HIV Care Cost in England

A Cross-Sectional Analysis of Antiretroviral Treatment and the Impact of Generic Introduction

KJ Ong; AJ van Hoek; RJ Harris; J Figueroa; L Waters; C Chau; S Croxford; P Kirwan; A Brown; MJ Postma; ON Gill; V Delpech

Disclosures

HIV Medicine. 2019;20(6):377-391. 

In This Article

Abstract and Introduction

Abstract

Objectives: Reliable and timely HIV care cost estimates are important for policy option appraisals of HIV treatment and prevention strategies. As HIV clinical management and outcomes have changed, we aimed to update profiles of antiretroviral (ARV) usage pattern, patent/market exclusivity details and management costs in adults (≥ 18 years old) accessing HIV specialist care in England.

Methods: The data reported quarterly to the HIV and AIDS Reporting System in England was used to identify ARV usage pattern, and were combined with British National Formulary (BNF) prices, non-ARV care costs and patent/market exclusivity information to generate average survival-adjusted lifetime care costs. The cumulative budget impact from 2018 to the year in which all current ARVs were expected to lose market exclusivity was calculated for a hypothetical 85 000 (± 5000) person cohort, which provided an illustration of potential financial savings afforded by bioequivalent generic switches. Price scenarios explored BNF70 (September 2015) prices and generics at 10/20/30/50% of proprietary prices. The analyses took National Health Service (NHS) England's perspective (as the payer), and results are presented in 2016/2017 British pounds.

Results: By 2033, most currently available ARVs would lose market exclusivity; that is, generics could be available. Average per person lifetime HIV cost was ~£200 000 (3.5% annual discount) or ~£400 000 (undiscounted), reducing to ~£70 000 (3.5% annual discount; ~£120 000 undiscounted) with the use of generics (assuming that generics cost 10% of proprietary prices). The cumulative budget to cover 85 000 (± 5000) persons for 16 years (2018–2033) was £10.5 (± 0.6) billion, reducing to £3.6 (± 0.2) billion with the use of generics.

Conclusions: HIV management costs are high but financial efficiency could be improved by optimizing generic use for treatment and prevention to mitigate the high cost of lifelong HIV treatment. Earlier implementation of generics as they become available offers the potential to maximize the scale of the financial savings.

Introduction

HIV causes a chronic infection that can be controlled by life-long antiretroviral (ARV) use. Reliable estimates of lifetime HIV care costs aid policy decision-making around treatment optimization and HIV prevention strategies such as HIV testing or the offer of pre-exposure prophylaxis (PrEP). Such estimates are challenging to derive because of the complex and changing treatment options, variation in stages of HIV progression, the long time-scale of treatment, and the introduction of generics over time. In the UK, there is open access to free testing for and treatment of HIV infection through the National Health Service (NHS).

In 2016, 96% of the 84 725 persons living with diagnosed HIV infection accessing specialist HIV care in England were receiving ARV treatment (ART).[1] National spending on HIV specialized services in 2016/2017 was close to £540 million, with slightly more than three-quarters of this total being spent on ART (;[2] A. Duncan, Department of Health, personal communications). The lifetime HIV care cost has been estimated at £360 800 (undiscounted, 2013 values), modelled on men who have sex with men (MSM) aged 30 years and estimated to live for another 41.5 years to reach the age of 71.5 years.[3] This cost was lower (£179 600) when assuming an 80% discount on list price 3 years after ARV patent expiry. The ART regime was based on 2012 British HIV Association treatment guidelines. The analysis used non-ARV HIV care costs derived from cohort data recorded over the years 1996–2008, for persons starting ART with two nucleoside reverse transcriptase inhibitors (NRTIs) in combination with a nonnucleoside reverse transcriptase inhibitor (NNRTI) or protease inhibitor (PI).[4] New ARVs with better side-effect profiles have since been introduced, and patient outcome improvements were observed in the UK Collaborative HIV Cohort (UK CHIC) data over the years 2000–2007.[5] At the same time, life expectancy in persons living with diagnosed HIV infection has also improved.[6] Given such changes in disease diagnosis and management landscapes, it is prudent to revisit the future resources needed for HIV care, including both ARV and non-ARV costs.

The objectives of this study were to generate a profile of ARV usage patterns for adults aged ≥ 18 years living with diagnosed HIV infection in England, collate details of patent and market exclusivity for currently available ARVs, and model the lifetime cost per person applicable in technology appraisals and annual budget impact analysis at a cohort level for HIV care payers. In the estimates of lifetime cost and annual budget impact, potential financial savings from switches to bioequivalent generics were considered.

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