Cost Of HIV Care Research Articles

Current out of pocket care costs among HIV and hypertension co-morbid patients in urban and peri-urban Uganda.

Despite improvements to the cascade of HIV care in East Africa, access to care for non-communicable disease co-morbidities like hypertension (HTN) remains a persistent problem. The integration of care for these conditions presents an opportunity to achieve efficiencies in delivery as well as decrease overall costs for patients. This study aims to build evidence on the burden of current out-of-pocket costs of care among HIV-HTN co-morbid patients. We administered a pre-tested, cross-sectional, out-of-pocket cost survey to 94 co-morbid patients receiving HIV care from 10 clinics in the Wakiso and Kampala districts of Uganda from June to November 2021. The survey assessed socio-demographic characteristics, direct medical costs (e.g., medications, consultations), indirect costs (e.g., transport, food, caregiving), and economic costs (i.e., foregone income) associated with seeking HIV and HTN care, as well as possible predictors of monthly care costs. Patients were sampled both during a government-imposed nation-wide full COVID-19 lockdown (n = 30) and after it was partially lifted (n = 64). Median HIV care costs constitute between 2.7 and 4.0% of median monthly household income, while HTN care costs are between 7.1 to 7.9%. For just under half of our sample, the median monthly cost of HTN care is more than 10% of household income, and more than a quarter of patients report borrowing money or selling assets to cover costs. We observe uniformly lower reported costs of care for both conditions under full COVID-19 lockdown, suggesting that access to care was limited. The main predictors of monthly HIV and HTN care costs varied by disease and costing perspective. Patient out of pocket costs of care for HIV and HTN were substantial, but significantly lower during the 2021 full COVID-19 lockdown in Uganda. New strategies such as service integration need to be explored to reduce these costs.

Estimating the cost due to resistance against antiretroviral therapies in individuals with HIV: Perspective of the Kingdom of Saudi Arabia

ObjectivesThe emergence of resistance to antiretroviral therapy (ART) has an impact on the cost of HIV care. This study aimed to estimate the direct and indirect costs associated with the first episode of drug resistance in individuals with HIV receiving first-line ART. MethodsWe developed a cost calculator to estimate the cost of drug resistance over a period of 12 months in the Kingdom of Saudi Arabia. The model inputs (estimated using expert opinion and publicly available sources) included costs associated with testing for resistance, adverse events of a new regimen, and indirect costs. ResultsThe direct and indirect medical expenses for the year resistance developed were 6980 Saudi Arabian riyal (SAR) and SAR 2862, respectively. The addition of the cost of new ARTs would increase the total annual costs (between SAR 5174 and SAR 34,265 per patient). One-way sensitivity analysis also reported significant impact of initial and switching therapies used after resistance develops on the total costs of resistance per year. ConclusionsThere is a significant cost burden associated with drug resistance, which emphasizes the need to select an appropriate initial ART regimen that has a strong genetic barrier and conduct pre-treatment resistance tests (if possible).

Assessing the Relationship Between HIV Quality of Care and Treatment Literacy on ART Adherence and Viral Suppression Among Female Sex Workers Living in the Dominican Republic.

This study assessed the relationship between the quality of HIV care and treatment literacy on antiretroviral therapy (ART) adherence and viral suppression among female sex workers (FSWs) living with HIV (n = 211) in Santo Domingo, Dominican Republic. Multivariable logistic regression results indicate better patient-provider communication (AOR 1.04; 95% CI 1.01-1.07) and respectful treatment (AOR 2.17; 95% CI 1.09-4.32) increase the odds of viral suppression, while higher costs reduce both the odds of ART adherence (AOR 0.57, 95% CI 0.34- 0.95) and being virally suppressed (AOR 0.59, 95% CI 0.41-0.85). Greater treatment literacy was associated with an increased odds of ART adherence (AOR 4.15 for understanding of viral load; 95% CI 1.50-11.52) and viral suppression (AOR 2.75 for understanding of CD4 count; 95% CI 1.31-5.80). Findings support investments in treatment education, effective and respectful patient-provider communication, dignified care, and cost-support for associated HIV care costs to facilitate FSWs' pathway towards viral suppression.

What are the drivers of high-cost HIV patients?

We aimed to identify "high-cost" patients with HIV (PWH) and determine drivers behind higher costs. All PWH at the Southern Alberta HIV Clinic, Canada, and active in 2017 were included. Sociodemographic, clinical, and healthcare utilization data were collected. The direct care costs from the payers' perspective including antiretroviral drugs (ARV), outpatient visits, and hospital admissions were determined for 2017. Patients' annual total costs were grouped into top 5% (i.e., high-cost), top 20%, middle 60%, and bottom 20%. High-cost patients were older, Caucasian or indigenous Canadian, and more likely acquired HIV from intravenous drug use (all p < 0.05). High-cost patients had lower nadir CD4, more comorbidities, missed more clinic appointments, had more ARV interruptions, and developed more ARV resistance (p < 0.01). The overall median cost of HIV care was US$14,064 [IQR US$13,121-US$17,883] (2017 Cdn$). High-cost patients had a median cost of US$29,902 [IQR US$27,229-US$37,891] and accounted for 14% of total costs and 84% of all inpatient costs. Hospitalizations constituted 58% of costs for high-cost patients. Although heterogeneous, high-cost patients have distinct sociodemographic and clinical characteristics driving their healthcare utilization. Addressing these social determinants of health and using novel ARV administration approaches may preserve health and save costs.

Economic impact on direct healthcare costs of missing opportunities for diagnosing HIV within healthcare settings.

The economic consequences of a missed opportunity for HIV testing at an earlier stage of infection within a healthcare setting are poorly described. For all newly diagnosed HIV patients followed at the Southern Alberta HIV/AIDS Clinic (SAC), Calgary, Canada, between 1 April 2011 and 1 April 2016, all clinical encounters occurring <3years prior to diagnosis within the region were obtained. The direct costs of HIV care after diagnosis to 31 March 2019 were determined from a payers' perspective and reported as mean cost per patient per month (PPPM) in 2019 Canadian dollars (CDN$). Patients with no encounters for 3years prior to diagnosis were compared with patients with encounters, with special attention to patients with HIV clinical indicator conditions (HCICs). Of 388 patients, 60% had one or more prior encounter without HIV testing; 14% had been treated for an HCIC. Females, older patients and heterosexuals were more likely to have prior encounters. At diagnosis, patients with previous encounters presented with lower CD4 counts and higher rates of AIDS. The mean PPPM costs for patients with any prior encounter or for an HCIC-based encounter were 16% and 33% higher, respectively, than for patients with no prior encounters. While mean PPPM costs for antiretroviral drugs and outpatient visits were slightly higher, in-patient costs were 10 times higher for people with HIV who had a previous HCIC encounter vs. those with no encounters (CDN$316 vs. $31, respectively). Any healthcare visit, especially for an HCIC, represents relatively easy opportunities for HIV testing. Not testing can result in poorer health and higher costs. Targeted clinical testing and novel interventions to correct overlooked testing opportunities within healthcare settings may be an easy way to implement cost savings.

Fast-track treatment initiation counselling in South Africa: A cost-outcomes analysis

IntroductionIn 2016, under its new National Adherence Guidelines (AGL), South Africa formalized an existing model of fast-track HIV treatment initiation counselling (FTIC). Rollout of the AGL included an evaluation study at 24 clinics, with staggered AGL implementation. Using routinely collected data extracted as part of the evaluation study, we estimated and compared the costs of HIV care and treatment from the provider’s perspective at the 12 clinics implementing the new, formalized model (AGL-FTIC) to costs at the 12 clinics continuing to implement some earlier, less formalized, model that likely varied across clinics (denoted here as early-FTIC).MethodsThis was a cost-outcome analysis using standard methods and a composite outcome defined as initiated antiretroviral therapy (ART) within 30 days of treatment eligibility and retained in care at 9 months. Using patient-level, bottom-up resource-utilization data and local unit costs, we estimated patient-level costs of care and treatment in 2017 U.S. dollars over the 9-month evaluation follow-up period for the two models of care. Resource use and costs, disaggregated by antiretroviral medications, laboratory tests, and clinic visits, are reported by model of care and stratified by the composite outcome.ResultsA total of 350/343 patients in the early-FTIC/AGL-FTIC models of care are included in this analysis. Mean/median costs were similar for both models of care ($135/$153 for early-FTIC, $130/$151 for AGL-FTIC). For the subset achieving the composite outcome, resource use and therefore mean/median costs were similar but slightly higher, reflecting care consistent with treatment guidelines ($163/$166 for early-FTIC, $168/$170 for AGL-FTIC). Not surprisingly, costs for patients not achieving the composite outcome were substantially less, mainly because they only had two or fewer follow-up visits and, therefore, received substantially less ART than patients who achieved the composite outcome.ConclusionThe 2016 adherence guidelines clarified expectations for the content and timing of adherence counseling sessions in relation to ART initiation. Because clinics were already initiating patients on ART quickly by 2016, little room existed for the new model of fast-track initiation counseling to reduce the number of pre-ART clinic visits at the study sites and therefore to reduce costs of care and treatment.Trial registrationClinical Trial Number: NCT02536768.

Costs of integrating hypertension care into HIV care in rural East African clinics.

Sub-Saharan Africa faces twin epidemics of HIV and noncommunicable diseases including hypertension. Integrating hypertension care into chronic HIV care is a global priority, but cost estimates are lacking. In the SEARCH Study, we performed population-level HIV/hypertension testing, and offered integrated streamlined chronic care. Here, we estimate costs for integrated hypertension/HIV care for HIV-positive individuals, and costs for hypertension care for HIV-negative individuals in the same clinics. Microcosting analysis of healthcare expenditures within Ugandan HIV clinics. SEARCH (NCT: 01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient hypertension care costs using micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29 per person per year, a 2.1% marginal increase over prior estimates for HIV care alone. For HIV-negative participants, hypertension care cost $11.39 per person per year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19 per patient per year; 98% of total) and laboratory testing ($0.10 per patient per year; 2%). Key costs for HIV-negative patients included medications ($5.09 per patient per year; 45%) and clinic staff salaries ($3.66 per patient per year; 32%). For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics.

Management of diabetes and associated costs in a complex humanitarian setting in the Democratic Republic of Congo: a retrospective cohort study

ObjectiveWe aimed to evaluate an Integrated Diabetic Clinic within a Hospital Outpatient Department (IDC-OPD) in a complex humanitarian setting in North Kivu, Democratic Republic of Congo. Specific objectives were to:...

Selecting Evidence-Based HIV Prevention Behavioral Interventions for HIV-Negative Persons for National Dissemination.

This paper describes the development of a formula to determine which evidence-based behavioral interventions (EBIs) targeting HIV-negative persons would be cost-saving in comparison to the lifetime cost of HIV treatment and the process by which this formula was used to prioritize those with greatest potential impact for continued dissemination. We developed a prevention benefit index (PBI) to rank risk-reduction EBIs for HIV-negative persons based on their estimated cost for achieving the behavior change per one would-be incident infection of HIV. Inputs for calculating the PBI included the mean estimated cost-per-client served, EBI effect size for the behavior change, and the HIV incidence per 100,000 persons in the target population. EBIs for which the PBI was ≤ $402,000, the estimated lifetime cost of HIV care, were considered cost-saving. We were able to calculate a PBI for 35 EBI and target population combinations. Ten EBIs were cost-saving having a PBI below $402,000. One EBI did not move forward for dissemination due to high start-up dissemination costs. DHAP now supports the dissemination of 9 unique EBIs targeting 13 populations of HIV-negative persons. The application of a process, such as the PBI, may assist other health-field policymakers when making decisions about how to select and fund implementation of EBIs.

Costs of Integrating Hypertension Care into HIV Care in Rural East African Clinics

Background: Sub-Saharan Africa faces twin epidemics of HIV and non-communicable diseases including hypertension. While integration of hypertension care into the chronic HIV-focused healthcare infrastructure is a key global priority, cost estimates for integration are largely unavailable. In the SEARCH Study, we performed population-based testing for HIV and hypertension and offered integrated streamlined chronic care. Here, we estimate costs for hypertension care integrated with HIV care for HIV-positive individuals, and the cost for hypertension care for HIV-negative people concomitantly in the same clinics. Methods: SEARCH (NCT:01864603) conducted community health campaigns for diagnosis and linkage to care for both HIV and hypertension. HIV-positive patients received hypertension/HIV care jointly including blood pressure monitoring and medications; HIV-negative patients received hypertension care alone at the same clinics. Within 10 Ugandan study communities during 2015-2016, we estimated incremental annual per-patient costs for hypertension care using standard micro-costing techniques, time-and-motion personnel studies, and administrative/clinical records review. Findings: Overall, 70 HIV-positive and 2355 HIV-negative participants received hypertension care. For HIV-positive participants, average incremental cost of hypertension care was $6.29/person/year, representing a 2.1% marginal increased cost over previously published estimates for HIV care alone. For HIV-negative persons, hypertension care cost $11.39/person/year, a 3.8% marginal increase over HIV care costs. Key costs for HIV-positive patients included hypertension medications ($6.19/patient/year; 98% of total) and laboratory testing ($0.10/ patient/year;2%). Key costs for HIV-negative patients included medications ($5.09/patient/year;45%) and clinic staff salaries ($3.66/patient/year;32%), while minor costs included laboratory testing ($0.10/patient/year;1%), fixed costs ($1.98/patient/year;17%) and other recurring costs ($0.56/patient/year;5%). Interpretation: For only 2-4% estimated additional costs, hypertension care was added to HIV care, and also expanded to all HIV-negative patients in prototypic Ugandan clinics, demonstrating substantial synergy. Our results should encourage accelerated scale-up of hypertension care into existing clinics to address the growing hypertension epidemic, secondarily reduce HIV care-related stigma, and improve community health. Funding: Research reported in this manuscript was supported by Division of AIDS, NIAID, of the National Institutes of Health under award number U01AI099959 and in part by the President’s Emergency Plan for AIDS Relief (PEPFAR), and Gilead Sciences. Declaration of Interest: Related to work in this manuscript, all authors declare no conflicts of interests. Ethical Approval: The SEARCH Study was approved by institutional review boards at Makerere University College of Health Sciences (Kampala, Uganda), the Kenya Medical Research Institute (Nairobi, Kenya), and the University of California, San Francisco, as well as by the Uganda National Council for Science and Technology.

Desimplification of Single Tablet Antiretroviral (ART) Regimens-A Practical Cost-Savings Strategy?

Introduction:The use of lifelong antiretroviral therapy (ART) results in increased costs of care; the ability to finance and control sustained costs of ART needs to be discussed.Approach:The Southern Alberta Clinic initiated a practical cost savings approach that switched select patients from a branded ART to a less expensive generic variation. Our approach surveyed physicians and patients on their acceptance of switching and then launched a program asking patients if they would switch to generic variations for cost control purposes.Results:Our early findings found >50% of patients approached agreed to switch. We found no evidence of increased risk of viral breakthrough, resistance, side effects, or displeasure with generic drugs. Measured cost savings in the first year were >$1.1 million with annual projected savings of between $4.3 million and $2.6 million (in 2017 Cdn$).Conclusion:Our approach can provide an option for controlling costs of HIV care without compromising quality.

Long-term HIV/AIDS survivors: Patients living with HIV infection retained in care for over 20 years. What have we learned?

Individuals diagnosed with HIV before 1996 had poor prognoses. Few HIV care centers can track patients continuously from the 1980s to present. We determined the sociodemographic, clinical, and health care utilization characteristics of patients diagnosed and followed for >20 years (i.e. long-term HIV/AIDS survivors) to understand what factors contributed to survival. All HIV-positive patients diagnosed before 1996 were categorized as active, moved/lost, or died as of 1 January 2016. Baseline sociodemographic, clinical characteristics, antiretroviral therapy (ART) usage, retention, HIV care costs, and health status were analyzed. Of 876 patients, 49.5% died, 30.3% moved or left, 20.3% remained active in care for a median of 23.4 years. At diagnosis, continuously-followed patients were younger with a higher CD4 cell count, attended regular clinic visits at higher frequencies, and had received more ART than patients who moved or died. As of 1 January 2016, their median age was 57 years (interquartile range 53-62), 15% were aged >65 years, median CD4 cell count was 591 cells/mm3 (475-863) with 68% >500 cells/mm3. Sixty-two percent remained employed. The total cost of HIV care was $32,251,030 (Cdn$); median cost per patient per year $15,418 ($13,697-$18,392). Individuals diagnosed prior to 1996 benefited from early diagnosis and engagement to care, regular follow-ups, and timely initiation of ART, strongly supporting the modern guidelines of care.

The cost-effectiveness of HIV pre-exposure prophylaxis in men who have sex with men and transgender women at high risk of HIV infection in Brazil.

IntroductionMen who have sex with men (MSM) and transgender women (TGW) in Brazil experience high rates of HIV infection. We examined the clinical and economic outcomes of implementing a pre‐exposure prophylaxis (PrEP) programme in these populations.MethodsWe used the Cost‐Effectiveness of Preventing AIDS Complications (CEPAC)‐International model of HIV prevention and treatment to evaluate two strategies: the current standard of care (SOC) in Brazil, including universal ART access (No PrEP strategy); and the current SOC plus daily tenofovir/emtracitabine PrEP (PrEP strategy) until age 50. Mean age (31 years, SD 8.4 years), age‐stratified annual HIV incidence (age ≤ 40 years: 4.3/100 PY; age > 40 years: 1.0/100 PY), PrEP effectiveness (43% HIV incidence reduction) and PrEP drug costs ($23/month) were from Brazil‐based sources. The analysis focused on direct medical costs of HIV care. We measured the comparative value of PrEP in 2015 United States dollars (USD) per year of life saved (YLS). Willingness‐to‐pay threshold was based on Brazil's annual per capita gross domestic product (GDP; 2015: $8540 USD).ResultsLifetime HIV infection risk among high‐risk MSM and TGW was 50.5% with No PrEP and decreased to 40.1% with PrEP. PrEP increased per‐person undiscounted (discounted) life expectancy from 36.8 (20.7) years to 41.0 (22.4) years and lifetime discounted HIV‐related medical costs from $4100 to $8420, which led to an incremental cost‐effectiveness ratio (ICER) of $2530/YLS. PrEP remained cost‐effective (<1x GDP) under plausible variation in key parameters, including PrEP effectiveness and cost, initial cohort age and HIV testing frequency on/off PrEP.ConclusionDaily tenofovir/emtracitabine PrEP among MSM and TGW at high risk of HIV infection in Brazil would increase life expectancy and be highly cost‐effective.

Short-term cost and efficiency analysis of raltegravir versus atazanavir/ritonavir or darunavir/ritonavir for treatment-naive adults with HIV-1 infection in Spain

Introduction: The AIDS Clinical Trial Group (ACTG) 5257 clinical trial showed that raltegravir (RAL) was superior to atazanavir/ritonavir (ATV/r) and darunavir/ritonavir (DRV/r), when used in combination with emtricitabine/tenofovir DF (FTC/TDF), in a 96-week composite endpoint combining virologic efficacy and tolerability for treatment-naive adults with HIV-1 infection. This study aimed to estimate the efficiency associated with these three regimens in Spain.Methods: An economic model was developed to estimate costs for antiretroviral drugs, adverse event management, and HIV care for individuals initiating first-line therapy. Antiretroviral drug costs were based on hospital costs with mandatory discounts applied. Adverse event management costs and HIV care costs were obtained from published sources and inflated to 2015 euros. Head-to-head efficacy and safety data (discontinuation rates, mean CD4 cell-count changes, adverse event incidence) up to 96 weeks for each regimen were obtained from the clinical trial. The efficiency of each regimen, as measured by the cost per successfully treated patient (i.e. on first-line therapy for 96 weeks), was estimated and examined in sensitivity analyses. All cost outcomes were discounted at 3.0% annually.Results: Total costs per successfully treated patient were €22,377 for RAL, €26,629 for ATV/r, and €23,928 for DRV/r. These results were found to be robust in sensitivity analyses.Discussion: RAL has the lowest cost per successfully treated patient when compared with DRV/r and ATV/r, each used in combination with FTC/TDF, for treatment-naive adults with HIV-1 infection in Spain. This economic evidence complements the clinical benefits of RAL reported in the ACTG 5257 clinical trial.

Trends in healthcare expenditure among people living with HIV/AIDS in the United States: evidence from 10\xa0Years of nationally representative data

BackgroundWhile previous studies have examined HIV cost expenditures within the United States, the majority of these studies focused on data collected prior to or shortly after the advent and uptake of antiretroviral therapy, focused only on a short time frame, or did not provide cost comparisons between HIV/AIDS and other chronic conditions. It is critical that researchers provide accurate and updated information regarding the costs of HIV care to assist key stakeholders with economic planning, policy development, and resource allocation.MethodsWe used data from the Medical Expenditure Panel Survey-Household Component for the years 2002–2011, which represents a nationally representative U.S. civilian non-institutionalized population. Using generalized linear modeling, we estimated the adjusted direct medical expenditures by HIV/AIDS status after controlling for confounding factors.ResultsData were from 342,732 people living with HIV/AIDS. After adjusting for socio-demographic factors, comorbidities and time trend covariates, the total direct expenditures for HIV/AIDS was $31,147 (95% CI $23,645–$38,648) or 800–900% higher when compared to those without HIV/AIDS (i.e., diabetes, stroke, and cardiovascular disease). Based on the adjusted mean, the aggregate cost of HIV/AIDS was approximately $10.7 billion higher than the costs for those without HIV/AIDS.ConclusionsOur estimates of cost expenditures associated with HIV care over a 10-year period show a financial burden that exceeds previous estimates of direct medical costs. There is a strong need for investment in combination prevention and intervention programs, as they have the potential to reduce HIV transmission, and facilitate longer and healthier living thereby reducing the economic burden of HIV/AIDS.

The potential impact and cost of focusing HIV prevention on young women and men: A modeling analysis in western Kenya.

ObjectiveWe compared the impact and costs of HIV prevention strategies focusing on youth (15–24 year-old persons) versus on adults (15+ year-old persons), in a high-HIV burden context of a large generalized epidemic.DesignCompartmental age-structured mathematical model of HIV transmission in Nyanza, Kenya.InterventionsThe interventions focused on youth were high coverage HIV testing (80% of youth), treatment at diagnosis (TasP, i.e., immediate start of antiretroviral therapy [ART]) and 10% increased condom usage for HIV-positive diagnosed youth, male circumcision for HIV-negative young men, pre-exposure prophylaxis (PrEP) for high-risk HIV-negative females (ages 20–24 years), and cash transfer for in-school HIV-negative girls (ages 15–19 years). Permutations of these were compared to adult-focused HIV testing coverage with condoms and TasP.ResultsThe youth-focused strategy with ART treatment at diagnosis and condom use without adding interventions for HIV-negative youth performed better than the adult-focused strategy with adult testing reaching 50–60% coverage and TasP/condoms. Over the long term, the youth-focused strategy approached the performance of 70% adult testing and TasP/condoms. When high coverage male circumcision also is added to the youth-focused strategy, the combined intervention outperformed the adult-focused strategy with 70% testing, for at least 35 years by averting 94,000 more infections, averting 5.0 million more disability-adjusted life years (DALYs), and saving US$46.0 million over this period. The addition of prevention interventions beyond circumcision to the youth-focused strategy would be more beneficial if HIV care costs are high, or when program delivery costs are relatively high for programs encompassing HIV testing coverage exceeding 70%, TasP and condoms to HIV-infected adults compared to combination prevention programs among youth.ConclusionFor at least the next three decades, focusing in high burden settings on high coverage HIV testing, ART treatment upon diagnosis, condoms and male circumcision among youth may outperform adult-focused ART treatment upon diagnosis programs, unless the adult testing coverage in these programs reaches very high levels (>70% of all adults reached) at similar program costs. Our results indicate the potential importance of age-targeting for HIV prevention in the current era of ‘test and start, ending AIDS’ goals to ameliorate the HIV epidemic globally.

The Looming Surge in Costs of HIV Care for Older Patients

The use of potent combination antiretroviral therapy (ART) has resulted in improved long-term survival of people with HIV infection and an ongoing

The Cost of Antiretroviral Drug Resistance in HIV-Positive Patients

Antiretroviral (ARV) drug resistance limits treatment choices, often necessitating the selection of drugs with less desirable pill burdens, toxicity profiles, drug interactions and dosing schedules, and may increase cost. We examine the impact of resistance on the cost of HIV care. All adult HIV-positive individuals newly referred for HIV care from 1 January 2007 to 1 January 2011 and followed until 31 December 2011 at the Southern Alberta Clinic, Calgary, AB, Canada, were included. We determined the cost of all ARV drugs, and HIV-related outpatient and inpatient care, reported as mean per patient per month (PPPM) costs in 2011 Canadian dollars (CDN). Overall, 78% of patients received genotypic antiretroviral resistance testing (GART); 57% among ARV-naive patients, 21% after suspected viral failure, and 20% during a treatment interruption. Resistance was detected in 6%, 49% and 21% of all tests respectively. The total mean PPPM cost for patients with GART was CDN 1,179. Patients with primary resistance had mean total PPPM costs of CDN 956. Patients with no resistance had mean PPPM costs of CDN 1,058, by contrast with the CDN 1,291 costs of patients with secondary/acquired resistance. Mean costs for one, two or three ARV class resistance was CDN 1,278, 1,337 and 1,801, respectively. Mean PPPM costs increased by 31% from CDN 1,068 to 1,396, respectively, before and after a positive resistance test. Transmission of resistant virus as well as emergence of resistance during ARV therapy leads to increased costs. Mean costs increased by number of resistant classes. Routine GART and optimizing ARV regimens to avoid resistance might minimize the long-term costs of HIV care.

The Value of HIV Screening in the United States in the Era of Effective Treatment

The US Preventive Services Task Force (USPSTF) recently released a draft recommendation for routine HIV screening in the general adult population under age 65 in the US, consistent with the 2006 Centers for Disease Control and Prevention (CDC) recommendations. The USPSTF draft assigns a grade A to this recommendation, which means that if it is adopted, most adults with public or private insurance coverage will be able to receive an HIV test without an out-of-pocket expenditure. The benefits of HIV screening include documented reductions in risk behavior among those who learn that they are HIV infected; earlier access to antiretroviral therapy, leading to avoidance of morbidity and mortality; and a potential 96% reduction in transmission of HIV to heterosexual partners among HIV-infected adults adhering to antiretroviral therapy. Results from models of HIV disease progression and treatment evaluating the cost-effectiveness of HIV screening in the US were part of the rationale CDC used to support expanding access to HIV testing, and these models continue to be used to evaluate different testing implementation strategies, although the USPSTF did not consider modeling studies in its recent evidence review. The majority of published analyses of the costeffectiveness of HIV screening in the US project the lifetime benefits and costs of earlier detection and entry into care for HIV-infected individuals and weigh these costs and benefits when calculating cost-effectiveness ratios; population benefits from reduced transmission are estimated as secondary benefits. Although including transmission benefits can result in more attractive cost-effectiveness ratios for screening interventions, the effects are attenuated by the additional time between the secondary infection event and the point in HIV disease progression where clinical symptoms emerge. Recently, Farnham and colleagues published a paper in Medical Decision Making arguing that HIV screening can be economically justified based solely on the benefit of HIV transmissions avoided attributable to sexual risk behavior change associated with the knowledge of being HIV infected. Their findings rely on 2 key parameters: the benefit of reduced sexual transmission by patients who newly learn of their HIV infection, and the lifetime cost and loss of qualityadjusted life-years avoided by preventing a secondary HIV infection. The annual transmission benefit that these authors derive from the literature is large, but they conservatively assume that the effect lasts for only 1 year and do not consider further transmission dynamics that may result in additional benefits depending on antiretroviral coverage and risk group. The lifetime cost avoided that they use was derived from previous work by this author and colleagues and may not be fully relevant in in the current situation. With the increasing success of antiretroviral treatment, HIV-infected individuals are living long enough to incur medical expenses for non-HIV conditions that they might have incurred in the absence of HIV, and there was no adjustment for the proportion of HIV care costs going to these conditions in the analysis by Farnham and colleagues. The impact of HIV screening on avoiding qualityof-life losses associated with HIV infection may also be diminished by more effective and less toxic HIV treatments. In the current issue of Medical Decision Making, Isogai and colleagues report the results of a health utility prediction model based on assessments completed by more than 800 HIV patients in Ontario, Canada, between 2007 and 2009. The authors’ final model included CD4 count (a measure Received 21 March 2013 from the Department of Public Health, Weill Cornell Medical College, New York, NY. Revision accepted for publication 4 April 2013.

Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa

There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs.