Distribution of health care expenditures for HIV-infected patients

Understanding the Risk of Human Immunodeficiency Virus (HIV) Virologic Failure in the Era of Undetectable Equals Untransmittable

The “Undetectable = Untransmittable” campaign indicates that persons living with Human Immunodeficiency Virus (HIV) who maintain a suppressed viral load cannot sexually transmit the virus. However, there is little knowledge of the percent of individuals at a population level who sustain viral suppression long term. The aims of this study were to: (1) establish a baseline of persons living with diagnosed HIV who resided in New York and had consecutive suppressed viral load tests; (2) describe the risk of virologic failure among those who were consecutively suppressed; and (3) gain an understanding of the length of time between consecutive viral suppression to virologic failure. A total of 102,339 New Yorkers aged 13–90 years were living with diagnosed HIV at the beginning of 2012; 47.9% were consecutively suppressed (last two HIV viral load test results from 2010–2011 that were < 420 days apart and < 200 copies/mL). Of consecutively suppressed individuals, 54.3% maintained viral suppression for the entire study period and 33.6% experienced virologic failure during the study period. Among persons who experienced virologic failure, 82.6% did so six or more months after being consecutively suppressed. Our findings support the need for ongoing viral load monitoring, adherence support, and ongoing risk reduction messaging to prevent forward HIV transmission.

Health care utilization in medically complex people living with HIV before and after admission to an HIV-specific community facility: a pre-post comparison study

BACKGROUND

People living with HIV and multiple comorbidities have high rates of health service use. This study evaluates system usage before and after admission to a community facility focused on HIV care.

METHODS

We used Ontario administrative health databases to conduct a pre-post comparison of rates and costs of hospital admissions, emergency department visits, and family physician and home care visits among medically complex people with HIV in the year before and after admission to Casey House, an HIV-specific hospital in Toronto, for all individuals admitted between April 2009 and March 2015. Negative binomial regression was used to compare rates of health care utilization. We used Wilcoxon rank sum tests to compare associated health care costs, standardized to 2015 Canadian dollars. To contextualize our findings, we present rates and costs of health service use among Ontario residents living with HIV.

RESULTS

During the study period, 268 people living with HIV were admitted to Casey House. Emergency department use declined from 4.6 to 2.5 visits per person-year (p = 0.02) after discharge from Casey House, and hospitalization rates declined from 1.4 to 1.1 admissions per person-year (p = 0.05). Conversely, home care visits increased from 24.3 to 35.6 visits per person-year (p = 0.01) and family physician visits increased from 18.3 to 22.6 visits per person-year (p < 0.001) in the year after discharge. These changes were associated with reduced overall costs to the health care system. The reduction in overall costs was not significant (p = 0.2); however, costs of emergency department visits (p < 0.001) and physician visits (p < 0.001) were significantly less.

INTERPRETATION

Health care utilization by people with HIV was significantly different before and after admission to a community hospital focused on HIV care. This has implications for health care in other complex patient populations.

Generation of HIV-1-infected patients' gene-edited induced pluripotent stem cells using feeder-free culture conditions

OBJECTIVES

The discovery of induced pluripotent stem cells (iPSC) has brought promise to regenerative medicine as it breaks the ethical barrier of using embryonic stem cells. Such cell culture-derived patient-specific autologous stem cells are needed for transplantation. Here we report deriving HIV-1-infected patients' iPSC lines under transgene-free methods and under feeder-free and xeno-free culture conditions to meet the requirement for clinical application.

METHODS AND RESULTS

We have reprogrammed patients' peripheral blood mononuclear cells with EBNA1/OriP episomal vectors, or a defective and persistent Sendai virus vector (SeVdp) to ensure a nonintegrating iPSC generation. Both single picked and pooled iPSC lines demonstrated high pluripotency and were able to differentiate into various lineage cells in vivo. The established cell lines could be modified by genetic editing using the TALENs or CRISPR/Cas 9 technology to have a bi-allelic CCR5Δ32 mutations seamlessly. All generated iPSC lines and modified cell lines had no evidence of HIV integration and maintained normal karyotype after expansion.

CONCLUSIONS

This study provides a reproducible simple procedure for generating therapeutic grade iPSCs from HIV-infected patients and for engineering these cells to possess a naturally occurring genotype for resistance to HIV-1 infection when differentiated into immune cells.

Assessment of out-of-pocket and catastrophic expenses incurred by patients with Human Immunodeficiency Virus (HIV) in availing free antiretroviral therapy services in India

OBJECTIVES

With the free availability of antiretroviral therapy in India, one expects that the out-of-pocket (OOP) expenditure would reduce and would not be a significant financial burden. However, the cost of seeking care is also dependent on accessibility of services, as well as other non-medical and indirect expenses. This study aims to analyze the OOP expenditure in availing antiretroviral therapy (ART) services and determine the prevalence and pattern of catastrophic and impoverishing health expenditure. The study also discusses the policy implications of these findings in the light of growing commitment toward universal health coverage.

STUDY DESIGN

This was a cross-sectional study.

METHODS

A total of 434 patients receiving antiretroviral treatment were interviewed. OOP expenses included a measure of direct medical expenditure, non-medical expenditure, and indirect expenditure incurred in availing ART services. A threshold level of 40% of 'capacity to pay' was taken as catastrophic expenditure. Based on previous research, different demographic, socio-economic, and clinical factors were selected as independent variables to determine their association with catastrophic expenditure. Logistic regression was conducted to study the association between independent and dependent variables keeping the level of significance at <0.05.

RESULTS

The mean OOP expenditure among patients with human immunodeficiency virus (HIV) taking ART was Rs. 238.8 ± 193.7. Majority of these expenses were incurred on non-medical expenditure (58.1%), while indirect expenditure accounted for 29.7%. The direct health expenditure was the lowest (12.2%) type of expenditure in the total OOP expenditure. OOP spending was catastrophic in 8.1% (35/434) of households in our study. Patients belonging to nuclear family (odds ratio [OR] = 2.99; 95% confidence interval [CI] = 1.19-7.58), who are unemployed (OR = 2.56; 95% CI = 1.18-5.54), of lower socio-economic classes (OR = 8.46; 95% CI = 1.93-37.02), those who traveled more than 50 km for getting drugs (OR = 2.80; 95% CI = 1.26-6.23), and those having CD4 cell count lower than 200 (OR = 3.11; 95% CI = 1.32-7.32) were found to be independently and significantly associated with catastrophic OOP health expenditure among patients with HIV.

CONCLUSIONS

A high direct and indirect expenditure was observed among patients with HIV seeking treatment in North India leading to catastrophic expenditure in a significant number of households. A service-level integration of HIV care at subdistrict levels within the Universal health coverage (UHC) framework could reduce catastrophic expenditure.

Heterogeneity in the costs of medical care among people living with HIV/AIDS in the United States

OBJECTIVE

The costs of medical care for people with HIV/AIDS (PWH) vary substantially across demographic groups, stages of disease progression and regionally across the United States. We aimed to estimate medical costs for PWH and examine the heterogeneity in costs within key patient groups typically distinguished in cost-effectiveness analyses.

DESIGN

Retrospective cohort study using health administrative databases for diagnosed PWH in care at 17 HIV Research Network sites across the United States.

METHODS

We estimated mean quarterly costs for key patient groups using multivariable generalized linear mixed effects models. We used quantile regression to highlight differences in the effect of covariates within each patient group (difference between covariate estimates at the mean versus the 90th percentile of quarterly costs), identifying covariates with a larger effect among the highest cost PWH, or generating greater uncertainty in mean cost estimates.

RESULTS

Our sample included 40 022 patients with a median age of 39 years. Mean quarterly costs were highest for people who inject drugs with advanced disease progression and for PWH on antiretroviral treatment (ART). Within patient groups, we found the most heterogeneity at different levels of resource use for PWH on ART and PWH off ART with CD4 cell counts less than 200 cells/μl, people who inject drugs, as well as PWH in the South.

CONCLUSION

The study quantifies heterogeneity in costs both across and within key PWH patient groups. Our results highlight the need for sensitivity analysis on cost estimates and may inform decisions on model structure in cost-effectiveness analyses on HIV/AIDS treatment and prevention strategies.

Risk and Cost Associated With Drug-Drug Interactions Among Aging HIV Patients Receiving Combined Antiretroviral Therapy in France

Background

We aimed to describe the frequency, risk factors, and costs attributable to drug–drug interactions (DDIs) among an aging French HIV population.

Methods

We conducted a retrospective cohort study using French nationwide health care e-records: the SNIIRAM database. People living with HIV (PLWH) aged >65 years and receiving combined antiretroviral treatment (cART) during 2016 were included. A DDI was defined as “These drugs should not be co-administered,” represented by a red symbol on the University of Liverpool website. Attributable DDIs’ cost was defined as the difference between individuals with and without DDIs regarding all reimbursed health care acts.

Results

Overall, 9076 PLWH met the study criteria. Their baseline characteristics were: mean age, 71.3 ± 4.9 years; 25% female; median HIV duration (interquartile range [IQR]), 16.2 (9.5–20.3) years; median comorbidities (IQR), 2 (1–3). During 2016, they received a median (IQR) of 14 (9–21) comedications (non-cART), and 1529 individuals had at least 1 DDI (16.8%; 95% confidence interval [CI], 16.1–17.6). In multivariate analysis, raltegravir or dolutegravir plus 2 nucleoside reverse-transcriptase inhibitors (NRTIs) significantly and independently reduced the risk of DDIs (adjusted odds ratio [aOR], 0.02; 95% CI, 0.005–0.050; P < .0001) compared with non-nucleoside reverse-transcriptase inhibitor plus 2 NRTIs, whereas cART with boosted agents (protease inhibitors or elvitegravir) significantly increased the risk (aOR, 4.12; 95% CI, 3.34–5.10; P < .0001). Compared with propensity score–matched PLWH without DDIs, the presence of DDIs was associated with a $2693 additional cost per year (P < .0001).

Conclusions

The presence of DDIs is frequent and significantly increases health care costs in the aging population of PLWH.

How has the cost of antiretroviral therapy changed over the years? A database analysis in Italy

Background

The number of human immunodeficiency virus (HIV)-related hospitalizations has decreased worldwide in recent years, due to the availability of combined antiretroviral therapies (cART). The present analysis aimed to analyse the economic, and clinical burden of HIV management, after the introduction of systematic use of cART.

Methods

Data from HIV-infected patients, treated at Policlinico San Martino Hospital in Genova (Italy) were retrospectively collected. A comparison between years 2009 and 2015 was performed. HIV-related admissions were identified by using the Diagnosis-Related Group (DRG) codes. The resource consumption of outpatient services was derived by using a modelling approach. Expenditure for drugs was also analysed, as aggregate data.

Results

The number of HIV-infected patients was 898 in 2009 and 1006 in 2015. Overall, the virological success rate improved from 2009 to 2015, as the percentage of patients with HIV-RNA < 50 copies/mL increased from 79 to 89% (P < 0.05). The average incidence of hospitalizations per-patient decreased from 0.30 in 2009, to 0.13 in 2015. Average expenditure per-patient decreased from €10,107 in 2009 to €9063 in 2015.

Conclusions

The present analysis confirmed the role of cART in controlling HIV viral load and, consequently, in reducing hospitalizations, admissions to day-hospital and the use of outpatient services.

Clinical improvements and economic savings more than compensated the investments required to treat HIV-infected patients with cART. Health Authorities should invest in modern cART supply and universal treatment, to use at best the available resources and obtain a cost-effective improvement of health in people living with HIV. Additional research, with the involvement of different centers and the use of patient-specific data, are recommended to consolidate the findings of this analysis.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3507-x) contains supplementary material, which is available to authorized users.

Common elements and features of a mobile-based self-management system for people living with HIV

Background

In recent years, mobile-based applications have become important technologies to the delivery of healthcare around the world. Mobile-based self-management systems with standard features for providing, evaluating, and improving HIV care are significantly required in developing countries.

Objective

To determine the common elements of a mobile-based self-management system for people living with HIV (PLWH).

Methods

This cross-sectional study was done in two main phases in 2017. In the first phase, a review was conducted in relevant databases such as; PubMed, Scopus, Up To Date, and Web of Science. The keywords used to search for resources were as follows; Self-care, Self-management, Data elements, Minimum data set, Mobile application, Mobile health, and HIV/AIDS. In the second phase, the infectious diseases specialists and health information managers affiliated with Tehran University of Medical Sciences were consulted to score identified elements by a questionnaire. Frequency and mean of collected data were calculated using SPSS software (version 19).

Results

By full-text reviewing of 9 related articles, the identified elements were justified in 3 main categories and 37 subcategories including: clinical data elements (17), technical capabilities (12) and demographic data elements (8). According to the findings, among the clinical category, 11 data elements were selected by the statistical population. Among the identified technical capabilities, 11 features were selected. Moreover, 6 data elements were selected as the demographic category.

Conclusion

We obtained data elements and technical capabilities of a mobile-based self-management system for people living with HIV. Using these elements and features, designing of self-management system architecture will be possible. Self-management skills of PLWH and their communication with healthcare providers will improve by using this system.

Using a retention in care protocol to promote positive health and systems related outcomes

People living with HIV can experience the full benefits of retention when they are continuously engaged in care. Continuous engagement in care promotes improved adherence to ART and positive health outcomes. An infectious disease clinic has implemented a protocol to primarily improve patient retention. The retrospective, facility-based, costing study took place in an infectious disease clinic in Washington DC. Retention was defined in two ways and over a 12-month period. Micro-costing direct measurement methods were used to collect unit costs in time series. Return on investment accounted for the cost of treatment based on CD4 strata. ROI was expressed in 2016USD. The difference in CD4 and viral load levels between the two periods of analysis were determined for active patients, infected with HIV. The year before the intervention was compared to the year of the intervention. Total treatment expenditure decreased from $2,435,653.00 to $2,283,296.23, resulting in a $152,356.77 gain from investment for the healthcare system over a 12-month investment period. The viral load suppression rate increased from 81 to 95 (p = 0.04) over the investment period. The number of patients in need of HIV related opportunistic infection prophylaxis decreased from 21 to 13 (p = 0.06). Improved immunologic, virologic and healthcare expenditure outcomes can be linked to the quality of retention practice.

The cost of comorbidities in treatment for HIV/AIDS in California

BACKGROUND

Antiretroviral therapy has increased longevity for people living with HIV (PLWH). As a result, PLWH increasingly experience the common diseases of aging and the resources needed to manage these comorbidities are increasing. This paper characterizes the number and types of comorbidities diagnosed among PLWH covered by Medicare and examines how non-HIV comorbidities relate to outpatient, inpatient, and pharmaceutical expenditures.

METHODS

The study examined Medicare expenditures for 9767 HIV-positive Californians enrolled in Medicare in 2010 (7208 persons dually covered by Medicare and Medicaid and 2559 with Medicare only). Costs included both out of pocket costs and those paid by Medicare and Medicaid. Comorbidities were determined by examining diagnosis codes.

FINDINGS

Medicare expenditures for Californians with HIV averaged $47,036 in 2010, with drugs accounting for about 2/3 of the total and outpatient costs 19% of the total. Inpatient costs accounted for 18% of the total. About 64% of the sample had at least one comorbidity in addition to HIV. Cross-validation showed that adding information on comorbidities to the quantile regression improved the accuracy of predicted individual expenditures. Non-HIV comorbidities relating to health habits-diabetes, hypertension, liver disease (hepatitis C), renal insufficiency-are common among PLWH. Cancer was relatively rare, but added significantly to cost. Comorbidities had little effect on pharmaceutical costs, which were dominated by the cost of antiretroviral therapy, but had a major effect on hospital admission.

CONCLUSIONS

Comorbidities are prevalent among PLWH and add substantially to treatment costs for PLWH. Many of these comorbidities relate to health habits that could be addressed with additional prevention in ambulatory care, thereby improving health outcomes and ultimately reducing costs.

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

BACKGROUND

While 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.

METHODS

We 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.

RESULTS

Data 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.

CONCLUSIONS

Our 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.

Implementation and Operational Research: A Cost-Effective, Clinically Actionable Strategy for Targeting HIV Preexposure Prophylaxis to High-Risk Men Who Have Sex With Men

BACKGROUND

Preexposure prophylaxis (PrEP) is effective at preventing HIV infection among men who have sex with men (MSM), but there is uncertainty about how to identify high-risk MSM who should receive PrEP.

METHODS

We used a mathematical model to assess the cost-effectiveness of using the HIV Incidence Risk Index for MSM (HIRI-MSM) questionnaire to target PrEP to high-risk MSM. We simulated strategies of no PrEP, PrEP available to all MSM, and eligibility thresholds set to HIRI-MSM scores between 5 and 45, in increments of 5 (where a higher score predicts greater HIV risk). Based on the iPrEx, IPERGAY, and PROUD trials, we evaluated PrEP efficacies from 44% to 86% and annual costs from $5900 to 8700. We designate strategies with incremental cost-effectiveness ratio (ICER) ≤$100,000/quality-adjusted life-year (QALY) as "cost-effective."

RESULTS

Over 20 years, making PrEP available to all MSM is projected to prevent 33.5% of new HIV infections, with an ICER of $1,474,000/QALY. Increasing the HIRI-MSM score threshold reduces the prevented infections, but improves cost-effectiveness. A threshold score of 25 is projected to be optimal (most QALYs gained while still being cost-effective) over a wide range of realistic PrEP efficacies and costs. At low cost and high efficacy (IPERGAY), thresholds of 15 or 20 are optimal across a range of other input assumptions; at high cost and low efficacy (iPrEx), 25 or 30 are generally optimal.

CONCLUSIONS

The HIRI-MSM provides a clinically actionable means of guiding PrEP use. Using a score of 25 to determine PrEP eligibility could facilitate cost-effective use of PrEP among high-risk MSM who will benefit from it most.

Prevalence, patterns, and perceived value of complementary and alternative medicine among HIV patients: a descriptive study

BACKGROUND

Use of complementary and alternative medicine (CAM) is widespread among different patient populations despite the availability of evidence-based conventional medicine and lack of supporting evidence for the claims of most CAM types. This study explored the prevalence, patterns, and perceived value of CAM among human immunodeficiency virus (HIV) patients.

METHODS

This quantitative descriptive study was conducted between November 1, 2014 and March 31, 2015 among a cross-sectional, convenience sample of attendees of the HIV clinic of a public tertiary health care institution. Face-to-face interviews using a 34-item questionnaire were conducted. Data analysis included descriptive statistics, chi-square tests, and binary logistic regression analysis.

RESULTS

CAM was used by 113 (32.8%) of a total of 343 HIV patients, but <1% informed their health care providers of CAM usage. Medicinal herbs were the most common type of CAM used (n = 110, 97.3%) followed by spiritual therapy (n = 56, 49.6%), including faith healing/prayer and meditation. The most used medicinal herbs were Aloe vera (n = 54, 49.1%), ginger (n = 33, 30.0%), and garlic (n = 23, 20.9%). The most used vitamins were complex B vitamins (n = 70, 61.9%), followed by vitamin A (n = 58, 51.3%), vitamin E (n = 51, 45.1%), and vitamin D (n = 42, 37.1%). Most CAM users continued using conventional medicine in addition to CAM and were willing to use CAM without supervision and without informing their health care provider. Patients were generally satisfied with CAM therapy (n = 91, 80.5%). The main reasons for CAM use were the desire to take control of their treatment (8.8%) or just trying anything that could help (18.8%). Main influences were the mass media (32.7%) and non-hospital health personnel (19.5%). Predictors of CAM use were being 30-50 years, married and having a secondary school education.

CONCLUSION

About one-third of HIV patients used CAM, but virtually none informed their healthcare provider. Medicinal herbs were the most common type of CAM, followed by spiritual therapy and vitamins. A patient's decision to use CAM was influenced for the most part by the mass media and non- hospital health care personnel.

Maximizing the benefits of ART and PrEP in resource-limited settings

Antiretroviral therapy (ART) is increasingly being used as an HIV-prevention tool, administered to uninfected people with ongoing HIV exposure as pre-exposure prophylaxis (PrEP) and to infected people to reduce their infectiousness. We used a modelling approach to determine the optimal population-level combination of ART and PrEP allocations required in South Africa to maximize programme effectiveness for four outcome measures: new infections, infection-years, death and cost. We considered two different strategies for allocating treatment, one that selectively allocates drugs to sex workers and one that does not. We found that for low treatment availability, prevention through PrEP to the general population or PrEP and ART to sex workers is key to maximizing effectiveness, while for higher drug availability, ART to the general population is optimal. At South Africa's current level of treatment availability, using prevention is most effective at reducing new infections, infection-years, and cost, while using the treatment as ART to the general population best reduces deaths. At treatment levels that meet the UNAIDS's ambitious new 90-90-90 target, using all or almost all treatment as ART to the general population best reduces all four outcome measures considered.

Cost considerations in the current antiretroviral era

BACKGROUND

US national guidelines call for cost-conscious practices including the selection of antiretroviral therapy.

OBJECTIVE

The objective is to analyze the relative cost-effectiveness of contemporary antiretroviral therapy in real-world clinical settings.

DESIGN

Observational cohort study.

METHODS

Retrospective follow-up study of treatment-naïve persons living with HIV initiating antiretroviral therapy (ART) between January 2007 and December 2012 at an academically affiliated HIV clinic was conducted. Analysis was restricted to patients with the five most commonly prescribed regimens (N = 491). Patients were followed until December 14 to determine the durability of the initial regimen prescribed; median durations were calculated using Kaplan-Meier survival analyses. The average 340b price of the ART regimen 30-day supply was used for cost. Sensitivity analyses were performed adjusting for missing data and pricing indices and using mean durability (±1 SD).

RESULTS

Initial regimens contained emtricitabine and tenofovir, along with a third drug. Median durability was shortest for ritonavir-boosted atazanavir (31.9 months) and longest for ritonavir-boosted darunavir and raltegravir (both 47.8 months). All regimens were dominated, meaning less durable and more costly, relative to efavirenz ($710.64/month) and raltegravir-based regimens ($1075.03/month). These findings were reproduced in sensitivity analysis, although rilpivirine became a valuable option in some scenarios. Relative to the efavirenz-based regimen, raltegravir had an incremental cost of $47/month of additional therapy.

CONCLUSION

In this sample, raltegravir and efavirenz-based regimens are the most cost-effective options for treatment-naive patients. Sensitivity analyses suggest rilpivirine is a reasonable choice in limited scenarios. These findings are relevant given changes in recommended regimens for treatment-naive persons, which include raltegravir and darunavir but exclude efavirenz and rilpivirine-based regimens.

SUMMARY

Of five commonly prescribed regimens for treatment-naïve HIV patients in one clinic (2007-2012), emtricitabine and tenofovir with efavirenz and raltegravir were the only consistently cost-effective options; the rilpivirine-based regimen was valuable in limited scenarios. Further data on the comparative effectiveness of efavirenz and rilpivirine are needed before they are abandoned.

Adherence to antiretroviral therapy among HIV-infected prisoners: a systematic review and meta-analysis

Data on antiretroviral therapy (ART) adherence among prison inmates are limited and not previously synthesized in a systematic manner. The objective of this study was to provide accurate and up-to-date ART adherence estimates among prison inmates. We searched electronic databases for all studies reporting adherence as a primary or secondary outcome among prison inmates. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity and publication bias were assessed. Eleven studies involving 2895 HIV-infected prison inmates were included. The studies were carried out between 1992 and 2011 and reported between 1998 and 2013. A pooled analysis of all studies indicated a pooled estimate of 54.6% (95% confidence interval 48.1-60.9%) of prison inmates had adequate (≥95%) ART adherence. The adherence estimates were significantly higher among cross-studies and studies that used self-reported measures. In summary, our findings indicate that optimal adherence remains a challenge among prison inmates. It is crucial to monitor ART adherence and develop appropriate interventions to improve adherence among these population.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel

IMPORTANCE

New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults.

OBJECTIVE

To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis.

EVIDENCE REVIEW

A panel of experts in HIV research and patient care convened by the International Antiviral Society-USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence.

FINDINGS

Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure.

CONCLUSIONS AND RELEVANCE

Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.

Determining the Cost-Savings Threshold for HIV Adherence Intervention Studies for Persons with Serious Mental Illness and HIV

Persons with serious mental illnesses are at increased risk for contracting and transmitting HIV and often have poor adherence to medication regimens. Determining the economic feasibility of different HIV adherence interventions among individuals with HIV and serious mental illness is important for program planners who must make resource allocation decisions. The goal of this study was to provide a methodology to estimate potential cost savings from an HIV medication adherence intervention program for a new study population, using data from prior published studies. The novelty of this approach is the way CD4 count data was used as a biological marker to estimate costs averted by greater adherence to anti-retroviral treatment. Our approach is meant to be used in other adherence intervention studies requiring cost modeling.

Late Presentation into Care of HIV Disease and Its Associated Factors in Asia: Results of TAHOD

Many HIV-infected individuals do not enter health care until late in the infection course. Despite encouraging earlier testing, this situation has continued for several years. We investigated the prevalence of late presenters and factors associated with late presentation among HIV-infected patients in an Asian regional cohort. This cohort study included HIV-infected patients with their first positive HIV test during 2003-2012 and CD4 count and clinical status data within 3 months of that test. Factors associated with late presentation into care (CD4 count <200 cells/μl or an AIDS-defining event within ±3 months of first positive HIV test) were analyzed in a random effects logistic regression model. Among 3,744 patients, 2,681 (72%) were late presenters. In the multivariable model, older patients were more likely to be late presenters than younger (≤30 years) patients [31-40, 41-50, and ≥51 years: odds ratio (OR) = 1.57, 95% confidence interval (CI) 1.31-1.88; OR = 2.01, 95% CI 1.58-2.56; and OR = 1.69, 95% CI 1.23-2.31, respectively; all p ≤ 0.001]. Injecting drug users (IDU) were more likely (OR = 2.15, 95% CI 1.42-3.27, p < 0.001) and those with homosexual HIV exposure were less likely (OR = 0.45, 95% CI 0.35-0.58, p < 0.001) to be late presenters compared to those with heterosexual HIV exposure. Females were less likely to be late presenters (OR = 0.44, 95% CI 0.36-0.53, p < 0.001). The year of first positive HIV test was not associated with late presentation. Efforts to reduce the patients who first seek HIV care at the late stage are needed. The identified risk factors associated with late presentation should be utilized in formulating targeted public health intervention to improve earlier entry into HIV care.

Predictors of HIV Disclosure in Infected Persons Presenting to Establish Care

Persons receiving effective HIV treatment experience longevity and improvement in quality of life. For those infected, social support is associated with improved medication adherence. Disclosure of infection status is likely a prerequisite for social support. However, little research describes patterns of HIV disclosure by infected persons. We retrospectively evaluated factors associated with disclosure among patients initiating HIV care at a university-based clinic from 2007 to 2012. Of 490 persons initiating care, 13 % had not disclosed their HIV infection to anyone. Black race significantly predicted non-disclosure and persons living with a significant other or friends were more likely to have disclosed their HIV infection versus those living alone. CD4 + T lymphocyte count <200 was associated with nondisclosure and disclosure only to family members. Future research is needed to better understand factors associated with disclosure of HIV infection status, because this could enhance receipt of social support and contribute to improved HIV health outcomes.

Evidence of High Out of Pocket Spending for HIV Care Leading to Catastrophic Expenditure for Affected Patients in Lao People's Democratic Republic

BACKGROUND

The scaling up of antiviral treatment (ART) coverage in the past decade has increased access to care for numerous people living with HIV/AIDS (PLWHA) in low-resource settings. Out-of-pocket payments (OOPs) represent a barrier for healthcare access, adherence and ART effectiveness, and can be economically catastrophic for PLWHA and their family. We evaluated OOPs of PLWHA attending outpatient and inpatient care units and estimated the financial burden for their households in the Lao People's Democratic Republic. We assumed that such OOPs may result in catastrophic health expenses in this context with fragile economical balance and low health insurance coverage.

METHODS

We conducted a cross-sectional survey of a randomized sample of routine outpatients and a prospective survey of consecutive new inpatients at two referral hospitals (Setthathirat in the capital city, Savannaket in the province). After obtaining informed consent, PLWHA were interviewed using a standardized 82-item questionnaire including information on socio-economic characteristics, disease history and coping strategies. All OOPs occurring during a routine visit or a hospital stay were recorded. Household capacity-to-pay (overall income minus essential expenses), direct and indirect OOPs, OOPs per outpatient visit and per inpatient stay as well as catastrophic spending (greater than or equal to 40% of the capacity-to-pay) were calculated. A multivariate analysis of factors associated with catastrophic spending was conducted.

RESULTS

A total of 320 PLWHA [280 inpatients and 40 outpatients; 132 (41.2%) defined as poor, and 269 (84.1%) on ART] were enrolled. Monthly median household income, essential expenses and capacity-to-pay were US$147.0 (IQR: 86-242), $126 (IQR: 82-192) and $14 (IQR: 19-80), respectively. At the provincial hospital OOPs were higher during routine visits, but three fold lower during hospitalization than in the central hospital ($21.0 versus $18.5 and $110.8 versus $329.8 respectively (p<0.01). The most notable OOPs were related to transportation and to loss of income. A total of 150 patients (46.8%; 95%CI: 41.3-52.5) were affected by catastrophic health expenses; 36 outpatients (90.0%; 95%CI: 76.3-97.2) and 114 inpatients (40.7%; 95%CI: 34.9-46.7). A total of 141 (44.0%) patients had contracted loans, and 127 (39.6%) had to sell some of their assets. In the multivariate analysis, being of Lao Loum ethnic group (Coef.-1.4; p = 0.04); being poor (Coef. -1.0; p = 0.01) and living more than 100 km away from the hospital (Coef.-1.0; p = 0.002) were positively associated with catastrophic spending. Conversely being in the highest wealth quartile (Coef. 1.6; p<0.001), living alone (Coef. 1.1; p = 0.04), attending the provincial hospital (Coef. 1.0; p = 0.002), and being on ART (Coef.1.2; p = 0.003), were negatively associated with catastrophic spending.

CONCLUSION

PLWHA's households face catastrophic OOPs that are not directly attributable to the cost of ART or to follow-up tests, particularly during a hospitalization period. Transportation, distance to healthcare and time spent at the health facility are the major contributors for OOPs and for indirect opportunity costs. Being on ART and attending the provincial hospital were associated with a lower risk of catastrophic spending. Decentralization of care, access to ART and alleviation of OOPs are crucial factors to successfully decrease the household burden of HIV-AIDS expenses.

Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection

Background

Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections.

Methods

The current study will determine whether the former unsanctioned SIF, that provided assisted injection and was operated by the grass root organization called Vancouver Area Network of Drug Users (VANDU), cost less than the health care consequences of not having such a program in Vancouver, Canada. By analyzing data gathered in 2013, this paper relies on two mathematical models to estimate the number of new HIV and HCV infections prevented by the former unsanctioned facility in Vancouver’s Downtown Eastside.

Results

A conservative estimate indicates that the SIF location that provided assisted injections has a benefit-cost ratio of 33.1:1 due to its low operational cost. At the baseline sharing rate, the facility, on an average, reduced 81 HCV and 30 HIV cases among PWID each year. Such reductions in blood borne infections among PWID resulted in annual savings worth CAN$4.3 million dollars in health care expenditure. In addition to this, the current paper relies on a sensitivity analysis based on different needle sharing rate scenarios.

Conclusions

The sensitivity analysis and the baseline rates indicate that funding SIF facilities operated by peer drug users that facilitate assisted injection appear to be an efficient and effective use of financial resources in the public health domain since they lead to a significant decline in the rate of mortality within a vulnerable population.

mRNA transfection of a novel TAL effector nuclease (TALEN) facilitates efficient knockout of HIV co-receptor CCR5

Homozygosity for a natural deletion variant of the HIV-coreceptor molecule CCR5, CCR5Δ32, confers resistance toward HIV infection. Allogeneic stem cell transplantation from a CCR5Δ32-homozygous donor has resulted in the first cure from HIV ('Berlin patient'). Based thereon, genetic disruption of CCR5 using designer nucleases was proposed as a promising HIV gene-therapy approach. Here we introduce a novel TAL-effector nuclease, CCR5-Uco-TALEN that can be efficiently delivered into T cells by mRNA electroporation, a gentle and truly transient gene-transfer technique. CCR5-Uco-TALEN mediated high-rate CCR5 knockout (>90% in PM1 and >50% in primary T cells) combined with low off-target activity, as assessed by flow cytometry, next-generation sequencing and a newly devised, very convenient gene-editing frequency digital-PCR (GEF-dPCR). GEF-dPCR facilitates simultaneous detection of wild-type and gene-edited alleles with remarkable sensitivity and accuracy as shown for the CCR5 on-target and CCR2 off-target loci. CCR5-edited cells were protected from infection with HIV-derived lentiviral vectors, but also with the wild-type CCR5-tropic HIV-1BaL strain. Long-term exposure to HIV-1BaL resulted in almost complete suppression of viral replication and selection of CCR5-gene edited T cells. In conclusion, we have developed a novel TALEN for the targeted, high-efficiency knockout of CCR5 and a useful dPCR-based gene-editing detection method.

What we know and what we do not know about factors associated with and interventions to promote antiretroviral adherence

Antiretroviral therapy (ART) adherence remains critical for achieving successful outcomes. Factors affecting ART adherence can occur at the individual level or be related to the treatment regimen, daily schedule, and/or interpersonal relationships. While treatment-related barriers have diminished with recent simplified ART regimens, guidelines still recommend considering regimen simplicity. ART readiness should be assessed prior to starting ART, with follow-up adherence assessments once ART is initiated, and at all subsequent clinical visits. Adherence interventions work best when multifaceted, targeted for at-risk and nonadherent participants, and tailored to individuals' needs. Successful interventions have included education and counseling, provision of social support, directly observed therapy, and financial incentives. Pillboxes and two-way short-text messaging service (SMS) reminders have been shown to be effective and are widely recommended tools for promoting ART adherence. Further research is needed to determine the optimal combination of adherence interventions, as well as generalizability, implementation, and cost-effectiveness.

Costs of health resource utilization among HIV-positive individuals in British Columbia, Canada: results from a population-level study

BACKGROUND

Through delayed HIV disease progression, highly active antiretroviral therapy (HAART) may reduce direct medical costs, thus at least partially offsetting therapy costs. Recent findings regarding the secondary preventive benefits of HAART necessitate careful consideration of funding allocations for HIV/AIDS care. Our objective is to estimate non-HAART direct medical costs at different levels of disease progression and over time in British Columbia, Canada.

METHODS

We considered the population of individuals with HIV/AIDS within a set of linked disease registries and health administrative databases (N = 11,836) from 1996 to 2010. Costs of hospitalization, physician billing, diagnostic testing and non-HAART medications were calculated in 2010 Canadian dollars. Effects of covariates on quarterly costs were assessed with a two-part model with logit for probability of non-zero costs and a generalized linear model (GLM). Net effects of CD4 strata on direct non-HAART medical costs were evaluated over time during the study period.

RESULTS

Compared with person-quarters in which CD4 >500/mm(3), costs were Can$185 (95 % confidence interval [CI] 132-239) greater for CD4 350-500/mm(3), Can$441 (95 % CI 366-516) greater for CD4 200-350/mm(3) and Can$1,173 (95 % CI 1,051-1,294) greater when CD4 <200/mm(3). Prior to HIV care initiation, individuals incurred costs Can$385 (95 % CI 283-487) greater than in periods with CD4 >500/mm(3). Hospitalization comprised the majority of the increment in costs amongst those with no measured CD4. Evaluated at CD4 state conditional means, those with CD4 <200/mm(3) incurred quarterly costs of Can$5,781 (95 % CI 4,716-6,846) versus Can$1,307 (95 % CI 1,154-1,460; p < 0.001) for CD4 ≥500/mm(3) in 2010.

CONCLUSION

Non-HAART direct medical costs were substantially lower for individuals during periods of sustained virologic suppression and high CD4 count. HIV treatment and prevention evaluations require detailed health resource use data to inform funding allocation decisions.

Analysis of Treatment Costs for HIV RNA Reductions and CD4 Increases for Darunavir Versus Other Antiretrovirals in Treatment-Experienced, HIV–Infected Patients

BACKGROUND

For patients with preexisting HIV drug resistance, a wide range of antiretrovirals are used, with differences in efficacy and cost. The additional cost per incremental 25 cell rise in CD4 count, or 0.5 log reduction in HIV RNA, was calculated for 8 antiretrovirals using pivotal clinical trials data.

METHOD

For approved antiretrovirals in HIV therapy--experienced patients, 24-week efficacy (benefit over control in HIV RNA and CD4 count) was extracted from pivotal trials in published reports and compared with the additional treatment cost versus the control arm of each trial (2006 US wholesale acquisition costs). Treatment costs in the POWER trials were calculated directly from the treatment use database.

RESULTS

Data were available from 11 clinical trials in more than 4,000 antiretroviral treatment--experienced patients: Gilead 907 (TDF vs. placebo), TORO1/2 (T-20/OBR vs. OBR), RESIST-1/2 (TPV/r vs. control PI), BMS-045 (ATV/r vs. LPV/r), CONTEXT (fAPV/r vs. LPV/r), CAESAR (3TC vs. placebo), CNA3002 (ABC vs. placebo), and POWER 1/2 (DRV/r vs. control PI). Additional cost per 0.5 log reduction in HIV RNA was $152 for ritonavir-boosted darunavir (DRV/r), $4,453 for lamivudine (3TC), $4,274 for abacavir (ABC), $4,641 for tenofovir (TDF), and $13,217 for enfuvirtide (T-20). Cost per 25 cell rise in CD4 ranged from $132 for darunavir/r to $16,464 for T-20.

CONCLUSION

There is a wide range of costs associated with efficacy improvements across the classes of antiretrovirals used for antiretroviral treatment--experienced patients. This analysis does not account for differences in toxicity, use of concomitant medications, or long-term adherence, which could also influence value assessments.

Estimation of the Direct Cost of HIV-Infected Patients in Greece on an Annual Basis

OBJECTIVE

HIV infection is currently regarded as a global chronic disease. The purpose of this study was to assess the direct cost of illness per patient per year in Greece.

METHODS

A retrospective study for the estimation of the direct cost of HIV infection was performed from the third-party payer perspective. Data from 447 patients monitored in a general hospital of Athens were collected from their medical records. The survey involved all services and treatments that patients (stratified into three health states according to the number of CD4 cells/ml as defined by the Centers for Disease Control and Prevention classification system for HIV infection) received in 1 year, as well as demographic data.

RESULTS

The annual direct cost per patient was calculated at €6859 ± €4699. Antiretroviral therapy cost was estimated at €5741, while the annual cost of providing health care services regardless of health state was computed at €1118, with laboratory investigation and imaging studies representing €924 (13.5%), outpatient visits €34 (0.5%), and hospitalization €160 (2.3%) of total cost, respectively. Overall, direct cost per patient was found to increase as the CD4 T lymphocytes decreased, leading to prolonged hospitalization and an increase in the number of laboratory tests. Direct cost for patients with more than 500 CD4 cells/μl was estimated at €6067, whereas for those with 200 to 499 cells/μl and less than 200 cells/μl, it was assessed at €6857 and €7654, respectively.

CONCLUSIONS

The direct cost of HIV infection per patient increased as CD4 T lymphocytes decreased. The largest part of expenses was attributed to antiretroviral therapy, followed by laboratory tests/imaging studies, hospitalization, and finally outpatient visits.

Increased costs of HIV care associated with aging in an HIV-infected population

OBJECTIVES

Improved survival has shifted the HIV epidemic in the developed world towards more individuals >50 years of age. Older individuals, with new or longstanding HIV infection, are at greater risk for HIV-related and non-HIV-related conditions, compounding the burden and complexity of HIV management. The aim of the study was to examine the impact of age on the cost of HIV care in a well-defined HIV-infected population.

METHODS

All HIV-infected individuals >16 years old receiving HIV care between 1 January 2000 and 1 January 2011 were included in the study. The costs of antiretroviral therapy (ART), HIV-related out-patient care and HIV-related in-patient care were collected using mean cost per person, per month (PPPM) as the comparator variable for the comparison between older (>50 years old) and younger (≤ 50 years old) patients.

RESULTS

The proportion of older patients increased from 9.6% to 25.4% and proportional costs increased from 25% to 31% from 1999 to 2010. Older patients were more likely than younger patients to be on ART (89% vs. 69%, respectively; P<0.01) and to have AIDS (29% vs. 20%, respectively; P<0.05) but had similar median CD4 counts (404 vs. 396 cells/μL, respectively; not significant). They incurred higher costs for all aspects of HIV care throughout the entire 12 years. By 2010, the mean PPPM cost of HIV care for longstanding older patients was $1325 compared with $1075 for younger patients. More expensive ART as a consequence of more complex regimens, more comorbid interactions and greater adherence accounted for most of the cost difference.

CONCLUSIONS

The aging of the HIV-infected population in care is leading to increased HIV care costs. Health care planners and funding agencies need to be aware of the impact of this important shift in HIV demographics on the overall costs of HIV care.

A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Ottawa, Canada

BACKGROUND

Supervised injection facilities (SIFs) are venues where people who inject drugs (PWID) have access to a clean and medically supervised environment in which they can safely inject their own illicit drugs. There is currently only one legal SIF in North America: Insite in Vancouver, British Columbia, Canada. The responses and feedback generated by the evaluations of Insite in Vancouver have been overwhelmingly positive. This study assesses whether the above mentioned facility in the Downtown Eastside of Vancouver needs to be expanded to other locations, more specifically that of Canada's capital city, Ottawa.

METHODS

The current study is aimed at contributing to the existing literature on health policy by conducting cost-benefit and cost-effective analyses for the opening of SIFs in Ottawa, Ontario. In particular, the costs of operating numerous SIFs in Ottawa was compared to the savings incurred; this was done after accounting for the prevention of new HIV and Hepatitis C (HCV) infections. To ensure accuracy, two distinct mathematical models and a sensitivity analysis were employed.

RESULTS

The sensitivity analyses conducted with the models reveals the potential for SIFs in Ottawa to be a fiscally responsible harm reduction strategy for the prevention of HCV cases--when considered independently. With a baseline sharing rate of 19%, the cumulative annual cost model supported the establishment of two SIFs and the marginal annual cost model supported the establishment of a single SIF. More often, the prevention of HIV or HCV alone were not sufficient to justify the establishment cost-effectiveness; rather, only when both HIV and HCV are considered does sufficient economic support became apparent.

CONCLUSIONS

Funded supervised injection facilities in Ottawa appear to be an efficient and effective use of financial resources in the public health domain.

Cost of treatment in a US commercially insured, HIV-1-infected population

OBJECTIVE

Recent 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.

RESULTS

Newly 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).

CONCLUSIONS

Despite 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.

Costing analysis of national HIV treatment and care program in Vietnam

Supplemental Digital Content is Available in the Text.

Background:

Vietnam achieved rapid scale-up of antiretroviral therapy (ART), although external funds are declining sharply. To achieve and sustain universal access to HIV services, evidence-based planning is essential. To date, there had been limited HIV treatment and care cost data available in Vietnam.

Methods:

Cost data of outpatient and inpatient HIV care were extracted at 21 sentinel facilities (17 adult and 4 pediatric) that epitomize the national program. Step-down costing for administration costs and bottom-up resource costing for drugs, diagnostics, and labor were used. Records of 1401 adults and 527 pediatric patients were reviewed.

Results:

Median outpatient care costs per patient-year for pre-ART, first year ART, later year ART, and second-line ART were US $100, US $316, US $303, and US $1557 for adults; and US $171, US $387, US $320, and US $1069 for children, respectively. Median inpatient care cost per episode was US $162 for adults and US $142 for children. Non-antiretroviral (ARV) costs in adults at stand-alone facilities were 44% (first year ART) and 24% (later year ART) higher than those at integrated facilities. Adults who started ART with CD4 count ≤100 cells per cubic millimeter had 47% higher non-ARV costs in the first year ART than those with CD4 count >100 cells per cubic millimeter. Adult ARV drug costs at government sites were from 66% to 85% higher than those at donor-supported sites in the first year ART.

Conclusions:

The study found that HIV treatment and care costs in Vietnam are economical, yet there is potential to further promote efficiency through strengthening competitive procurement, integrating HIV services, and promoting earlier ART initiation.

California's "Bridge to Reform": identifying challenges and defining strategies for providers and policymakers implementing the Affordable Care Act in low-income HIV/AIDS care and treatment settings

Background

In preparation for full Affordable Care Act implementation, California has instituted two healthcare initiatives that provide comprehensive coverage for previously uninsured or underinsured individuals. For many people living with HIV, this has required transition either from the HIV-specific coverage of the Ryan White program to the more comprehensive coverage provided by the county-run Low-Income Health Programs or from Medicaid fee-for-service to Medicaid managed care. Patient advocates have expressed concern that these transitions may present implementation challenges that will need to be addressed if ambitious HIV prevention and treatment goals are to be achieved.

Methods

30 semi-structured, in-depth interviews were conducted between October, 2012, and February, 2013, with policymakers and providers in 10 urban, suburban, and rural California counties. Interview topics included: continuity of patient care, capacity to handle payer source transitions, and preparations for healthcare reform implementation. Study team members reviewed interview transcripts to produce emergent themes, develop a codebook, build inter-rater reliability, and conduct analyses.

Results

Respondents supported the goals of the ACA, but reported clinic and policy-level challenges to maintaining patient continuity of care during the payer source transitions. They also identified strategies for addressing these challenges. Areas of focus included: gaps in communication to reach patients and develop partnerships between providers and policymakers, perceived inadequacy in new provider networks for delivering quality HIV care, the potential for clinics to become financially insolvent due to lower reimbursement rates, and increased administrative burdens for clinic staff and patients.

Conclusions

California's new healthcare initiatives represent ambitious attempts to expand and improve health coverage for low-income individuals. The state's challenges in maintaining quality care and treatment for people living with HIV experiencing these transitions demonstrate the importance of setting effective policies in anticipation of full ACA implementation in 2014.

Direct treatment costs of HIV/AIDS in Portugal

OBJECTIVE To analyze the direct medical costs of HIV/AIDS in Portugal from the perspective of the National Health Service. METHODS A retrospective analysis of medical records was conducted for 150 patients from five specialized centers in Portugal in 2008. Data on utilization of medical resources during 12 months and patients’ characteristics were collected. A unit cost was applied to each care component using official sources and accounting data from National Health Service hospitals. RESULTS The average cost of treatment was 14,277 €/patient/year. The main cost-driver was antiretroviral treatment (€ 9,598), followed by hospitalization costs (€ 1,323). Treatment costs increased with the severity of disease from € 11,901 (> 500 CD4 cells/µl) to € 23,351 (CD4 count ≤ 50 cells/ µl). Cost progression was mainly due to the increase in hospitalization costs, while antiretroviral treatment costs remained stable over disease stages. CONCLUSIONS The high burden related to antiretroviral treatment is counterbalanced by relatively low hospitalization costs, which, however, increase with severity of disease. The relatively modest progression of total costs highlights that alternative public health strategies that do not affect transmission of disease may only have a limited impact on expenditure, since treatment costs are largely dominated by constant antiretroviral treatment costs.

Highly significant antiviral activity of HIV-1 LTR-specific tre-recombinase in humanized mice

Stable integration of HIV proviral DNA into host cell chromosomes, a hallmark and essential feature of the retroviral life cycle, establishes the infection permanently. Current antiretroviral combination drug therapy cannot cure HIV infection. However, expressing an engineered HIV-1 long terminal repeat (LTR) site-specific recombinase (Tre), shown to excise integrated proviral DNA in vitro, may provide a novel and highly promising antiviral strategy. We report here the conditional expression of Tre-recombinase from an advanced lentiviral self-inactivation (SIN) vector in HIV-infected cells. We demonstrate faithful transgene expression, resulting in accurate provirus excision in the absence of cytopathic effects. Moreover, pronounced Tre-mediated antiviral effects are demonstrated in vivo, particularly in humanized Rag2^−/−γc^−/− mice engrafted with either Tre-transduced primary CD4⁺ T cells, or Tre-transduced CD34⁺ hematopoietic stem and progenitor cells (HSC). Taken together, our data support the use of Tre-recombinase in novel therapy strategies aiming to provide a cure for HIV.

Current antiretroviral combination therapy can efficiently suppress virus replication, but cannot eliminate HIV. Therefore, no cure for HIV exists. A main hurdle for virus eradication is seen in the existence of resting cells that contain integrated replication-competent, but temporarily silenced, HIV genomes. Therefore, the most direct approach to eliminating virus reservoirs is to remove HIV genomes from infected cells. As previous studies suggested, this may be achievable by Tre-recombinase, an engineered enzyme that can excise integrated HIV from host cell chromosomes. The present work analyzes the expression of Tre-recombinase in human cells and demonstrates highly accurate Tre activity in complete absence of Tre-related cytopathic effects. Furthermore, in vivo analysis of Tre-recombinase demonstrates highly significant antiviral effects of Tre in HIV-infected humanized mice. The presented data suggest that Tre-recombinase might become a valuable component of a future therapy that aims at virus eradication.

Cost of noninfectious comorbidities in patients with HIV

Objectives

We hypothesized that the increased prevalence of noninfectious comorbidities (NICMs) observed among HIV-infected patients may result in increased direct costs of medical care compared to the general population. Our objective was to provide estimates of and describe factors contributing to direct costs for medical care among HIV-infected patients, focusing on NICM care expenditure.

Methods

A case-control study analyzing direct medical care costs in 2009. Antiretroviral therapy (ART)-experienced HIV-infected patients (cases) were compared to age, sex, and race-matched adults from the general population, included in the CINECA ARNO database (controls). NICMs evaluated included cardiovascular disease, hypertension, diabetes mellitus, bone fractures, and renal failure. Medical care cost information evaluated included pharmacy, outpatient, and inpatient hospital expenditures. Linear regression models were constructed to evaluate predictors of total care cost for the controls and cases.

Results

There were 2854 cases and 8562 controls. Mean age was 46 years and 37% were women. We analyzed data from 29,275 drug prescription records. Positive predictors of health care cost in the overall population: HIV infection (β = 2878; confidence interval (CI) = 2001–3755); polypathology (β = 8911; CI = 8356–9466); age (β = 62; CI = 45–79); and ART exposure (β = 18,773; CI = 17,873–19,672). Predictors of health care cost among cases: Center for Disease Control group C (β = 1548; CI = 330–2766); polypathology (β = 11,081; CI = 9447–12,716); age < 50 years (β = 1903; CI = 542–3264); protease inhibitor exposure (per month of use; β = 69; CI = 53–85); CD4 count < 200 cells/mm³ (β = 5438; CI = 3082–7795); and ART drug change (per change; β = 911; CI = 716–1106).

Conclusion

Total cost of medical care is higher in cases than controls. Lower medical costs associated with higher CD4 strata are offset by increases in the care costs needed for advancing age, particularly for NICMs.

The prevalence of transmitted resistance to first-generation non-nucleoside reverse transcriptase inhibitors and its potential economic impact in HIV-infected patients

Non-nucleoside reverse transcriptase inhibitor (NNRTI)-based highly active antiretroviral therapy (HAART) including efavirenz is recommended as a 1^st-line treatment choice in international HIV guidelines, and it is one of the most common components of initial therapy. Resistance to 1^st-generation NNRTIs is found among treated and untreated HIV-infected individuals creating a subpopulation of HIV-infected individuals in whom efavirenz is not fully effective. This analysis reviewed published articles and conference abstracts to examine the prevalence of 1^st-generation NNRTI resistance in Europe, the United States (US), and Canada and to identify published evidence of the economic consequences of resistance. The reported prevalence of NNRTI resistance was generally higher in US/Canada than in Europe and increased in both regions from their introduction in the late 1990s until the early 2000s. The most recent time-based trends suggest that NNRTI-resistance prevalence may be stable or decreasing. These estimates of resistance may be understated as resistance estimates using ultra-sensitive genotypic testing methods, which identify low-frequency mutations undetected by standard testing methods, showed increased prevalence of resistance by more than two-fold. No studies were identified that explicitly investigated the costs of drug resistance. Rather, most studies reported costs of treatment change, failure, or disease progression. Among those studies, annual HIV medical costs of those infected with HIV increased 1) as CD4 cells decreased, driven in part by hospitalization at lower CD4 cell counts; 2) for treatment changes, and 3) for each virologic failure. The possible erosion of efficacy or of therapy choices through resistance transmission or selection, even when present with low frequency, may become a barrier to the use of 1^st-generation NNRTIs and the increased costs associated with regimen failure and disease progression underlie the importance of identification of treatment resistance to ensure optimal initial therapy choice and regimen succession.

A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada

Background

This paper will determine whether expanding Insite (North America’s first and only supervised injection facility) to more locations in Canada such as Montreal, cost less than the health care consequences of not having such expanded programs for injection drug users.

Methods

By analyzing secondary data gathered in 2012, this paper relies on mathematical models to estimate the number of new HIV and Hepatitis C (HCV) infections prevented as a result of additional SIF locations in Montreal.

Results

With very conservative estimates, it is predicted that the addition of each supervised injection facility (up-to a maximum of three) in Montreal will on average prevent 11 cases of HIV and 65 cases of HCV each year. As a result, there is a net cost saving of CDN$0.686 million (HIV) and CDN$0.8 million (HCV) for each additional supervised injection site each year. This translates into a net average benefit-cost ratio of 1.21: 1 for both HIV and HCV.

Conclusions

Funding supervised injection facilities in Montreal appears to be an efficient and effective use of financial resources in the public health domain.

Durability of first ART regimen and risk factors for modification, interruption or death in HIV-positive patients starting ART in Europe and North America 2002-2009

OBJECTIVES

To estimate the incidence of and risk factors for modifications to first antiretroviral therapy (ART) regimen, treatment interruption and death.

METHODS

A total of 21 801 patients from 18 cohorts in Europe and North America starting ART on regimens including at least two nucleoside reverse transcriptase inhibitors and boosted protease inhibitor or non-nucleoside reverse transcriptase inhibitor during 2002-2009 were included. Incidence of modifications (change of drug class, substitution/addition within class, or switch to nonstandard regimen), interruption or death and associations with patient characteristics were estimated using competing-risks methods.

RESULTS

During median 28 months follow-up, 8786 (40.3%) patients modified first ART, 2346 (10.8%) interrupted and 427 (2.0%) died before changing regimen. Three-year cumulative percentages of modification, interruption and death were 47, 12 and 2%, respectively. After adjustment, rates of interruption were highest for IDUs and lowest for MSM, and higher for patients starting ART with CD4 cell count above 350 cells/μl than other patients. Compared to efavirenz, patients on lopinavir and other protease inhibitors had higher rates of modification and interruption, on atazanavir had lower rates of class change, and on nevirapine higher rates of interruption. Those on tenofovir/emtricitabine backbone had lowest rates of substitutions and switches to nonstandard regimen, and on abacavir/lamivudine lowest rates of interruption. Rates of substitution and switches to nonstandard regimen were lower in 2006-2009.

CONCLUSION

Rates of modification and interruption were high, particularly in the first year of ART. Decreased rates of substitutions or switches to nonstandard regimen in recent years may be linked to greater use of well tolerated once-daily drugs.

Engineered DNA modifying enzymes: components of a future strategy to cure HIV/AIDS

Despite phenomenal advances in AIDS therapy transforming the disease into a chronic illness for most patients, a routine cure for HIV infections remains a distant goal. However, a recent example of HIV eradication in a patient who had received CCR5-negative bone marrow cells after full-body irradiation has fuelled new hopes for a cure for AIDS. Here, we review new HIV treatment strategies that use sophisticated genome engineering to target HIV infections. These approaches offer new ways to tackle the infection, and alone or in conjunction with already established treatments, promise to transform HIV into a curable disease.

Heterogeneity in outcomes of treated HIV-positive patients in Europe and North America: relation with patient and cohort characteristics

BACKGROUND

HIV cohort collaborations, which pool data from diverse patient cohorts, have provided key insights into outcomes of antiretroviral therapy (ART). However, the extent of, and reasons for, between-cohort heterogeneity in rates of AIDS and mortality are unclear.

METHODS

We obtained data on adult HIV-positive patients who started ART from 1998 without a previous AIDS diagnosis from 17 cohorts in North America and Europe. Patients were followed up from 1 month to 2 years after starting ART. We examined between-cohort heterogeneity in crude and adjusted (age, sex, HIV transmission risk, year, CD4 count and HIV-1 RNA at start of ART) rates of AIDS and mortality using random-effects meta-analysis and meta-regression.

RESULTS

During 61 520 person-years, 754/38 706 (1.9%) patients died and 1890 (4.9%) progressed to AIDS. Between-cohort variance in mortality rates was reduced from 0.84 to 0.24 (0.73 to 0.28 for AIDS rates) after adjustment for patient characteristics. Adjusted mortality rates were inversely associated with cohorts' estimated completeness of death ascertainment [excellent: 96-100%, good: 90-95%, average: 75-89%; mortality rate ratio 0.66 (95% confidence interval 0.46-0.94) per category]. Mortality rate ratios comparing Europe with North America were 0.42 (0.31-0.57) before and 0.47 (0.30-0.73) after adjusting for completeness of ascertainment.

CONCLUSIONS

Heterogeneity between settings in outcomes of HIV treatment has implications for collaborative analyses, policy and clinical care. Estimated mortality rates may require adjustment for completeness of ascertainment. Higher mortality rate in North American, compared with European, cohorts was not fully explained by completeness of ascertainment and may be because of the inclusion of more socially marginalized patients with higher mortality risk.

Costs and effectiveness of neonatal male circumcision

OBJECTIVE

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage.

DESIGN

We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty.

SETTING

United States.

PARTICIPANTS

Birth cohort of men and women.

INTERVENTION

Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited).

OUTCOMES MEASURED

Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections.

RESULTS

Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses.

CONCLUSION

Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Underutilization of aspirin for primary prevention of cardiovascular disease among HIV-infected patients

BACKGROUND

Individuals infected with human immunodeficiency virus (HIV) are at increased risk for cardiovascular disease (CVD) events compared with uninfected persons. However, little is known about HIV provider practices regarding aspirin (ASA) for primary prevention of CVD.

METHODS

A cross-sectional study was conducted among patients attending the University of Alabama at Birmingham 1917 HIV Clinic during 2010 to determine the proportion receiving ASA for primary prevention of CVD and identify factors associated with ASA prescription. Ten-year risk for CVD events was calculated for men aged 45-79 and women aged 55-79. The 2009 US Preventive Services Task Force (USPSTF) guidelines were used to determine those qualifying for primary CVD prevention.

RESULTS

Among 397 patients who qualified to receive ASA (mean age, 52.2 years, 94% male, 36% African American), only 66 (17%) were prescribed ASA. In multivariable logistic regression analysis, diabetes mellitus (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.28-5.27), hyperlipidemia (OR, 3.42; 95% CI, 1.55-7.56), and current smoking (OR, 1.87; 95% CI, 1.03-3.41) were significantly associated with ASA prescription. Odds of ASA prescription more than doubled for each additional CVD-related comorbidity present among hypertension, diabetes, hyperlipidemia, and smoking (OR, 2.13, 95% CI, 1.51-2.99).

CONCLUSIONS

In this HIV-infected cohort, fewer than 1 in 5 patients in need received ASA for primary CVD prevention. Escalating likelihood of ASA prescription with increasing CVD-related comorbidity count suggests that providers may be influenced more by co-occurrence of these diagnoses than by USPSTF guidelines. In the absence of HIV-specific guidelines, interventions to improve HIV provider awareness of and adherence to existing general population guidelines on CVD risk reduction are needed.

Costs, consequences and feasibility of strategies for achieving the goals of the National HIV/AIDS strategy in the United States: a closing window for success?

Three key policy questions are explored here: Is it still epidemiologically feasible to attain the incidence and transmission rate reduction goals of the U.S. National HIV/AIDS Strategy (NHAS) by 2015? If so, what costs will be incurred in necessary program expansion, and will the investment be cost-effective? Would substantial expansion of prevention services for persons living with HIV (PLWH) augment the other strategies outlined in the NHAS in terms of effectiveness and cost-effectiveness? Eight policy scenarios were constructed based on three factors (two levels each): expansion (or not) of HIV diagnostic services; assumptions regarding levels of effectiveness of HIV treatment in achieving suppressed viral load; and possible levels of expansion of prevention services for PLWH. All scenarios assumed that the NHAS goal of 85 % linkage to HIV care would be fully achieved by 2015. Standard methods of economic evaluation and epidemiologic modeling were employed. Each of the eight policy scenarios was compared to a flat transmission rate comparison condition; then, key policy dyads were compared pairwise. Without expansion of diagnostic services and of prevention services for PLWH, scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for PLWH does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner.

Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel

DESCRIPTION

After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV.

METHODS

A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation.

RECOMMENDATIONS

Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

Should we treat acute HIV infection?

Critical advances in the early diagnosis of HIV now allow for treatment opportunities during acute infection. It remains unclear whether treatment of acute HIV infection with antiretroviral therapy improves long-term clinical outcomes for the individual and current guidelines are not definitive in recommending therapy at this stage of infection. However, treatment of acute HIV infection may have short-term benefit on viral set point when compared to delayed therapy as well as reducing the risk of transmission to others. Herein we review the immunological and clinical literature to discuss whether we should treat acute HIV infection, both from the perspective of the individual HIV-infected patient and from the public health perspective. As transmission of drug-resistant HIV variants are of concern, we also review recent clinical trial data to provide recommendations for which specific antiretroviral treatment regimens should be considered for the treatment of acute HIV infection.