Counting the cost of late presentation for HIV care

Boston, MA: While it’s well-established that individuals whose HIV infection is diagnosed late often pay a heavy price through missing the opportunity to benefit from timely medical care, the economic costs of late diagnosis are perhaps less well-recognised. According to an analysis from Alberta, Canada, reported at the Tenth Retroviruses Meeting here in Boston yesterday, late presenters cost health care services two and a half times more, for every month of care, than those who present with less advanced disease.

John Gill and colleagues from the South Alberta Clinic in Calgary derived the direct medical costs pertaining to care of all patients presenting with HIV infection during the five year period between April 1996 and April 2001. In all, the analysis included 262 people, 62 of whom first presented to the clinic with a CD4 count below 100, the remaining 200 with CD4 counts above this level. Comparing the two groups demographically, late presenters were more likely to be older, to have more than a high school education, and to have been at risk of HIV infection via sex between men.

Direct medical costs pertained to the twelve month period following HIV diagnosis, and included all drugs, lab tests, outpatient, inpatient and home care within this period. Overall, the average cost per patient per month (in Canadian dollars) was CA$2,064 for late presenters, and CA$829 for earlier presenters. Antiretroviral costs were 1.8 times higher in the late group (CA$749 per patient per month versus CA$410). Unsurprisingly, the costs of managing acute diseases contributed substantially to the excess costs associated with late presentation. Inpatient costs relating directly to HIV accounted for 40% of all direct medical costs for late presenters, and were nineteen times higher than those of the early group (CA$750 per patient per month versus CA$39).

Whether these cost differentials may in fact constitute a best case scenario is a moot point. Experience from the UK suggests that those diagnosed late in the course of their HIV disease, far from being true ‘late presenters’ have often presented for medical care repeatedly but not had their HIV infection diagnosed. While the Calgary group’s analysis did not include a tracing of patients’ medical history prior to presenting to their service, it seems likely that additional costs were incurred by the wider Canadian health care service nevertheless.