Might cost issues affect the success of HIV care programs in the future?

• Clinical guidelines now recommend that people living with HIV start treatment early
• Earlier treatment and rising drug prices have increased the overall cost of HIV care
• Alberta researchers say cost reductions are needed to sustain universal HIV treatment

Over the past 15 years several important advances have been made in the care and treatment of HIV infection. Clinical trials have found that initiating HIV treatment (ART) early results in better measures of health. Treatment guidelines now recommend that ART be offered to all people who test positive for HIV regardless of their CD4+ cell count. The effects of ART are so tremendous that scientists increasingly expect that many HIV-positive people will live into their senior years. Another important development has been the results of well-designed clinical trials that found that HIV-positive people who initiate ART and who achieve and maintain an undetectable viral load do not pass on the virus to their sexual partners.

Advances in treatment have resulted in a complete treatment being available in a pill that can be taken once daily. Additionally, a class of drugs called integrase inhibitors has become widely used because these drugs are well tolerated and powerful and have few drug interactions. Finally, long-acting treatments requiring infrequent dosing will become available in the future.

All of these changes, along with earlier initiation of ART and more people taking and staying on ART for longer, have an impact on current healthcare spending and projections of future spending.

Some regions and programs in Canada (and other high-income countries) have attempted to contain rising health spending in the HIV care sector by using at least the following approaches:

• cheaper regimens
• combinations of two rather than three drugs in a regimen
• generic formulations of older drugs
• proposing that medically stable patients visit clinics less often (twice a year)

A team of scientists at the Southern Alberta Clinic—the regional reference centre for HIV care—has been collecting extensive information about patient care and associated costs. They analysed data collected between January 2006 and December 2017 and found the following:

• the number of people in HIV care doubled
• total costs of care increased from $12 million per year to $30 million per year
• ART accounted for nearly 80% of spending
• a decrease in hospitalization due to HIV

The analysis by the Southern Alberta Clinic scientists is informative and should serve as a stimulus to other regions to also examine the drivers of their costs. The findings from Alberta are also a signal that more funding is needed to help sustain HIV care programs in the long term as well as ways to reduce costs without impacting the quality of care that patients receive. The financial issues raised by the scientists will likely become more urgent in the future as more HIV-positive people enter middle age and senior years.

Study details

The scientists reviewed health-related information collected in their database and other databases in the province. Costs were converted to and calculated in 2017 Canadian dollars.

Results—Changes in the population between 2006 and 2017

Key findings were as follows:

• the number of patients rose from 982 to 1,813
• the proportion of male patients decreased from 84% to 74%
• the proportion of people over the age of 50 almost doubled from 20% to 39%
• the proportion of people with a CD4+ count greater than 500 cells/mm³ increased from 35% to 63%
• the proportion of people with a suppressed viral load increased from 47% to 91%

The number of deaths each year remained stable at less than 31 people.

The scientists found that, over time, as the overall health of patients in the clinic improved, they required fewer CD4+ cell counts, viral load tests and clinic visits.

There was a trend for decreasing hospitalizations beginning in 2014; the majority of hospitalizations were unrelated to HIV infection.

Changes in costs

Over the course of the study, scientists found the following changes in annual costs:

• total medical care costs increased from $12 million in 2006 to $30 million in 2017
• the cost of ART increased from $9 million in 2004 to $24 million in 2017
• lab testing was responsible for about 9% of total costs (this declined modestly over the course of the study)

Factors driving costs

The scientists examined their data and found several reasons that the overall cost of care increased:

Although more people were taking ART, the scientists stated that “earlier initiation of ART and its continuous use also contributed to higher sustained costs in the population.” This point is underscored by research from Spain. In that country, although the healthcare system will save money with early initiation of ART (fewer HIV-related hospitalizations, reduced numbers of new HIV infections), there is still projected to be a large increase in costs over the coming two decades.

The Alberta scientists stated that they were unable to “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 transmission in our community resulting from earlier initiations,” as did other scientists.

The scientists stated that “the approach of early ART initiation and its resulting improved population health does have cost implications for 90-90-90 and U=U [goals]…. 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 programmes that need stable funding.”

Reducing costs

According to the scientists, the Southern Alberta Clinic has been able to reduce the cost of ART for some people by “use of generic drugs and desimplifying single tablet formulations of modern regimens…. These approaches may offer avenues for future cost containment without impacting quality of care.” However, it should be noted that modern ART, with its use of once-daily and well-tolerated regimens, likely contributes to better long-term health (and patient willingness to take treatment) than the use of older, less effective therapies. Desimplification (switching a single-tablet formulation to two or more tablets of the same drugs with one or more drugs being generic) can only reduce costs to a limited degree.

Readers should note that pharmaceutical companies are investing in the development of new HIV treatments, particularly long-acting treatments. It is unlikely that such therapies will be further developed if they are going to be priced at the same level as older first- or second-generation ART.

Finding a balance between the sustainability and expansion of public programs vs. excessive private sector profit, particularly concerning drug costs, will become a major issue in the coming decade. This issue will affect not only HIV, but likely treatments for cancer and other diseases as well.

In the meantime, much work lies ahead, as the scientists stated: “Dedicated and sustainable resources are needed to attain [90-90-90] goals. The questions of where the resources are needed [for example, in HIV drug treatments], what the positive long-term effects are, and how to achieve and guarantee sustained financing to fund these goals all need to be discussed and addressed to produce better HIV care moving forward.”

Resources

90–90–90 - An ambitious treatment target to help end the AIDS epidemic  -- UNAIDS

HIV treatment and an undetectable viral load to prevent HIV transmission – CATIE factsheet

Will de-simplification of HIV treatment become common in high-income countries? – CATIE News

De-simplifying single-tablet regimens for HIV treatment – CATIE News

B.C. researchers explore life expectancy among HIV-positive people – CATIE News

Italian and U.S. researchers look to the future and explore aging-related issues – CATIE News

Will gene therapy for HIV cause financial toxicity? – TreatmentUpdate 232

Issues unrelated to HIV are affecting survival – TreatmentUpdate 228

—Sean R. Hosein

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