Researchers from the United States have estimated the lifetime cost of treatment and care for an HIV-positive individual from the time of diagnosis to death to be approximately £200,000 (US$380,000). The estimates, based on 2004 US treatment guidelines and life expectancy data calculated from the Multicentre AIDS Cohort Study (MACS) study, were published in the November 2006 edition of the journal, Medical Care. With at least 70% of the costs attributed to antiretrovirals alone, the authors expect “further scrutiny of drug pricing and utilisation” to be high on the HIV agenda.
As HIV prevalence continues to rise - due to the impact of potent antiretroviral therapy and sustained new infection rates - the costs of providing increasingly expensive and sophisticated treatment and care are also increasing. In the United States, federal government spending on HIV-related medical care has tripled, from US$3.7 billion in 1995 to US$11.6 billion in 2005.
In 1993, when sequential monotherapy was the standard of care, the estimated life expectancy of an HIV-positive adult with a CD4 cell count of 500 cells/mm3 was 6.8 years. This resulted in an estimated lifetime cost equivalent to around £79,000 (US$150,000). Four years later, just after the introduction of potent triple antiretroviral therapy, estimated life expectancy increased to 10.8 years, and the estimated lifetime cost almost doubled to £140,000 (US$266,000).
Since then, HIV treatments in well-resourced nations have become even more potent – and expensive – but individuals who are fortunate enough to have access to these treatments are benefiting from longer, more productive lives.
Researchers from several public health, epidemiology and medicine departments at various universities on the north-east coast of the US collaborated to estimate life expectancy and HIV treatment costs based on MACS data and the US Department of Health and Human Services (DHHS) 2004 treatment guidelines. In addition, they estimated the cost of medical services utilising data from the HIV Research Network (HIVRN). The cost of antiretrovirals was based on the price paid by government-funded AIDS Drug Assistance Programmes (ADAPs). However, the cost of drugs other than antiretrovirals and opportunistic infection prophylaxis and treatments were not included in their calculations.
The researchers analysed a hypothetical cohort who presented for care with an average age of 39, and an average CD cell count of 310 cells/mm3; this was based on actual HIVRN data from 2002. They assumed that an individual would begin first-line therapy when CD4 counts fell below 350 cells/mm3; or if viral load was above 100,000 copies/ml; or if the individual already had symptomatic HIV disease or AIDS.
They also assumed that individuals made their way through four stages of treatment (first-, second- and third-line, and salvage therapy) as recommended in the 2004 DHHS guidelines. First-line therapy consisted of efavirenz (Sustiva) plus tenofovir (Viread) plus another nucleoside analogue. Second-line therapy consisted of ritonavir-boosted lopinavir (Kaletra) plus two nucleosides. Third-line therapy consisted of ritonavir-boosted atazanavir (Reyataz) and two nucelosides.
Salvage therapy included the use of enfuvirtide (T-20, Fuzeon) plus an optimised background regimen until viral load returned to baseline, and then only the continued use of the optimised background regimen.
Efficacy of these regimens was based on clinical trial data, and resulted in a life expectancy of 24.2 years after diagnosis and follow-up at an HIV treatment centre. However, they also provided an alternative 'real world' calculation that reduced clinical trial efficacy by 15%, resulting in a life expectancy of 21.3 years.
The longest life expectancy - 24.9 years - was based upon the use of T-20 with at least two other active drugs. It should be noted that new drugs – including ritonavir-boosted tipranavir (Aptivus) and ritonavir-boosted darunavir (Prezista) , as well as potentially potent new drug classes – have since become available for highly treatment-experienced individuals, which may result in even longer life expectancies than those estimated here.
They calculated that based on 2004 prices, discounted for future inflation, the cost of HIV treatment and care over 24.2 years was approximately £202,000 (US$385,200). The authors note that their projected lifetime cost estimates are comparable to the lifetime cost of women younger than 65 years old with cardiovascular disease.
If lifetime cost was estimated from the time of infection, rather than diagnosis, the total cost fell to approximately £160,000 (US$303,100). The authors note that “preventing the estimated 40,000 new HIV infections in the United States each year would avoid obligating $12.1 billion annually in future medical costs for HIV-infected patients assuming the current standard of care.”
At CD4 cell count of 300 cells/mm3 antiretroviral drug costs made up 77% of all HIV treatment and care. The proportion attributed to antiretroviral drug costs fell to 38% once CD4 cell counts fell to 50 cells/ mm3, as inpatient care costs increased. “With more than 70% of all costs coming from antiretroviral drugs,” the authors write, “further scrutiny of drug pricing and utilisation is to be expected. Access to ART may become increasingly difficult unless more government funds become available or the cost of HIV care is reduced.”
As a consequence of spiralling drug costs, many ADAPs – which pay for treatment for people with HIV who are un- or under-insured – have had to either limit individuals' enrolment into the programme or limit the drugs available on their formularies.
And, although drug pricing is lower in the United Kingdom, due to strict regulations, the cost of treatment and care has also become a sensitive issue on this side of the Atlantic due to changes in the way HIV treatment will be paid for by the new NHS system known as payment by results (PBR).
The authors conclude by arguing that by preventing new HIV infections, US$12 billion could be saved each year with “greater investments in evidence-based HIV prevention activities. […] However, these investments much be matched by the commitment of sufficient resources to HIV medical care so that persons living with HIV today can fulfil the expectation that they will live long and healthy lives.”
Schackman BR et al. The lifetime cost of current HIV care in the United States. Med Care 44: 990-997, 2006.