Cost of Treatment in a US Commercially Insured, HIV-1–Infected Population

Abstract

ObjectiveRecent treatment patterns and cost data associated with HIV in the United States are limited. This study assessed first-line persistence and healthcare costs of HIV-1 in patients by treatment line and CD4 cell count.Methods MarketScan Commercial Claims and Encounters Database (2007–2011) and Lab Database (2007–2010) were used to construct two HIV-1 cohorts: 1) newly treated HIV-1–infected patients with ≥6 months' continuous enrollment prior to first third-agent drug claim (Newly Treated Cohort) and 2) CD4 cell count test results (CD4 Measurements Cohort). All patients were ≥18 years old and without hepatitis co-infection. The Kaplan-Meier method was used to measure treatment switch rates. Generalized linear models (gamma distribution, log link) were used to compare healthcare costs by treatment line and CD4 cell count controlling for potential confounders.ResultsNewly treated patients (n = 8,617) had mean age of 41, 82% were male, and 20% had experienced AIDS-defining events at baseline. Over 20% of newly treated patients switched initial treatment regimen within 2 years. Average unadjusted (and covariate-adjusted) total healthcare cost/year was $33,674 ($28,861) for first-line, $39,191 ($35,805) for second-line, and $39,882 ($40,804) for third-line treatment. Covariate-adjusted costs of care on second- and third-line treatments were significantly more expensive than first-line treatment (24% [p<0.001] and 41% [p = 0.006] higher, respectively). The CD4 Measurements Cohort included 803 CD4 measurements (mean age 49, 76% male, 8% experienced an AIDS-defining event). Costs associated with CD4 measurements <100 cells/µL were 92% higher than those with >350 cells/µL (p<0.001). For higher CD4 cell counts, the majority of expenditures were for antiretrovirals (64% of total for CD4 >350 cells/µL).ConclusionsDespite modern advances in antiretroviral therapy and medical care, direct medical costs of HIV-1–infected patients increase after treatment switch and with lower CD4 counts, consistent with previous costing studies.

Cost-Effectiveness of Single- Versus Generic Multiple-Tablet Regimens for Treatment of HIV-1 Infection in the United States

“…Allowing hospitalization costs to be driven exclusively by CD4 counts for both STR and MTR results in an ICER of $37,438 per QALY. Considering a different source of inpatient and other costs [ 10 ] similarly increases the ICER to $35,521 per QALY. Finally, assuming, upon failing 6 th -line therapy, a successive sequence of further therapy lines with efficacy, safety and cost parameterization equal to that of the 6 th -line, results in a dominant scenario for STR as compared to gMTR: an increase of 0.49 discounted QALY, accompanied by $14,348 in discounted total cost savings.…”

“…Higher pill burden is associated with both significantly lower adherence rates and worse virological suppression [ 58 ]. Poor control of HIV [ 59 ], greater pill burden [ 12 ] and lower adherence [ 4 ] are all associated with higher risk of hospitalization and higher inpatient costs and other non-ART costs that may account up-until 45% of total lifetime costs of current HIV Care [ 10 , 47 ].…”

“…At first glance, these strategies seem appealing because they appear to present significant economic savings. Caution is warranted in interpreting these results, however, because some of these economic analyses are focused mainly on ART costs, ignoring other important costs such as inpatient and outpatient costs, or even wider economic societal implications, that may account for up to 45% of the total lifetime costs of HIV care [ 8 – 10 ]. Moreover, there are compelling data from a meta-analysis that suggest that treating with recommended treatments, rather than alternative recommendations is associated with markedly improved outcomes [ 11 ].…”

The cost-effectiveness of oral HIV pre-exposure prophylaxis and early antiretroviral therapy in the presence of drug resistance among men who have sex with men in San Francisco

“…We also used published estimates of HIV-related healthcare costs, first- and second-line ART costs, the costs of antibody testing, genotype resistance testing, and counseling and diagnosis [ 23 , 26 , 49 – 51 ]. Our base case assumed that second-line drug costs for drug-resistant patients were 1.24 times higher than first-line drug costs for drug-sensitive individuals [ 53 ], and varied this multiplier from 1 to 5 in sensitivity analysis. Annual PrEP costs included ART medication, laboratory fees (i.e., HIV antibody test every 2–3 months, sexually transmitted infections test every 6 months), and professional fees for patient visits and consultations [ 54 ].…”

HIV Prevention: The Key to Ending AIDS by 2030

“…Moreover, although various modelling exercises have been conducted, the likely costs of second and third-line treatments are unclear, although one limited study in the US showed that ‘…second and third-line treatments were both significantly more expensive than first-line treatment, increasing costs by 24% and 41% respectively’ [ 11 ]. Furthermore, as HIV and AIDS treatments are set to extend in scope and lengthen in time, critical infrastructural and professional deficiencies are already apparent: The management of HIV increasingly requires a multidisciplinary testing approach involving haematology, chemistry, and tests associated with the management of non-communicable diseases; thus, added expertise is needed.…”