Updated Direct Costs of Medical Care for HIV-Infected Patients Within a Regional Population From 2006 to 2017

HB Krentz; Q Vu; MJ Gill

Disclosures

HIV Medicine. 2020;21(5):289-298. 

In This Article

Discussion

The annual total direct costs of care for all patients living with HIV in our regional population increased by > 250% over the 12 years from 2005 to 2017; this was partially attributable to increased patient numbers; however, the earlier initiation of ART and its continuous use also contributed to higher sustained costs in the population. Encouragingly, individual costs of care as measured by mean PPPM costs rose only modestly. These results obtained directly from original data sources support the estimated cost model of Kasaie et al.[29] which suggests that early initiation of ART will increase incremental health system costs by €1.05 billion in Spain over the next two decades despite being cost-effective and also averting > 30% of new HIV cases.

The cost of ARV drugs for the population continued to increase, and by 2017 accounted for over 80% of all costs. Greater proportionality of ARV drug costs in all medical costs has also been reported by others.[3–6,20,28] The new earlier and sustained use of ART probably contributed to the decline in the number of patients with CD4 counts < 200 cells/μL, who generally incur significant medical costs.[28] The higher CD4 counts probably led to better health and to the fewer clinic/laboratory visits and HIV-related hospitalizations than seen in earlier time frames, thereby reducing these costs. The approach of early ART initiation and its resulting improved population health does have cost implications for the 90-90-90 and U = U agendas.[29–33] With increased numbers of patients diagnosed, engaged, retained in care, and accessing ART with suppressed viral loads, total population costs of care increase. Planners, policy makers, clinicians, community members and advocates need to be aware of these higher overall costs of providing lifelong care when developing long-term programmes that need stable funding.

Although overall total costs for the entire population have increased, the mean PPPM cost for individual patients has since 2007 only marginally changed, increasing to a high of $1712 in 2013 but recently decreasing to $1446 in 2017. We noted an encouraging shift in cost categories. In-patient hospitalization costs for a small number of patients still, however, contribute a greater proportion of overall PPPM costs. The higher PPPM costs seen in 2013–2015 may be related to the significant shift in the use of the more expensive INSTI drugs; policy shifts in the choices of ARV drugs used can impact costs.[34]

The decrease in mean PPPM costs for ARV drugs, and total PPPM costs in general, starting in 2016 is in part associated with the increasing availability and use of generic drugs and desimplifying single tablet formations of modern regimens for cost reductions, as shown previously for a subgroup of our cohort.[27] These approaches may offer avenues for future cost containment without impacting quality of care. Decreasing mean PPPM costs for out-patient visits also contribute to this decline. Hospital in-patient costs remain more variable depending on a number of factors, such as aging and comorbidities associated with lifestyle choices.

Our data question any ongoing use of current CD4 count as a metric for cost modelling. With high ART coverage of our population, 63.4% of patients in 2017 had achieved a CD4 count > 500 cells/μL. Our cost analysis stratifying by CD4 count show less differentiation between CD4 count categories > 75 cells/uL than reported in previous studies. This suggests that CD4 count strata are no longer a sensitive tool for use in modelling costs, particularly when 80–85% of total costs are generated by ART. This perspective agrees with the findings of Leon-Reyes et al.,[5] who reported that CD4 count at presentation was no longer a major factor for higher costs[35,36] Of note, as the HIV-infected population in care ages, despite improved HIV-related health, overall medical costs will continue to increase as a result of more HIV and non-HIV related co-morbities experienced by patients as they live longer with HIV infection.[37,38]

To date, we could not show that the costs of earlier initiation of ART were counterbalanced by reduced total medical costs from enhanced health of those on ART. However, such costs may take many years to become apparent. We did not measure the additional economic benefit of reduced transmissions in our community resulting from earlier initiation as previously modelled by Kasaie et al..[29]

Our study, although comprehensive, does have limitations. Our data reflect costs for a single population, albeit one that is representative of a region rather than a subset or sample of a population. Costs of ARV drugs and in-patient and out-patients visits can vary greatly between populations, regions and countries, reflecting differing approaches to providing care under different health care systems. The choice of ARV drugs used, when patients are initiated on ARVs, and how long they remain on regimens vary widely, as can hospital admission rates and the use of laboratory tests. Our reported prices may be higher or lower than those of other centres; however, the proportions of usage are roughly similar to those of other reported studies and thus are comparable. However, we measured costs of care in one population in one health care system with the same metrics over a very long period of time, reducing any potential bias that may occur when comparing different centres.

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