Contemporary costs of HIV healthcare in the HAART era

De-simplifying antiretroviral therapy from a single-tablet to a two-tablet regimen: Acceptance, patient-reported outcomes, and cost savings in a multicentre study

BACKGROUND

Antiretroviral therapy (ART), which is increasingly used by people with HIV, accounts for significant care costs, particularly because of single-tablet regimens (STRs). This study explored de-simplification to a two-tablet regimen (TTR) for cost reduction. The objectives of this study were: (1) acceptance of de-simplification, (2) patient-reported outcomes, and (3) cost savings.

METHODS

All individuals on Triumeq®, Atripla® or Eviplera® in five HIV clinics in the Netherlands were eligible. Healthcare providers informed individuals of this study. After inclusion, individuals were free to de-simplify. An electronic questionnaire was sent to assess study acceptance, adherence, quality of life (SF12) and treatment satisfaction (HIVTSQ). After 3 and 12 months, questionnaires were repeated. Cost savings were calculated using Dutch drug prices.

RESULTS

In total, 283 individuals were included, of whom 55.5% agreed to de-simplify their ART, with a large variability between treatment centres: 41.1-74.2%. Individuals who were willing to de-simplify tended to be older, had a longer history of HIV diagnosis, and used more co-medication than those who preferred to remain on an STR regimen. Patient-reported outcomes, including quality of life and treatment satisfaction, showed no significant difference between people with HIV who switched to a TTR and those who remained on an STR regimen. Furthermore, we observed a 17.8% reduction in drug costs in our cohort of people with HIV who were initially on an STR.

CONCLUSIONS

De-simplification from an STR to a TTR within the Dutch healthcare setting has been demonstrated as feasible, leads to significant cost reductions and should be discussed with every eligible person with HIV in the Netherlands.

Constrained Optimization for Decision Making in Health Care Using Python: A Tutorial

HIGHLIGHTS

This tutorial provides a user-friendly guide to mathematically formulating constrained optimization problems and implementing them using Python.Two examples are presented to illustrate how constrained optimization is used in health applications, with accompanying Python code provided.

Potent dual block to HIV-1 infection using lentiviral vectors expressing fusion inhibitor peptide mC46- and Vif-resistant APOBEC3G

Gene therapy strategies that effectively inhibit HIV-1 replication are needed to reduce the requirement for lifelong antiviral therapy and potentially achieve a functional cure. We previously designed self-activating lentiviral vectors that efficiently delivered and expressed a Vif-resistant mutant of APOBEC3G (A3G-D128K) to T cells, which potently inhibited HIV-1 replication and spread with no detectable virus. Here, we developed vectors that express A3G-D128K, membrane-associated fusion inhibitor peptide mC46, and O6-methylguanine-DNA-methyltransferase (MGMT) selectable marker for in vivo selection of transduced CD34+ hematopoietic stem and progenitor cells. MGMT-selected T cell lines MT4, CEM, and PM1 expressing A3G-D128K (with or without mC46) potently inhibited NL4-3 infection up to 45 days post infection with no detectable viral replication. Expression of mC46 was sufficient to block infection >80% in a single-cycle assay. Importantly, expression of mC46 provided a selective advantage to the A3G-D128K-modified T cells in the presence of replication competent virus. This combinational approach to first block HIV-1 entry with mC46, and then block any breakthrough infection with A3G-D128K, could provide an effective gene therapy treatment and a potential functional cure for HIV-1 infection.

A Cost-Effective Analysis of Motivational Interviewing with Palliative Care Versus Usual Care: Results from the Living Well Project

Little is known about the impact of early palliative care (EPC) combined with motivational interviewing (MI) for persons living with AIDS (PWA). We compared the cost and quality-adjusted life-years (QALYs) of EPC + MI (n = 61) versus usual care (UC) (n = 60) for patients with AIDS, not on antiretroviral medications, enrolled into the Living Well Project trial. Data on clinic, emergency department, and hospital visits were collected through self-report and billing records. Risk-adjusted average annual health care costs were estimated using a generalized linear model with a gamma log-link function. QALYs were calculated using the SF-12v2. Cost-effectiveness was defined as cost per QALY gained. Estimated intervention costs were $165 per participant. EPC + MI reduced costs by 33% (AOR = 0.67; CI 95%: 0.15, 0.93). QALYs did not differ between groups. Results suggest EPC + MI for PWA is cost-saving and maintains quality of life compared to UC due to reduced hospital and ED costs.

Universal Repeat Screening for Human Immunodeficiency Virus in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To assess the cost effectiveness of universal repeat screening for human immunodeficiency virus (HIV) infection in the third trimester of pregnancy.

METHODS

A decision-analytic model was constructed to compare two strategies: screening for HIV infection in the first trimester alone compared with the addition of repeat screening in the third trimester. Probabilities, costs, and utilities were derived from the literature and varied in sensitivity analyses. The assumed incidence of HIV infection in pregnancy was 0.0145% or 14.5 per 100,000. Outcomes included costs (in 2022 U.S. dollars), maternal and neonatal quality-adjusted life-years (QALYs), and cases of neonatal HIV infection. Our theoretical cohort contained 3.8 million pregnant individuals, the approximate number of births per year in the United States. The willingness-to-pay threshold was set at $100,000/QALY. We performed univariable and multivariable sensitivity analyses to determine inputs that most influenced the model.

RESULTS

Universal third-trimester screening prevented 133 cases of neonatal HIV infection in this theoretical cohort. Universal third-trimester screening led to an increased cost of $17.54 million and 2,732 increased QALYs, with an incremental cost-effectiveness ratio of $6,418.56 per QALY, less than the willingness-to-pay threshold. In a univariate sensitivity analysis, third-trimester screening remained cost effective with variation of HIV incidence in pregnancy to as low as 0.0052%.

CONCLUSION

In a theoretical U.S.-based cohort of pregnant individuals, universal repeat screening for HIV infection in the third trimester was found to be cost effective and to reduce vertical transmission of HIV. These results merit consideration of a broader HIV-screening program in the third trimester.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Resource Utilization and Caring Cost of People Living with Human Immunodeficiency Virus (PLHIV) in Saudi Arabia: A Tertiary Care University Hospital Experience

The human immunodeficiency virus (HIV) is associated with a significant burden of disease, including medical and non-medical costs. Therefore, it is considered to be a priority for all health authorities. The aim of this study is to determine healthcare and treatment costs of caring for PLHIV at one of the tertiary care university hospitals in Riyadh, Saudi Arabia. This was a micro-costing, retrospective, observational study from a tertiary care university hospital and included all confirmed HIV-infected patients who visited infectious disease clinics in the period from 1 January 2015 to 31 December 2018. A total of 42 PLHIV were included in this study. The mean age of the study participants was 38.76 ± 11.47 years with a mean disease duration of 5.27 ± 4.81 years. The majority of patients were male (85.7%) and Saudi (88.1%). More than half of included patients (59.5%) had a CD4 count of more than 500. During the study period, 26 patients (61.9%) were initiated on a single-tablet regimen. Overall, the main cost-driver was antiretroviral medications, which cumulatively represented more than 64% of the total cost. Patients who developed opportunistic infections had a statistically significant (p = 0.033) higher financial impact, both as a total and on a patient level, than those presented without opportunistic infections. On a patient level, the mean and median costs were higher and statistically significant for those with co-morbidities than those without co-morbidities (p = 0.002). The majority of the economic burden of PLHIV is attributable to antiretroviral therapy use. The healthcare costs of PLHIV can vary greatly, depending on the presenting illness, clinical stage, developed opportunistic infection, co-morbidity, and pharmacological therapy.

Construct Validity and Responsiveness of the Rapid Assessment of Physical Activity in Adults Living With HIV

Objective

To evaluate the construct validity and responsiveness of the Rapid Assessment of Physical Activity (RAPA) for measuring physical activity (PA) in adults living with HIV.

Design

Secondary analysis of an interrupted time-series intervention study.

Setting

Community-based fitness facility in Toronto, Canada.

Participants

Sixty-seven adults (N=67) living with HIV (n=5 women; mean age, 51.8±11.6 years) with available baseline data to assess for construct validity of the RAPA, of which 50 (n=4 women; age, 53.2±11.4 years) had follow-up data to evaluate responsiveness.

Interventions

Two months of a community-based exercise intervention involving thrice weekly multicomponent exercises.

Main Outcome Measures

We used a single-item PA questionnaire as a convergent outcome to the RAPA, while peak oxygen consumption, general health status, and number of concurrent health conditions were divergent outcomes. We tested 11 a priori hypotheses (6 construct validity, 5 responsiveness) using Spearman ρ, Wilcoxon signed-rank tests, Cohen's d, standardized effect size (SES), and standardized response mean (SRM). We considered acceptable construct validity and responsiveness if >75% of hypotheses were confirmed.

Results

All of the hypotheses (100%) for construct validity were confirmed. The RAPA demonstrated moderate correlations with the single-item PA questionnaire (ρ=0.61), and negligible correlations with divergent outcome measures (ρ=0.08-0.21). Two of the 5 hypotheses (40.0%) for responsiveness were confirmed. RAPA scores were significantly greater after 2 months of training (P<.001) and demonstrated a small to moderate effect size (d=0.50, SES=0.47, SRM=0.48). There was a low correlation between change in RAPA scores and change in single-item PA questionnaire scores (ρ=0.48).

Conclusions

The RAPA demonstrated acceptable construct validity and poor responsiveness in adults living with HIV. Therefore, the RAPA can be used cross-sectionally but may be used in conjunction with other measures of PA for adults living with HIV.

Characterization of Heavily Treatment-Experienced People With HIV and Impact on Health Care Resource Utilization in US Commercial and Medicare Advantage Health Plans

Background

This retrospective administrative claims study aimed to describe clinical characteristics, health care resource utilization (HCRU), and costs of people with HIV (PWH) in US commercial and Medicare Advantage health plans by antiretroviral treatment (ART) experience and CD4+ cell count.

Methods

Data from the national Optum Research Database between January 1, 2014, and March 31, 2018, for adult PWH continuously enrolled 6 months before and ≥12 months after the first ART identified (follow-up) were summarized by treatment (heavily treatment-experienced [HTE] with limited remaining ART options, treatment-experienced but not HTE [non-HTE], or treatment-naive starting a first antiretroviral regimen) and index CD4+ cell count (<200, 200–500, or >500 cells/mm³).

Results

Compared with non-HTE (n=7604) and treatment-naive PWH (n=4357), HTE PWH (n=2297) were older (53.5 vs 48.8 and 42.3 years), were more likely to have HIV-related emergency department visits (22.3% vs 12.4% and 18.6%) and inpatient stays (15.8% vs 7.1% and 10.3%), and had a higher mean (SD) daily pill burden (9.7 [7.7] vs 5.1 [5.9] and 3.6 [5.3] pills/d) and a higher mortality rate (5.9% vs 2.9% and 2.3%) during follow-up (all P<.001). More HTE (21.8%) and treatment-naive PWH (27.0%) had <200 CD4+ cells/mm³ vs non-HTE PWH (8.0%; P<.001). All-cause and HIV-related costs were higher among HTE PWH in all CD4+ cell count strata and treatment-naive PWH with CD4+ cell counts <200 cells/mm³ vs non-HTE PWH in all CD4+ cell count strata.

Conclusions

Improved support and clinical monitoring of HTE PWH are needed to prevent worsening outcomes and increased costs.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail

INTRODUCTION

This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia.

METHODS

A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020.

RESULTS

Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system.

CONCLUSIONS

Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

BACKGROUND

The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.

METHODS

To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).

FINDINGS

In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1-38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78-0·91) per female living with HIV in 2019, 0·99 male infections (0·91-1·10) for every female infection, and 1·02 male deaths (0·95-1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58-35·43, and a 39·66% decrease in deaths, 36·49-42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05-0·06) and the global incidence-to-mortality ratio was 1·94 (1·76-2·12). No regions met suggested thresholds for progress.

INTERPRETATION

Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.

FUNDING

The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

The Cost Effectiveness of Mental Health Treatment in the Lifetime of Older Adults with HIV in New York City: A Markov Approach

BACKGROUND

There are noticeable gaps in knowledge regarding the cost and effectiveness of integrated medical and behavioral services for older adults with HIV. Their lifespan is close to the population's level but their quality of life has sharply declined due to depression and substance use. Mental health disorders are widespread among an aging population with HIV.

OBJECTIVE

The aim of this study was to build a decision analytic model to evaluate medical interventions with and without mental health treatment using primary data of 139 older adults with HIV and health outcomes from the literature.

METHODS

We tracked the progression of depression and cumulative deaths among older adults with HIV using a Markov model with 50 annual cycles through three health states. Deterministic and probabilistic sensitivity analyses addressed uncertainty in estimating the parameters and around the model's assumptions.

RESULTS

An integrated medical and behavioral care system is cost effective at a willingness to pay of $50,000 per QALY compared with medical care only. The incremental cost was $516,452 and the incremental effectiveness was 38.8 quality-adjusted life-years (QALY), with an incremental cost-effectiveness ratio of $13,316 per QALY.

CONCLUSIONS

Appropriate and efficacious referrals to integrated medical + behavioral services, either in the same facility or connected to their primary care doctor, are instrumental to reverse loses in quality of life and avoid premature death. If mental health is left unattended, HIV would progress, causing declines in quality of life and ultimately triggering premature death. Reliable data on the cost and effectiveness of different types of HIV integrated services are needed.

What are the drivers of high-cost HIV patients?

We aimed to identify "high-cost" patients with HIV (PWH) and determine drivers behind higher costs. All PWH at the Southern Alberta HIV Clinic, Canada, and active in 2017 were included. Sociodemographic, clinical, and healthcare utilization data were collected. The direct care costs from the payers' perspective including antiretroviral drugs (ARV), outpatient visits, and hospital admissions were determined for 2017. Patients' annual total costs were grouped into top 5% (i.e., high-cost), top 20%, middle 60%, and bottom 20%. High-cost patients were older, Caucasian or indigenous Canadian, and more likely acquired HIV from intravenous drug use (all p < 0.05). High-cost patients had lower nadir CD4, more comorbidities, missed more clinic appointments, had more ARV interruptions, and developed more ARV resistance (p < 0.01). The overall median cost of HIV care was US$14,064 [IQR US$13,121-US$17,883] (2017 Cdn$). High-cost patients had a median cost of US$29,902 [IQR US$27,229-US$37,891] and accounted for 14% of total costs and 84% of all inpatient costs. Hospitalizations constituted 58% of costs for high-cost patients. Although heterogeneous, high-cost patients have distinct sociodemographic and clinical characteristics driving their healthcare utilization. Addressing these social determinants of health and using novel ARV administration approaches may preserve health and save costs.

Economic Burden Among Gay, Bisexual, and Other Men Who Have Sex With Men Living With HIV or Living Without HIV in the Multicenter AIDS Cohort Study

With HIV now considered a chronic disease, economic burden for people living with HIV (LWH) may threaten long-term disease outcomes. We studied associations between economic burden (employment, income, insurance, and financial difficulty) and HIV status for gay, bisexual, and other men who have sex with men (GBMSM) and how economic burden relates to disease progression.

The Cost-Effectiveness and Budget Impact of Ibalizumab-uiyk for Adults with Multidrug-Resistant HIV-1 Infection in the United States

BACKGROUND

Ibalizumab-uiyk (ibalizumab) is a first-in-class, long-acting, postattachment HIV-1 inhibitor for adults with multidrug-resistant (MDR) HIV-1 infection. This analysis examines the cost-effectiveness and budget impact of ibalizumab treatment for this difficult-to-treat population in the United States.

METHODS

A Markov model followed cohorts of adults with MDR HIV-1 infection through two final lines of antiretroviral therapy: ibalizumab + optimized background therapy (OBT) or OBT alone followed by nonsuppressive therapy. Model inputs were based on ibalizumab clinical trial data, market uptake projections, and published literature, with costs in 2019 dollars. The cost-effectiveness analysis assessed costs and health outcomes from a health care sector perspective for individuals receiving ibalizumab + OBT versus OBT alone over a lifetime time horizon. The budget-impact analysis estimated the impact on payer budgets of the introduction of ibalizumab over 3 years for a hypothetical commercial health plan.

RESULTS

Compared with individuals receiving OBT alone, individuals receiving ibalizumab + OBT incurred higher costs but lived longer, healthier lives, with an incremental cost of $133,040 per QALY gained. For a hypothetical commercial health plan with 1 million members, the introduction of ibalizumab + OBT was estimated to increase budgets by $217,260, $385,245, and $560,310 ($0.018, $0.032, and $0.047 per member per month) in years 1, 2, and 3, respectively. These results were found to be robust in sensitivity and scenario analyses.

CONCLUSIONS

Ibalizumab may represent a cost-effective and affordable option to improve health outcomes for individuals with MDR HIV-1 infection.

Estimated Lifetime HIV-Related Medical Costs in the United States

BACKGROUND

Lifetime cost estimates are a useful tool in measuring the economic burden of HIV in the United States. Previous estimation methods need to be updated, given improving antiretroviral therapy regimens and updated costs.

METHODS

We used an updated version of the agent-based model progression and transmission of HIV (PATH) 3.0 to reflect current regimens and costs. We simulated a cohort of those infected in 2015 until the last person had died to track the lifetime costs for treatment of HIV, including HIV health care utilization costs (inpatient, outpatient, opportunistic infection prophylaxis, non-HIV medication, and emergency department), opportunistic infection treatment costs, and testing costs. We assumed a median per-person diagnosis delay of 3 years and a 3% base monthly probability of dropout from care for a base-case scenario. Additionally, we modeled a most favorable scenario (median diagnosis delay of 1 year and 1% base dropout rate) and a least favorable scenario (median diagnosis delay of 5 years and 5% base dropout rate).

RESULTS

We estimated an average lifetime HIV-related medical cost for a person with HIV of $420,285 (2019 US$) discounted (3%) and $1,079,999 undiscounted for a median 3-year diagnosis delay and 3% base dropout rate. Our discounted cost estimate was $490,045 in our most favorable scenario and $326,411 in our least favorable scenario.

CONCLUSIONS

Lifetime per-person HIV-related medical costs depend on the time from infection to diagnosis and the likelihood of dropping out of care. Our results, which are similar to previous studies, reflect updated antiretroviral therapy regimens and costs for HIV treatment.

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.

Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program?

BACKGROUND

With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program.

METHODS

Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services.

RESULTS

The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program.

CONCLUSIONS

The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.

Development of a Mathematical Model to Estimate the Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program

BACKGROUND

The Health Resources and Services Administration's Ryan White HIV/AIDS Program provides services to more than half of all people diagnosed with HIV in the United States. We present and validate a mathematical model that can be used to estimate the long-term public health and cost impact of the federal program.

METHODS

We developed a stochastic, agent-based model that reflects the current HIV epidemic in the United States. The model simulates everyone's progression along the HIV care continuum, using 2 network-based mechanisms for HIV transmission: injection drug use and sexual contact. To test the validity of the model, we calculated HIV incidence, mortality, life expectancy, and lifetime care costs and compared the results with external benchmarks.

RESULTS

The estimated HIV incidence rate for men who have sex with men (502 per 100,000 person years), mortality rate of all people diagnosed with HIV (1663 per 100,000 person years), average life expectancy for individuals with low CD4 counts not on antiretroviral therapy (1.52-3.78 years), and lifetime costs ($362,385) all met our validity criterion of within 15% of external benchmarks.

CONCLUSIONS

The model represents a complex HIV care delivery system rather than a single intervention, which required developing solutions to several challenges, such as calculating need for and receipt of multiple services and estimating their impact on care retention and viral suppression. Our strategies to address these methodological challenges produced a valid model for assessing the cost-effectiveness of the Ryan White HIV/AIDS Program.

Estimation of the Incremental Cumulative Cost of HIV Compared with a Non-HIV Population

OBJECTIVE

There are limited real-world data comparing cumulative incremental healthcare costs in people living with HIV (PLWH) and those without HIV. This study evaluated all-cause cumulative and incremental costs in PLWH in the US using a matched-cohort design.

MATERIALS AND METHODS

This retrospective, multi-year, cross-sectional analysis evaluated annual costs from 2013 to 2017, and projected cumulative costs of HIV from age 25 to 69 years. IQVIA's commercial adjudicated claims database was used to identify patients with HIV and match them with patients without HIV (controls). Cumulative all-cause costs were derived from the health plan-allowed costs incurred from ages 25-69 years. Undiscounted, discounted, and incremental costs between PLWH and non-HIV populations were reported in 2017 US dollars (US$), and annual all-cause costs were estimated for each year by 10-year age bands.

RESULTS

A total of 25,261, 24,134, 31,654, 35,374, and 29,039 PLWH and 75,783, 72,402, 94,962, 106,122, and 87,117 matched controls were identified in the years 2013 through 2017, respectively. The mean undiscounted cumulative costs were $1,840,554 for PLWH and $285,065 for controls, an incremental cost difference of $1,555,489, while the mean discounted cumulative cost for PLWH was $983,897 compared with $133,340 for controls, an incremental cost difference of $850,557. Mean all-cause annual and cumulative costs were up to seven times higher for PLWH compared with controls. There was a trend for costs to increase each year with increasing age.

LIMITATIONS AND CONCLUSIONS

While cumulative all-cause cost estimates only approximate total cost burden for any given patient, and the results of this study may not be generalizable to all population subgroups, this is one of the first US studies to examine annual and cumulative costs in a real-world cohort of commercially insured PLWH compared with a population without HIV. In this large, representative sample of commercially insured US adults with HIV, PLWH had substantially higher all-cause cumulative costs than individuals without HIV.

U.S. Hospitalization rates and reasons stratified by age among persons with HIV 2014-15

Persons with HIV (PWH) are aging. The impact of aging on healthcare utilization is unknown. The objective of this study was to evaluate hospitalization rates and reasons stratified by age among PWH in longitudinal HIV care. Hospitalization data from 2014-2015 was obtained on all adults receiving HIV care at 14 diverse sites within the HIV Research Network in the United States. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis performed with multivariate negative binomial regression. Among 20,608 subjects during 2014-2015, all cause hospitalization rate was 201/1000PY. Non-AIDS defining infection (non-ADI) was the leading cause for admission (44.2/1000PY), followed by cardiovascular disease (CVD) (21.2/1000PY). In multivariate analysis of all-cause admissions, the incidence rate ratio (aIRR) increased with older age (age 18-29 reference): age 30-39 aIRR 1.09 (0.90,1.32), age 40-49 1.38 (1.16,1.63), age 50-59 1.58 (1.33,1.87), and age ≥ 60 2.14 (1.77,2.59). Hospitalization rates increased significantly with age for CVD, endocrine, renal, pulmonary, and oncology. All cause hospitalization rates increased with older age, especially among non-communicable diseases (NCDs), while non-ADIs remained the leading cause for hospitalization. HIV providers should be comfortable screening for and treating NCDs.

Inpatient, Outpatient, and Pharmacy Costs in Patients With and Without HIV in the US Veteran's Affairs Administration System

Objectives:

To evaluate the association between human immunodeficiency virus (HIV) patients and medical costs (inpatient, outpatient, pharmacy, total) using a national cohort of HIV-infected Veterans and non-HIV matched controls within the Veteran’s Affairs (VA) Administration system.

Design:

This study used claims (January 2000 to December 2016) extracted from the VA Informatics and Computing Infrastructure and VA Health Economics Resource Center. Cases included Veterans with an International Classification of Diseases, Ninth Revision/International Classification of Diseases, Tenth Revision for HIV with at least 1 prescription for a complete antiretroviral therapy regimen (January 2000 to September 2016). Two non-HIV controls were exact matched on race, sex, month, and year of birth. All patients were followed until the earliest of the following: last date of VA activity, death, or December 31, 2016.

Results:

A total of 79 578 patients (26 526 HIV and 53 052 non-HIV) met all study criteria. The average age was 49.3 years, 38% were black, 32% were white, and 97% were male for both the HIV and control cohorts. Adjusted multivariable logistic regression models demonstrated that HIV was associated with higher odds of incurring a pharmacy cost (odds ratio = 2286.45, 95% confidence interval: 322.79-16 195.82), 4-fold, and 2-fold higher odds of incurring both outpatient and inpatient costs compared to the matched controls, respectively. In adjusted multivariable gamma generalized linear models, HIV-positive patients had an almost 4-fold, 17-fold, and almost 2-fold higher cost than matched controls in total, pharmacy, and outpatient costs, respectively.

Conclusions:

This study found an association between HIV-positive patients having higher odds of incurring a medical cost as well as higher medical costs compared to non-HIV controls.

Deconstructing Syndemics: The Many Layers of Clustering Multi-Comorbidities in People Living with HIV

The HIV epidemic has dramatically changed over the past 30 years; there are now fewer newly infected people (especially children), fewer AIDS-related deaths, and more people with HIV (PWH) receiving treatment. However, the HIV epidemic is far from over. Despite the tremendous advances in anti-retroviral therapies (ART) and the implementation of ART regimens, HIV incidence (number of new infections over a defined period of time) and prevalence (the burden of HIV infection) in certain regions of the world and socio-economic groups are still on the rise. HIV continues to disproportionally affect highly marginalized populations that constitute higher-risk and stigmatized groups, underserved and/or neglected populations. In addition, it is not uncommon for PWH to suffer enhanced debilitating conditions resulting from the synergistic interactions of both communicable diseases (CDs) and non-communicable diseases (NCDs). While research utilizing only a comorbidities framework has advanced our understanding of the biological settings of the co-occurring conditions from a molecular and mechanistic view, harmful interactions between comorbidities are often overlooked, particularly under adverse socio-economical and behavioral circumstances, likely prompting disease clustering in PWH. Synergistic epidemics (syndemics) research aims to capture these understudied interactions: the mainly non-biological aspects that are central to interpret disease clustering in the comorbidities/multi-morbidities only framework. Connecting population-level clustering of social and health problems through syndemic interventions has proved to be a critical knowledge gap that will need to be addressed in order to improve prevention and care strategies and bring us a step closer to ending the HIV epidemic.

Systematic Review of Blood-Borne Pathogen Exposure Rates Among Medical Students

BACKGROUND

Blood-borne pathogen exposures (BBPEs) pose a risk to health care workers (HCWs). Needlestick injuries (NSIs) have declined overall, but not for surgical HCWs. There are limited data regarding BBPEs among medical students (MSs) in their clinical years. We aimed to quantify this risk for third- and fourth-year MSs.

METHODS

A literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The PUBMED database was searched to identify studies of third- and fourth-year MSs using the terms BBPE, NSI, and MS. Studies of other HCWs were excluded if MS data were not extractable. Additional studies were identified from references. Descriptive analysis was performed.

RESULTS

Seven of 171 articles published from 2002 to 2018 met study criteria. All used self-reported data from surveys/questionnaires. One-third of MSs reported BBPEs (n = 194/600, 32.3%) with a mean of 1 in 3.09 and a median of 1 in 3.53 (range: 1 in 1.9-8.3 students). Most events were NSIs (144/194, 74%) with a mean of 1 NSI per 4.05 MSs and median of 1 in 4.625 (range: 1 in 2.47-10.71). The remaining BBPEs reported included blood and bodily fluid splashes (n = 37, 19%), other mucocutaneous exposures (n = 7, 3.6%), and uncategorized injuries (n = 2, 1%).

CONCLUSIONS

One-third of senior MSs reported BBPEs during clinical rotations. Most BBPEs were NSIs. Quantifying this risk allows for anticipatory education and protocol development to protect students and other new HCWs. Educational efforts focused on NSI prevention before and during clinical rotations may help reduce BBPEs.

Desimplification of Single Tablet Antiretroviral (ART) Regimens-A Practical Cost-Savings Strategy?

INTRODUCTION

The use of lifelong antiretroviral therapy (ART) results in increased costs of care; the ability to finance and control sustained costs of ART needs to be discussed.

APPROACH

The Southern Alberta Clinic initiated a practical cost savings approach that switched select patients from a branded ART to a less expensive generic variation. Our approach surveyed physicians and patients on their acceptance of switching and then launched a program asking patients if they would switch to generic variations for cost control purposes.

RESULTS

Our early findings found >50% of patients approached agreed to switch. We found no evidence of increased risk of viral breakthrough, resistance, side effects, or displeasure with generic drugs. Measured cost savings in the first year were >$1.1 million with annual projected savings of between $4.3 million and $2.6 million (in 2017 Cdn$).

CONCLUSION

Our approach can provide an option for controlling costs of HIV care without compromising quality.

Pre-exposure prophylaxis for preventing acquisition of HIV: A cross-sectional study of patients, prescribers, uptake, and spending in the United States, 2015-2016

BACKGROUND

In 2015, there were approximately 40,000 new HIV diagnoses in the United States. Pre-exposure prophylaxis (PrEP) is an effective strategy that reduces the risk of HIV acquisition; however, uptake among those who can benefit from it has lagged. In this study, we 1) compared the characteristics of patients who were prescribed PrEP with individuals newly diagnosed with HIV infection, 2) identified the specialties of practitioners prescribing PrEP, 3) identified metropolitan statistical areas (MSAs) within the US where there is relatively low uptake of PrEP, and 4) reported median amounts paid by patients and third-party payors for PrEP.

METHODS AND FINDINGS

We analyzed prescription drug claims for individuals prescribed PrEP in the Integrated Dataverse (IDV) from Symphony Health for the period of September 2015 to August 2016 to describe PrEP patients, prescribers, relative uptake, and payment methods in the US. Data were available for 75,839 individuals prescribed PrEP, and findings were extrapolated to approximately 101,000 individuals, which is less than 10% of the 1.1 million adults for whom PrEP was indicated. Compared to individuals with newly diagnosed HIV infection, PrEP patients were more likely to be non-Hispanic white (45% versus 26.2%), older (25% versus 19% at ages 35-44), male (94% versus 81%), and not reside in the South (30% versus 52% reside in the South).Using a ratio of the number of PrEP patients within an MSA to the number of newly diagnosed individuals with HIV infection, we found MSAs with relatively low uptake of PrEP were concentrated in the South. Of the approximately 24,000 providers who prescribed PrEP, two-thirds reported primary care as their specialty. Compared to the types of payment methods that people living with diagnosed HIV (PLWH) used to pay for their antiretroviral treatment in 2015 to 2016 reported in the Centers for Disease Control and Prevention (CDC) HIV Surveillance Special Report, PrEP patients were more likely to have used commercial health insurance (80% versus 35%) and less likely to have used public healthcare coverage or a publicly sponsored assistance program to pay for PrEP (12% versus 45% for Medicaid). Third-party payors covered 95% of the costs of PrEP. Overall, we estimated the median annual per patient out-of-pocket spending on PrEP was approximately US$72. Limitations of this study include missing information on prescription claims of patients not included in the database, and for those included, some patients were missing information on patient diagnosis, race/ethnicity, educational attainment, and income (34%-36%).

CONCLUSIONS

Our findings indicate that in 2015-2016, many individuals in the US who could benefit from being on PrEP were not receiving this HIV prevention medication, and those prescribed PrEP had a significantly different distribution of characteristics from the broader population that is at risk for acquiring HIV. PrEP patients were more likely to pay for PrEP using commercial or private insurance, whereas PLWH were more likely to pay for their antiretroviral treatment using publicly sponsored programs. Addressing the affordability of PrEP and otherwise promoting its use among those with indications for PrEP represents an important opportunity to help end the HIV epidemic.

HIV-1 Tat: Role in Bystander Toxicity

HIV Tat protein is a critical protein that plays multiple roles in HIV pathogenesis. While its role as the transactivator of HIV transcription is well-established, other non-viral replication-associated functions have been described in several HIV-comorbidities even in the current antiretroviral therapy (ART) era. HIV Tat protein is produced and released into the extracellular space from cells with active HIV replication or from latently HIV-infected cells into neighboring uninfected cells even in the absence of active HIV replication and viral production due to effective ART. Neighboring uninfected and HIV-infected cells can take up the released Tat resulting in the upregulation of inflammatory genes and activation of pathways that leads to cytotoxicity observed in several comorbidities such as HIV associated neurocognitive disorder (HAND), HIV associated cardiovascular impairment, and accelerated aging. Thus, understanding how Tat modulates host and viral response is important in designing novel therapeutic approaches to target the chronic inflammatory effects of soluble viral proteins in HIV infection.

Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review

BACKGROUND

As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change.

OBJECTIVES

To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers.

METHODS

A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management.

RESULTS

22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996.

CONCLUSIONS

This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses.

DISCLOSURES

This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.

Evaluation of a Computer-Based HIV Education Program for Adults Living with HIV

This study evaluated a computer-delivered HIV and antiretroviral treatment education program in adults (N = 102) living with detectable HIV viral loads (> 200 copies/mL). The self-paced program provided immediate feedback for responses and financial incentives for responding correctly. The program was divided into three courses and a test of content from all three courses was delivered before and after participants completed each course. Test scores on the content delivered in Courses 1, 2 and 3 improved only after participants completed training on the relevant course. Initial test scores were positively correlated with health literacy and academic achievement; were negatively correlated with viral load; and were lowest for participants living in poverty. Education, academic achievement, and health literacy were related to how much participants learned following each course. Computer-based education is a convenient, effective approach to promoting an understanding of HIV and its treatment.

Point-of-care HIV viral load in pregnant women without prenatal care: a cost-effectiveness analysis

BACKGROUND

Routine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery.

OBJECTIVE

Our study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load.

STUDY DESIGN

A decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery-related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year.

RESULTS

Measuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery-related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3).

CONCLUSIONS

For HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.

Competing biomedical HIV prevention strategies: potential cost-effectiveness of HIV vaccines and PrEP in Seattle, WA

INTRODUCTION

Promising HIV vaccine candidates are steadily progressing through the clinical trial pipeline. Once available, HIV vaccines will be an important complement but also potential competitor to other biomedical prevention tools such as pre-exposure prophylaxis (PrEP). Accordingly, the value of HIV vaccines and the policies for rollout may depend on that interplay and tradeoffs with utilization of existing products. In this economic modelling analysis, we estimate the cost-effectiveness of HIV vaccines considering their potential interaction with PrEP and condom use.

METHODS

We developed a dynamic model of HIV transmission among the men who have sex with men population (MSM), aged 15-64 years, in Seattle, WA offered PrEP and HIV vaccine over a time horizon of 2025-2045. A healthcare sector perspective with annual discount rate of 3% for costs (2017 USD) and quality-adjusted life years (QALYs) was used. The primary economic endpoint is the incremental cost-effectiveness ratio (ICER) when compared to no HIV vaccine availability.

RESULTS

HIV vaccines improved population health and increased healthcare costs. Vaccination campaigns achieving 90% coverage of high-risk men and 60% coverage of other men within five years of introduction are projected to avoid 40% of new HIV infections between 2025 and 2045. This increased total healthcare costs by $30 million, with some PrEP costs shifted to HIV vaccine spending. HIV vaccines are estimated to have an ICER of $42,473/QALY, considered cost-effective using a threshold of $150,000/QALY. Results were most sensitive to HIV vaccine efficacy and future changes in the cost of PrEP drugs. Sensitivity analysis found ranges of 30-70% HIV vaccine efficacy remained cost-effective. Results were also sensitive to reductions in condom use among PrEP and vaccine users.

CONCLUSIONS

Access to an HIV vaccine is desirable as it could increase the overall effectiveness of combination HIV prevention efforts and improve population health. Planning for the rollout and scale-up of HIV vaccines should carefully consider the design of policies that guide interactions between vaccine and PrEP utilization and potential competition.

Extracellular vesicles expressing a single-chain variable fragment of an HIV-1 specific antibody selectively target Env+ tissues

Rationale: Antiretroviral therapy can effectively suppress HIV-1 replication in the peripheral blood to an undetectable level. However, elimination of the latent virus in reservoirs remains a challenge and is a major obstacle in the treatment of HIV-1-infected patients. Exosomes exhibit huge promise as an endogenous drug delivery nanosystem for delivering drugs to solid tissues given their unique properties, including low immunogenicity, innate stability, high delivery efficiency, and most importantly the ability to penetrate solid tissues due to their lipophilic properties. Methods: We engineered and expressed the scFv of a high affinity HIV-1-specific monoclonal antibody, 10E8, on the exosomal surface (10E8scFv-exos). Subsequently, the 10E8scFv-exos were loaded with curcumin (Cur), a chemical that kills HIV-1-infected cells, or miR-143, an apoptosis-inducing miRNA. We tested the ability of 10E8scFv-exos to deliver cargo to Env+ target cells and tissues, as well as their ability to suppress HIV-1 infection. Results: 10E8scFv-exos efficiently targeted CHO cells expressing a trimeric gp140 on their surface (Env+ cells) in vitro, as demonstrated by confocal imaging and flow cytometry. 10E8scFv-exos loaded with Cur or miR-143 showed specific killing of Env+ cells. In addition, 10E8scFv-exos loaded with Cur or miR-143 could suppress p24 expression in an HIV-1 latency cell line ACH2 and in PBMCs from an ART-treated HIV-1-infected patient. In an NCG mouse model grafted with tumorigenic Env+ CHO cells and which had developed solid tissue tumors, intravenously injected 10E8scFv-exos targeted the Env-expressing tissues and delivered Cur to induce a strong suppression of the Env+ tumor growth with low toxicity. Conclusion: In principle, engineered exosomes can deliver anti-HIV agents to solid tissues by specifically targeting cells expressing viral envelop proteins and inducing cell killing, suggesting that such an approach could be developed for eradicating virus-infected cells in tissue reservoirs.

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.

The Fragility Index in a Cohort of HIV/AIDS Randomized Controlled Trials

HIV/AIDS is associated with significant morbidity, mortality, and financial burden. For these reasons, robust clinical evidence is critical. We aim to investigate the fragility index, fragility quotient, and risk of bias of clinical trial endpoints in HIV medicine. The fragility index represents the minimum amount of trial endpoint "nonevents" changed to "events" in one trial arm required to nullify statistical significance. The fragility quotient contextualized the fragility index by dividing the index by the total trial sample size. We selected eligible trials from the Department of Health and Human Services guideline for the use of antiretroviral agents in HIV-1-infected adults and adolescents. We calculated the fragility index and fragility quotient for all included trials. The Cochrane "risk of bias" Tool 2.0 was used to evaluate the likelihood and sources of bias in the included trials. Thirty-nine RCTs were included for our analysis of fragility. Thirty-six were included for our analysis of the risk of bias. The median fragility index was 5. Three RCTs were at high risk of bias, all due to the selection of the endpoint or statistical test. Twenty had some concerns for risk of bias. The analyzed HIV medicine RCT endpoints were fragile, overall. This indicates that a median of 5 patients across all included studies would nullify the statistical significance of the endpoints. Furthermore, we found evidence that concerns for bias are present at a high rate.

The cost of hospital care for HIV patients in Colombia: an insurer's perspective

The aim of this study was to evaluate the cost derived from the hospitalization of people living with HIV (PLHIV) in Colombia between 2011 and 2015. This is an analysis of the direct cost of PLHIV hospitalization from the perspective of an insurer of the Colombian General Social Security System. The costs were calculated in Colombian pesos and corrected for inflation on the basis of the 2017 Consumer Price Index of the Bank of the Republic of Colombia. It was converted to US dollars at the Market Representative Exchange Rate of the same year. We analyzed 1129 hospitalizations in 612 PLHIV, of which 12% started with a diagnosis of HIV during the same hospitalization, with the majority in the AIDS stage (63%). The median overall cost of hospitalizations was US$1509 (25th and 75th percentiles: US$711-US$3254), being even higher in patients with AIDS and as the CD4 T lymphocyte count decreased. The cost derived from the medical care of PLHIV increases as the clinical control of the disease worsens, and it is a key indicator of the impact of the strategies implemented for the timely identification of the infection and subsequent management of the disease.

Impact of Medicare Part D on mental health treatment and outcomes for dual eligible beneficiaries with HIV

Depression is common among women with HIV and untreated depression can result in poor quality of life and worsen HIV outcomes. Women with HIV who are dually enrolled in Medicaid and Medicare faced a potential disruption in medication access when Medicare Part D was implemented in 2006. The goal of this study was to estimate the effects of Medicare Part D implementation on antidepressant use, depressive symptoms, and hospitalization in Medicaid-Medicare dual eligible women with HIV. This study used 2003-2008 data from the Women's Interagency HIV Study. The effects of Medicare Part D were estimated using a difference-in-differences approach, adjusting for temporal trends using a matched control group of Medicaid-only enrollees. Before Medicare Part D implementation, dual eligibles differed from Medicaid-only enrollees in antidepressant use and hospitalization, despite having identical prescription drug coverage through Medicaid. For dual enrollees, the transition to Medicare Part D was not associated with changes in antidepressant use, depressive symptoms, or hospitalization. We did not find disruptive effects on antidepressant use and related outcomes among dual eligibles in this study. Stable antidepressant use may be due to better access to medical care for dual eligibles through Medicare both before and after Medicare Part D implementation, which may have eclipsed any effects of the transition. It may also signal that classification of antidepressants as a protected drug class under Medicare Part D was effective in preventing psychiatric medication disruption.

The Cost-Effectiveness of Financial Incentives for Viral Suppression: HPTN 065 Study

OBJECTIVE

To evaluate the cost-effectiveness of financial incentives for human immunodeficiency virus (HIV) viral suppression compared to standard of care.

STUDY DESIGN

Mathematical model of 2-year intervention offering financial incentives ($70 quarterly) for viral suppression (<400 copies/ml³) based on the HPTN 065 clinical trial with HIV patients in the Bronx, NY and Washington, D.C.

METHODS

A disease progression model with HIV transmission risk equations was developed following guidelines from the Second Panel on Cost-Effectiveness in Health and Medicine. We used health care sector and societal perspectives, 3% discount rate, and lifetime horizon. Data sources included trial data (baseline N = 16,208 patients), CDC HIV Surveillance data, and published literature. Outcomes were costs (2017 USD), quality-adjusted life years (QALYs), HIV infections prevented, and incremental cost-effectiveness ratio (ICER).

RESULTS

Financial incentives for viral suppression were estimated to be cost-saving from a societal perspective and cost-effective ($49,877/QALY) from a health care sector perspective. Compared to the standard of care, financial incentives gain 0.06 QALYs and lower discounted lifetime costs by $4210 per patient. The model estimates that incentivized patients transmit 9% fewer infections than the standard-of-care patients. In the sensitivity analysis, ICER 95% credible intervals ranged from cost-saving to $501,610/QALY with 72% of simulations being cost-effective using a $150,000/QALY threshold. Modeling results are limited by uncertainty in efficacy from the clinical trial.

CONCLUSIONS

Financial incentives, as used in HTPN 065, are estimated to improve quality and length of life, reduce HIV transmissions, and save money from a societal perspective. Financial incentives offer a promising option for enhancing the benefits of medication in the United States.

De-simplifying single-tablet antiretroviral treatments: uptake, risks and cost savings

OBJECTIVES

As more HIV-positive individuals receive antiretroviral therapy (ART), payers are seeking options for covering these increased and sustained drug costs. Strategic use of available generic antiretroviral (ARV) formulations may be feasible. De-simplifying a single-tablet co-formulation (STF) into two or more tablets using both brand and generic drugs has been proposed. We determine if voluntary de-simplification of one STF could be utilized as a cost-saving strategy. We report on the challenges, uptake, outcomes and cost savings of this initiative.

METHODS

Patients stable on the most commonly used STF (Triumeq^® ) were offered the option of remaining on Triumeq^® or switching to generic abacavir/lamivudine and Tivicay^® between 1 January 2015 and 1 January 2018; those starting ART consisting of abacavir/lamivudine/doulutegravir in the same period were offered the option of starting Triumeq^® or generic abacavir/laminvudine and Tivicay^® . No incentives were provided. We examined the acceptance/decline rates, patient satisfaction, health care outcomes and annual cost savings.

RESULTS

Of 626 patients receiving Triumeq^® , 321 were approached; 177 (55.1%) agreed to de-simplify. Of patients initiating ART, 62.7% chose the generic co-formulation. Patients switching to or starting on the generic co-formulation were more likely to be male, > 45 years old, Caucasian, men who have sex with men (MSM) and more HIV-experienced, and to have more comorbidities (all P < 0.05). Preference for STF was cited for declining de-simplification. No concern about generic ARVs was expressed. The rate of viral load > 500 HIV-1 RNA copies/mL after baseline was 2.7% in switched patients compared with 7.0% in those declining to switch. No de novo resistance occurred. A saving of Cdn$1 319 686 was achieved in the first year.

CONCLUSIONS

Reliance on altruism, while respecting patient autonomy, achieved de-simplification in > 50% of patients approached, and generated immediate cost savings with no increased risk of adverse events, viral breakthrough or resistance.

Sensitivity of joint contagiousness and susceptibility-based dynamic optimal control strategies for HIV prevention

Predicting the population-level effects of an infectious disease intervention that incorporate multiple modes of intervention is complicated by the joint non-linear dynamics of both infection transmission and the intervention itself. In this paper, we consider the sensitivity of Dynamic Optimal Control Profiles (DOCPs) for the optimal joint investment in both a contagiousness and susceptibility-based control of HIV to bio-behavioral, economic, and programmatic assumptions. The DOCP is calculated using recently developed numerical algorithms that allow controls to be represented by a set of piecewise constant functions that maintain a constant yearly budget. Our transmission model assumes multiple stages of HIV infection corresponding to acute and chronic infection and both within- and between-individual behavioral heterogeneity. We parameterize a baseline scenario from a longitudinal study of sexual behavior in MSM and consider sensitivity of the DOCPs to deviations from that baseline scenario. In the baseline scenario, the primary determinant of the dominant control were programmatic factors, regardless of budget. In sensitivity analyses, the qualitative aspects of the optimal control policy were often robust to significant deviation in assumptions regarding transmission dynamics. In addition, we found several conditions in which long-term joint investment in both interventions was optimal. Our results suggest that modeling in the service of decision support for intervention design can improve population-level effects of a limited set of economic resources. We found that economic and programmatic factors were as important as the inherent transmission dynamics in determining population-level intervention effects. Given our finding that the DOCPs were robust to alternative biological and behavioral assumptions it may be possible to identify DOCPs even when the data are not sufficient to identify a transmission model.

Short-term cost analysis of raltegravir versus atazanavir + ritonavir or darunavir + ritonavir for treatment-naive adults with HIV-1 infection in the United States

The head-to-head AIDS Clinical Trial Group (ACTG) 5257 clinical trial found raltegravir (RAL) to be superior to atazanavir + ritonavir (ATV/r) and darunavir + ritonavir (DRV/r), when used in combination with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) by treatment-naive adults with HIV-1 infection, in a 96-week composite endpoint combining virologic efficacy and tolerability. The objective of this study was to estimate the total HIV treatment costs associated with these three regimens in the United States.

Long-term HIV/AIDS survivors: Patients living with HIV infection retained in care for over 20 years. What have we learned?

Individuals diagnosed with HIV before 1996 had poor prognoses. Few HIV care centers can track patients continuously from the 1980s to present. We determined the sociodemographic, clinical, and health care utilization characteristics of patients diagnosed and followed for >20 years (i.e. long-term HIV/AIDS survivors) to understand what factors contributed to survival. All HIV-positive patients diagnosed before 1996 were categorized as active, moved/lost, or died as of 1 January 2016. Baseline sociodemographic, clinical characteristics, antiretroviral therapy (ART) usage, retention, HIV care costs, and health status were analyzed. Of 876 patients, 49.5% died, 30.3% moved or left, 20.3% remained active in care for a median of 23.4 years. At diagnosis, continuously-followed patients were younger with a higher CD4 cell count, attended regular clinic visits at higher frequencies, and had received more ART than patients who moved or died. As of 1 January 2016, their median age was 57 years (interquartile range 53-62), 15% were aged >65 years, median CD4 cell count was 591 cells/mm³ (475-863) with 68% >500 cells/mm³. Sixty-two percent remained employed. The total cost of HIV care was $32,251,030 (Cdn$); median cost per patient per year $15,418 ($13,697-$18,392). Individuals diagnosed prior to 1996 benefited from early diagnosis and engagement to care, regular follow-ups, and timely initiation of ART, strongly supporting the modern guidelines of care.

Reaction Kinetics Direct a Rational Synthesis of an HIV-1 Inactivator of Nucleocapsid Protein 7 and Provide Mechanistic Insight into Cellular Metabolism and Antiviral Activity

Mercaptobenzamide thioester SAMT-247 is a non-toxic, mutation-resistant HIV-1 maturation inhibitor with a unique mechanism of antiviral activity. NMR spectroscopic analyses of model reactions that mimic the cellular environment answered fundamental questions about the antiviral mechanism and inspired a high-yielding (64 % overall), scalable (75 mmol), and cost-effective ($4 mmol^-1 ) three-step synthesis that will enable additional preclinical evaluation.

Optimal allocation of HIV prevention funds for state health departments

OBJECTIVE

To estimate the optimal allocation of Centers for Disease Control and Prevention (CDC) HIV prevention funds for health departments in 52 jurisdictions, incorporating Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program funds, to improve outcomes along the HIV care continuum and prevent infections.

METHODS

Using surveillance data from 2010 to 2012 and budgetary data from 2012, we divided the 52 health departments into 5 groups varying by number of persons living with diagnosed HIV (PLWDH), median annual CDC HIV prevention budget, and median annual HRSA expenditures supporting linkage to care, retention in care, and adherence to antiretroviral therapy. Using an optimization and a Bernoulli process model, we solved for the optimal CDC prevention budget allocation for each health department group. The optimal allocation distributed the funds across prevention interventions and populations at risk for HIV to prevent the greatest number of new HIV cases annually.

RESULTS

Both the HIV prevention interventions funded by the optimal allocation of CDC HIV prevention funds and the proportions of the budget allocated were similar across health department groups, particularly those representing the large majority of PLWDH. Consistently funded interventions included testing, partner services and linkage to care and interventions for men who have sex with men (MSM). Sensitivity analyses showed that the optimal allocation shifted when there were differences in transmission category proportions and progress along the HIV care continuum.

CONCLUSION

The robustness of the results suggests that most health departments can use these analyses to guide the investment of CDC HIV prevention funds into strategies to prevent the most new cases of HIV.

The Design of New HIV-IN Tethered Bifunctional Inhibitors Using Multiple Microdomain Targeted Docking

Currently, used antiretroviral HIV therapy drugs exclusively target critical groups in the enzymes essential for the viral life cycle. Increased mutagenesis of their genes changes these viral enzymes, which once mutated can evade therapeutic targeting, effects which confer drug resistance. To circumvent this, our review addresses a strategy to design and derive HIV-Integrase (HIV-IN) inhibitors which simultaneously target two IN functional domains, rendering it inactive even if the enzyme accumulates many mutations. First we review the enzymatic role of IN to insert the copied viral DNA into a chromosome of the host T lymphocyte, highlighting its main functional and structural features to be subjected to inhibitory action. From a functional and structural perspective we present all classes of HIV-IN inhibitors with their most representative candidates. For each chosen compound we also explain its mechanism of IN inhibition. We use the recently resolved cryo EM IN tetramer intasome DNA complex onto which we dock various reference IN inhibitory chemical scaffolds such as to target adjacent functional IN domains. Pairing compounds with complementary activity, which dock in the vicinity of a IN structural microdomain, we design bifunctional new drugs which may not only be more resilient to IN mutations but also may be more potent inhibitors than their original counterparts. In the end of our review we propose synthesis pathways to link such paired compounds with enhanced synergistic IN inhibitory effects.

Patient perspectives on de-simplifying their single-tablet co-formulated antiretroviral therapy for societal cost savings

OBJECTIVES

The incremental costs of expanding antiretroviral (ARV) drug treatment to all HIV-infected patients are substantial, so cost-saving initiatives are important. Our objectives were to determine the acceptability and financial impact of de-simplifying (i.e. switching) more expensive single-tablet formulations (STFs) to less expensive generic-based multi-tablet components. We determined physician and patient perceptions and acceptance of STF de-simplification within the context of a publicly funded ARV budget.

METHODS

Programme costs were calculated for patients on ARVs followed at the Southern Alberta Clinic, Canada during 2016 (Cdn$). We focused on patients receiving Triumeq® and determined the savings if patients de-simplified to eligible generic co-formulations. We surveyed all prescribing physicians and a convenience sample of patients taking Triumeq® to see if, for budgetary purposes, they felt that de-simplification would be acceptable.

RESULTS

Of 1780 patients receiving ARVs, 62% (n = 1038) were on STF; 58% (n = 607) of patients on STF were on Triumeq®. The total annual cost of ARVs was $26 222 760. The cost for Triumeq® was $8 292 600. If every patient on Triumeq® switched to generic abacavir/lamivudine and Tivicay® (dolutegravir), total costs would decrease by $4 325 040. All physicians (n = 13) felt that de-simplifying could be safely achieved. Forty-eight per cent of 221 patients surveyed were agreeable to de-simplifying for altruistic reasons, 27% said no, and 25% said maybe.

CONCLUSIONS

De-simplifying Triumeq® generates large cost savings. Additional savings could be achieved by de-simplifying other STFs. Both physicians and patients agreed that selective de-simplification was acceptable; however, it may not be acceptable to every patient. Monitoring the medical and cost impacts of de-simplification strategies seems warranted.

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.

Antiretroviral pill count and clinical outcomes in treatment-naïve patients with HIV infection

OBJECTIVES

Treatment guidelines recommend single-tablet regimens for patients with HIV infection starting antiretroviral therapy. These regimens might be as effective and cost less if taken as separate drugs. We assessed whether the one pill once a day combination of efavirenz, emtricitabine and tenofovir reduces the risk of disease progression compared with multiple-pill formulations of the same regimen.

METHODS

We selected treatment-naïve patients starting one-, two- or three-pill formulations of this regimen in data from the Antiretroviral Therapy Cohort Collaboration. These patients were followed until an AIDS event or death or until they modified their regimen. We analysed these data using Cox regression models, then used our models to predict the potential consequences of exposing a future population to either a one-pill regimen or a three-pill regimen.

RESULTS

Among 11 739 treatment-naïve patients starting the regimen, there were 386 AIDS events and 87 deaths. Follow-up often ended when patients switched to the same regimen with fewer pills. After the first month, two pills rather than one was associated with an increase in the risk of AIDS or death [hazard ratio (HR) 1.39; 95% confidence interval (CI) 1.01-1.91], but three pills rather than two did not appreciably add to that increase (HR 1.19; 95% CI 0.84-1.68). We estimate that 77 patients would need to be exposed to a one-pill regimen rather than a three-pill regimen for 1 year to avoid one additional AIDS event or death.

CONCLUSIONS

This particular single-tablet regimen is associated with a modest decrease in the risk of AIDS or death relative to multiple-pill formulations.

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.

The Clinical and Economic Impact of Attaining National HIV/AIDS Strategy Treatment Targets in the United States

Background

The US National HIV/AIDS Strategy (NHAS) aims for 72% (90% diagnosed times 80% of those virally suppressed) viral suppression among persons with human immunodeficiency virus (HIV) by 2020. We examined the clinical and economic impact of reaching this target, in the general US population and among black men who have sex with men (MSM), the group with the highest HIV prevalence.

Methods

Using a mathematical simulation, we project the 5- and 20-year clinical outcomes, costs, and incremental cost-effectiveness ratios for (1) Current Pace of detection, linkage, retention, and virologic suppression and (2) NHAS investments in expanded testing ($24-$74 per test) and adherence ($400 per person-year), calibrated to achieve 72% suppression by 2020. We examined alternative rates of testing, retention, and suppression and the efficacy and cost of adherence interventions.

Results

Compared with Current Pace over 20 years, NHAS averted 280000 HIV transmissions (80000 in black MSM) and 199000 (45000) deaths and saved 2138000 (453000) years of life, while increasing costs by 23%. The incremental cost-effectiveness ratio for NHAS compared with Current Pace was $68900 per quality-adjusted life-year ($38300 for black MSM) and was most sensitive to antiretroviral therapy costs.

Conclusions

Reaching NHAS targets would yield substantial clinical benefits and be cost-effective in both the general US and black MSM populations.

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.