Using more resources to encourage individuals to continue medical care and long-term drug therapy "could transform our HIV epidemic, potentially reducing our future cases by more than 50 percent and saving thousands of lives every year," he added.

Poor engagement in care for HIV-infected individuals remains the greatest barrier to prevention of both HIV-related comorbidities and HIV transmission. "Despite having good treatments available, current reports suggest that fewer than half of individuals who need therapy are actually getting appropriate HIV medicine to control their virus, leading to more transmission of disease," Dr Shah noted in the news release.

Recent advances in antiretroviral therapy for HIV have resulted in regimens that are more effective, better tolerated, and less complex and that also decrease the risk for HIV transmission. Previous studies have suggested that a "test and treat" strategy could substantially reduce HIV prevalence during the coming decades. However, in the United States, about 20% of all individuals living with HIV are unaware of their infection. In addition, even when HIV infection is diagnosed, connecting patients with appropriate healthcare remains suboptimal: only about 70% complete an HIV care visit within 3 months of diagnosis. As a result, it is estimated that less than half of all individuals with HIV in the United States are virologically suppressed, even though nearly 80% are probably aware of their HIV status.

Dr Shah and colleagues therefore designed an epidemic-economic computer model based on current HIV epidemiological data. They used this to simulate HIV transmission and HIV care in the United States to "estimate the economic and epidemiologic consequences of incomplete or intermittent engagement in care and explore the potential impact of interventions that strengthen such engagement relative to early treatment initiation alone."

The researchers examined the effects of improved interventions, including annual HIV screening for high-risk groups, increased 3-month linkage to HIV healthcare (to 90%), and enhanced retention in care (50% relative reduction in yearly disengagement from care and 50% increase in reengagement for those not in care).

They estimated healthcare costs, HIV incidence, AIDS mortality, and quality-adjusted life-years (QALYs) during a 20-year period.

Even with early antiretroviral therapy initiation, based on current levels of HIV care engagement, the study predicts that 1.39 million new HIV infections (95% uncertainty range [UR], 0.91 million - 2.2 million) and 435,000 AIDS deaths (95% UR, 249,000 - 774,000) would occur at a cost of $256 billion during the next 20 years (95% UR, $199 billion - $298 billion).

Strategies focused only on improved screening would result in only modest benefits during the 20-year period. Annual screening of high-risk individuals would prevent 215,000 new HIV infections (16% reduction; 95% UR, 9% - 20%), at a cost of $49.2 billion (95% UR, $34 billion - $65 billion), or $84,700 per QALY gained (95% UR, $57,200 - $160,000). Screening the general population every 3 years, along with screening high-risk individuals annually, would cost an additional $21.9 billion to prevent only 11,600 additional infections. Overall, increased screening would prevent 18% to 21% of AIDS-related deaths (95% UR, 10% - 28%).

Improved screening combined with increased 3-month linkage would also result in modest epidemiologic benefits, preventing about 292,000 HIV infections (21% reduction; 95% UR, 13% - 26%) and 107,000 AIDS-related deaths (25% reduction; 95% UR, 16% - 30%), at a cost of $52.9 billion (95% UR, $39 billion - $70 billion), or $65,700 per QALY gained (95% UR, $44,500 - $111,000).

However, strategies that combine improved screening with increased linkage and retention of care would result in the greatest population-level effect, preventing 752,000 HIV infections (54% reduction; 95% UR, 37% - 68%) and 276,000 AIDS-related deaths (64% reduction; 95% UR, 46% - 78%), at a cost of $96 billion (95% UR, $67 billion - $138 billion), or $45,300 per QALY gained (95% UR, $27,800 - $72,300).

"[T]o alter the course of the HIV epidemic in the United States, strategies of 'test and treat' alone may be insufficient; attention to the full continuum of care will be essential," the authors conclude.

This work was supported by the National Institute of Allergy and Infectious Diseases, the Canadian Institutes of Health Research, and the B. Frank and Kathleen Polk Assistant Professorship in Epidemiology. One coauthor has served as a consultant to Bristol-Myers Squibb for work unrelated to this project. The other authors have disclosed no relevant financial relationships.

Clin Infect Dis. Published online September 11, 2015. Full text

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