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

Ending the HIV Epidemic in Black America: Qualitative Insights Following COVID-19

BACKGROUND

The disproportionate effects of the human immunodeficiency virus (HIV) and the Coronavirus 2019 (COVID-19) on Black American communities highlight structural systems rooted in racism and must be addressed with national strategies that improve both biomedicine and social determinants of health.

PURPOSE

The purpose of this study was to qualitatively examine the experiences and interpretations of experts in the HIV workforce (local, state, and national HIV-related organizations) regarding the state of HIV and COVID-19 among Black Americans.

METHODS

Within key informant interviews and a focus group recorded and transcribed verbatim, fifteen members of the HIV workforce and Black community described their experiences and provided insights to inform ending the negative outcomes resulting from HIV and COVID-19.

RESULTS

Data were analyzed using NVivo software, and eight themes emerged to address disease disproportionality through a Black lens. Themes reflected (1) accessing information and care; (2) key potential partners/stakeholders; (3) investing in Black communities; (4) governmental support; (5) increasing engagement and advocacy; (6) HIV-related community conversations; (7) developments since COVID-19; and (8) the Ending the HIV Epidemic (EHE) trajectory.

CONCLUSIONS

Themes directly speak to recommendations to adjust education and policy strategies for HIV and COVID-19 prevention and intervention. Such recommendations, (1) amplifying Black voices, (2) investing sustainable dollars into Black communities, and (3) leaning into advocacy, can bolster the foundation for the HIV workforce and Black community to break ineffective response patterns and lead the fight against these systemic issues of inequity.

Health Care Service Utilization Among People with HIV, Chronic Pain, and Depression: Utilization and Cost Outcomes from the HIV-PASS Study

In the United States (U.S.), 90% of annual health care expenditures are devoted to people with chronic physical and mental health conditions. For people with HIV (PWH), two common, chronic comorbidities are pain and depression. This report assesses the impact of a brief psychotherapy intervention for PWH and comorbid chronic pain and depression on health care service utilization. Data from the HIV Pain and Sadness Study (HIV-PASS) randomized trial were used. Electronic health records were reviewed to tabulate use of the following services: (a) outpatient rehabilitation; (b) outpatient psychiatric; and (c) hospital-based (e.g., emergency department). Estimated average marginal effects were analyzed to determine how many times a participant accessed the service and the charge at each event. The sample consisted of 187 adults recruited from three U.S. sites. Individuals randomized to the three-month, seven session HIV-PASS intervention had average charges for hospital-based services that were significantly less during the post-treatment phase (months 4-12; 95%CI: -$16,612, -$131; p =.046) than those randomized to the comparison condition. On average, comparison condition participants were charged $8,371 more for hospital services in the 8-month period following intervention. No significant differences between treatment conditions were observed in use of outpatient rehabilitation, outpatient psychiatric services, or hospital-based care. Consistent with predictions, lower health care charges among those randomized to the HIV-PASS behavioral intervention were incurred for hospital services, indicating that a brief behavioral intervention could lead to decreased use of more emergent and expensive care services among persons with HIV, depression, and chronic pain.

Healthcare resource utilization and related cost of non-HIV comorbidity management in people with HIV in a Spanish cohort from 2007-2016

OBJECTIVE

To estimate the cost and healthcare resource utilization (HRU) associated with the prevalence of comorbidities in people living with HIV (PLWH) in a Spanish cohort over ten years.

METHODS

A cohort study carried out at the HIV outpatient clinic of the University Hospital Virgen del Rocío based on data collected during 2007-2016. PLWH with at least one follow-up visit were included. Comorbidities were determined by examining diagnostic codes in the electronic medical records. Costs were estimated from hospitalizations, emergency and non-HIV visits, laboratory tests for conditions unrelated to HIV infection, HIV antiretroviral therapy, and other non-HIV diagnostic tests. A linear regression was performed with non-ART costs as the dependent variable and patient characteristics (sex, HIV transmission route, age, CD4, comorbidities, and infection duration) as independent variables.

RESULTS

The study included 2,798 PLWH; 83% were men with a mean age of 38.6 years. Overall, 52.5% of PLWH had at least one non-HIV comorbidity and 21.2% had ≥3 comorbidities. The most prevalent comorbidities were hepatitis C (25.3%) and hypertension (22.9%). The presence of comorbidities increased the total healthcare cost up to 80% in PLWH with ≥3 comorbidities compared with those without comorbidities (over a 10-year period (115,867.3€ vs 64,290.7€, p < .001). The number of comorbidities was linked to higher healthcare costs in PLWH in the adjusted model.

CONCLUSION

Comorbidities raised the total healthcare costs for PLWH, with a greater impact on those with multiple comorbidities compared to those with few or none. Both clinical and economic decision-makers must consider and assess the cost of comorbidities when evaluating HIV treatment guidelines or recommendations.

Impact of different antiretroviral therapy regimens on bone mineral density in people living with HIV: a retrospective and longitudinal study in China

BACKGROUND

HIV infection and antiretroviral therapy (ART) are associated with bone loss of people living with HIV (PLWH), but limited studies exist on the impacts of ART regimens on bone mineral density (BMD) in China. This study evaluated BMD changes with three common ART regimens: tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) + efavirenz (EFV), tenofovir alafenamide (TAF)-containing, and dolutegravir (DTG)-containing (non-TDF/non-TAF) therapies.

METHODS

In this retrospective study, the prevalence of low BMD was analyzed in PLWH who underwent dual-energy X-ray absorptiometry (DXA) before ART initiation. BMD changes were assessed in participants who had follow-up DXA scans after ≥ 1 year of ART with TDF + 3TC + EFV, TAF-containing, or DTG-containing regimens. We used multivariate logistic regression to evaluate the impact of different ART regimens on > 3% BMD reduction, adjusting for demographic and clinical variables that were significant in univariate analysis (P < 0.10).

RESULTS

22.99% (630/2740) of PLWH before ART initiation had low BMD. Among 571 individuals followed up for over 1 year, BMD at the femoral neck (FN) and total hip (TH) decreased significantly in the TDF + 3TC + EFV [FN: -0.03(-0.07, 0.00) g/cm2, TH: -0.02(-0.05, 0.00) g/cm2, P < 0.001 for both] and TAF-containing regimens [FN: -0.02(-0.05, 0.01) g/cm2, TH: -0.02(-0.04, 0.01) g/cm2, P < 0.001 for both]. Lumbar spine (LS) BMD decreased significantly only with TDF + 3TC + EFV [-0.02(-0.05, 0.01) g/cm2, P < 0.001]. TDF + 3TC + EFV caused greater BMD loss at the FN and LS than the TAF-containing regimen[FN: -3.66% (-8.05%, 0.34%) vs. -2.38% (-5.44%, 1.12%), P = 0.044; LS: -2.11% (-4.50%, 0.62%) vs.-0.06% (-2.05%, 2.57%), P < 0.001]. Compared to TDF + 3TC + EFV, DTG-containing regimens showed smaller BMD reductions across all sites [FN: -1.49% (-4.65%, 3.83%), TH: 0.00% (-3.98%, 3.18%), LS: 0.59% (-2.73%, 3.09%), P = 0.004, 0.008 and 0.004, respectively]. TAF-containing and DTG-containing regimens showed no significant differences in BMD changes. Multivariable logistic regression showed that TDF + 3TC + EFV, compared to DTG-containing regimens, had higher odds of > 3% FN and LS BMD reduction (FN: OR 2.91, 95% CI: 1.33 to 6.37, P = 0.009; LS: OR 2.93, 95% CI: 1.17 to 7.32, P = 0.022), while TAF-containing regimens were not independently linked to > 3% BMD loss (P > 0.05).

CONCLUSIONS

TAF-containing and DTG-containing regimens caused less bone loss than TDF + 3TC + EFV, offering safer options for preserving bone health in Chinese PLWH.

Amphetamine-related intoxications in people living with HIV: An observational study in an emergency department in Barcelona (Spain) from 2018 to 2020

BACKGROUND

Stimulant drugs, particularly amphetamines, are more commonly implicated in drug-related deaths in people living with HIV; however, the clinical characteristics of amphetamine-related intoxication in people living with HIV are poorly described.

MATERIAL AND METHODS

We conducted a retrospective study in people living with HIV who were admitted for amphetamine-related intoxication to an emergency department of a teaching hospital between 2018 and 2021. Severe intoxication (SI) was arbitrarily defined as requiring admission to the emergency medical support unit and receiving medical treatment for ≥6 h.

RESULTS

In total, 170 male patients with a median age of 36.2 + 7.5 years were included in the study. A total of 77 (45.3%) individuals had mental disorders, and 120 (85.7%) had HIV-1 RNA suppression, with a median CD4 cell count of 696 (interquartile range 490-905). In total, 61 (37.9%) individuals were on ritonavir/cobicistat-based regimens. Presenting clinical syndromes included agitation in 60 (35.3%) subjects, anxiety in 37 (21.7%), psychosis in 27 (15.8%), chest pain in 26 (15.3%) and altered level of consciousness in 20 (11.7%). SI was observed in 48 (28.2%) individuals, 12 (7.1%) required admission to the intensive care unit, and two (1.2%) died. Altered level of consciousness (odds ratio [OR] 6.5; 95% confidence interval [CI] 2.2-18.9; p < 0.01), psychosis (OR 5.8; 95% CI 2.2-15.1; p < 0.01) and suicide attempt (OR 4.6; 95% CI 1.8-11.6; p 0.01) were associated with SI in the adjusted analysis.

CONCLUSIONS

Amphetamine-related intoxication causes high morbidity in people living with HIV. Healthcare providers serving these patients should consider incorporating harm-reduction measures in the prevention of amphetamine-related intoxication.

Economic Burden of HIV in a Commercially Insured Population in the United States

Background: With advances in antiretroviral therapy (ART), people with HIV infection are living longer. Pre-exposure prophylaxis (PrEP) to reduce HIV infection risk continues to be underutilized in high-risk individuals. Recent data on economic burden for patients with newly diagnosed HIV-1 or initiated with PrEP are limited. Objectives: To assess characteristics, healthcare resource utilization (HRU), and costs among adults and adolescents either with newly diagnosed HIV-1 or initiated with PrEP. Methods: This retrospective observational study utilized data from the IBM MarketScan® Commercial Claims and Encounters database. Adults with newly diagnosed HIV-1 or those initiated with PrEP were included (index date was the first HIV diagnosis or PrEP prescription, respectively, between January 1, 2016, and April 30, 2021). Corresponding cohorts of adolescents were considered exploratory. Descriptive analyses were conducted to assess baseline demographics and clinical characteristics, and all-cause and HIV-related HRU and costs per patient per month (PPPM) during follow-up. Results: Data from 18 154 adults and 220 adolescents with newly diagnosed HIV and 34 123 adults and 175 adolescents initiated with PrEP were included. Approximately 70% of adolescents and 9% of adults receiving PrEP were female. Baseline depression/anxiety was present in 16.1% and 24.6% of adults and 14.5% and 45.1% of adolescents in the HIV and PrEP cohorts, respectively. Substance abuse in the HIV and PrEP cohorts, respectively, was reported in 10.1% and 7.0% of adults, and 2.7% and 17.7% of adolescents. During follow-up, among adults with newly diagnosed HIV, mean (SD) total all-cause and HIV-related PPPM costs were $2657 ($5954) and $1497 ($4463), respectively; pharmacy costs represented 47% of all-cause costs and 67% of HIV-related costs, but only 37% of patients had an HIV-related prescription. All-cause costs PPPM for adults with PrEP were $1761 ($1938), with pharmacy costs accounting for 71%. Conclusions: Despite advances in ART, patients with newly diagnosed HIV and at-risk patients receiving PrEP continue to incur HRU costs. The chronic nature of HIV warrants further exploration of factors contributing to disease burden and opportunities to improve prevention strategies.

Treatment and comorbidity burden among people living with HIV: a review of systematic literature reviews

Background

As the human immunodeficiency virus (HIV) treatment landscape continues to evolve, the prolonged life expectancy and long-term exposure to antiretroviral drugs have modified the burden associated with living with HIV.

Objective

To better understand the current treatment and comorbidity burden in people living with HIV (PLWH).

Methods

Peer-reviewed systematic literature reviews (SLRs) between 2017 and 2020 that included US studies and examined drug adherence/pill burden, resistance burden, or comorbidities in PLWH were identified. Methods and findings were extracted for the overall studies and examined in the subset of US studies.

Results

Among 665 publications identified, 47 met the inclusion criteria (drug adherence/pill burden: 5; resistance: 3; comorbidities: 40). While antiretroviral drug adherence levels varied across SLRs, single-tablet regimens (STR) were associated with higher adherence versus multiple-tablet regimens. STRs were also associated with lower risk of treatment discontinuation, higher cost-effectiveness, and lower risk of hospitalization. Longer survival resulted in a high comorbidity burden, with non-AIDS causes accounting for 47% of deaths among PLWH in the US. HIV doubled the risk of cardiovascular disease and was associated with other health problems, including bone and muscle diseases, depression, and cancers. Several antiretroviral regimens were associated with chronic diseases, including cardiometabolic conditions. Lifetime HIV costs are substantially increasing, driven by antiretroviral, adverse event, and comorbidity treatment costs cumulated due to longer survival times.

Conclusions

There is a considerable burden associated with HIV and antiretroviral treatment, highlighting the benefits of less complex and safer regimens, and the unmet need for effective preventative interventions.

Association of inflammatory biomarkers and cardiovascular risk scores in an Italian cohort of HIV positive patient undergoing antiretroviral therapy

BACKGROUND

Several algorithms have been developed to predict cardiovascular risk (CVR) over time, however none of them seem to be accurate when applied to HIV patients.

OBJECTIVE

The aim of this study was to assess plasma inflammatory biomarkers in relation to multiple CVR scores (FRS, ASCVD, PROCAM and the DAD-5 Years-Estimated-Risk) in an Italian cohort of HIV patients undergoing a combined Antiretroviral Therapy (cART).

METHODS

We enrolled HIV patients undergoing cART without any change in the HIV-related pharmacological therapy over the last 48 weeks Demographic and anamnestic data were collected, and a biochemical panel including the following biomarkers was collected: CRP, Cystatin-C, microalbuminuria, IL-18, IL-2, IL-4, IL-6, IL-10, TNF-α and IFN- γ. CVR scores were obtained for each patient and compared to the biochemical panel to assess statistical correlation.

RESULTS

90 Caucasian HIV patients were enrolled. Assessment of CVR scores showed FRS values of 6.98±6.11%, ASCVD 7.18±6.25%, PROCAM 6.7±7.4% and DAD-5 Years Estimated Risk 3.10±3.41%. We found correlations between the levels of circulating cytokines measured and the cardiovascular risk prediction scores.

CONCLUSIONS

Our data showed that the values of selected inflammatory biomarkers strongly correlate with the CVR scores, suggesting that they can be employed as reliable predictors of cardiovascular disease in HIV patients. The routine use of selected biomarkers associated with systemic inflammation could be a valid and readily available tool for clinicians to assess and monitor cardiovascular risk in HIV patients.

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HIV-1 therapeutic vaccines in clinical development to intensify or replace antiretroviral therapy: the promising results of the Tat vaccine

INTRODUCTION

Upon the introduction of the combination antiretroviral therapy (cART), HIV infection has become a chronic disease. However, cART is unable to eradicate the virus and fails to restore the CD4 counts in about 30% of the treated individuals. Furthermore, treatment is life-long, and it does not protect from morbidities typically observed in the elderly. Therapeutic vaccines represent the most cost-effective intervention to intensify or replace cART.

AREAS COVERED

Here, we briefly discuss the obstacles to the development and evaluation of the efficacy of therapeutic vaccines and review recent approaches evaluated in clinical trials.

EXPERT OPINION

Although vaccines were generally safe and immunogenic, evidence of efficacy was negligible or marginal in most trials. A notable exception is the therapeutic Tat vaccine approach showing promising results of cART intensification, with CD4 T-cell increase and proviral load reduction beyond those afforded by cART alone. Rationale and evidence in support of choosing Tat as the vaccine target are thoroughly discussed.

Prevalence, Demographic Correlates, and Medical Correlates of Cognitive Impairment Among Iranian People Living With HIV: A Cross-sectional Survey Study

ABSTRACT

While taking antiretroviral therapy, 30%-60% of people living with HIV (PLWH) experience neurocognitive impairment (NCI). To determine NCI prevalence among Iranian PLWH, by the computerized Vienna Test System, 63 adults living without HIV and 63 Iranian PLWH aged 18-50 years (M = 35.3, SD = 7.9) were assessed for cognitive function. NCI was determined by receiver operating characteristic curve cutoff points based on the adults living without HIV. Associations between demographics, HIV serostatus markers, and mean T-scores were investigated. Performance differences were tested by including significant covariates in an analysis of covariance. NCI prevalence rates were 57.14% in PLWH and 19.05% in adults living without HIV. Global neurocognitive performance and all cognitive domains were significantly different between the groups, except for visual memory and selective attention. In Iran, NCI prevalence parallels that reported in PLWH worldwide. There should be a strategy to screen Iranian PLWH for NCI.

Does improvement in the environmental sustainability rating help to reduce the COVID-19 cases? Controlling financial development, price level and carbon damages

The study's objective is to evaluate the impact of environmental sustainability rating, financial development, changes in the price level and carbon damages on the new COVID-19 cases in a cross-sectional panel of 17 countries. The study developed two broad models to analyse the relationship between the stated factors at the current level and forecast level. The results show that improvement in the environmental sustainability rating and financial efficiency reduces the COVID-19 cases, while continued economic growth and changes in price level likely to exacerbate the COVID-19 cases across countries. The forecast results suggest the U-shaped relationship between COVID-19 cases and carbon damages controlling financial development, price level and environmental sustainability rating. The variance decomposition analysis shows that carbon damages, environmental sustainability rating and price level changes will largely influence COVID-19 cases over the next year. The soundness of economic and ecological regulated policies would be helpful to contain coronavirus cases globally.

Cost-effectiveness and budget impact of dolutegravir/lamivudine for treatment of human immunodeficiency virus (HIV-1) infection in the United States

BACKGROUND: Dolutegravir(DTG)/lamivudine(3TC) is the first 2-drug regimen recommended as an initial treatment for people living with HIV (PLHIV). OBJECTIVE: To assess the cost-effectiveness and potential budget impact of DTG/3TC in the US healthcare setting. METHODS: A previously published hybrid decision-tree and Markov cohort state transition model was adapted to estimate the incremental costs and health outcome benefits over a patients' lifetime. DTG/3TC was compared with current standard of care in treatment naive and treatment experienced virologically suppressed PLHIV. Health states included in the model were based upon virologic response and CD4 cell count, with death as an absorbing state. Clinical data was informed by the Phase III GEMINI 1 and 2 clinical trials, a published network meta-analysis (NMA) in treatment-naive patients and the Phase III TANGO clinical trial in treatment experienced patients. Costs and utilities were informed by published data and discounted annually at a rate of 3%. A separate 5-year budget impact analysis was conducted assuming 5%-15% uptake in eligible treatment naive and 10%-30% uptake in eligible treatment experienced patients. RESULTS: In the treatment naive analyses based on GEMINI 1 and 2, DTG/3TC dominated, i.e., was less costly and more effective, than all comparators. DTG/3TC resulted in 0.083 incremental quality-adjusted life-years (QALYs) at a cost saving of $199,166 compared with the DTG + tenofovir disoproxil(TDF)/emtricitabine(FTC) comparator arm. The incremental QALY and cost savings for DTG/3TC compared with DTG/abacavir(ABC)/3TC, cobicistat-boosted darunavir(DRV/c)/tenofovir alafenamide(TAF)/FTC, and bictegravir (BIC)/TAF/FTC, based on NMA results were 0.465, 0.142, and 0.698, and $42,948, $122,846, and $44,962, respectively. In the analyses of treatment-experienced virologically suppressed patients based on TANGO, DTG/3TC offered slightly lower QALYs (-0.037) with an estimated savings of $78,730 when compared with continuation of TAF-based regimen (TBR). Sensitivity analyses demonstrated that these conclusions were relatively insensitive to alternative parameter estimates. The budget impact analysis estimated that by 5th year a total of 70,240 treatment naive patients and 1,340,480 treatment experienced patients could be eligible to be prescribed DTG/3TC. The estimated budget savings over 5 years ranged from $1.12b to $3.35b (corresponding to 27,512 to 82,536 on DTG/3TC by year 5) in the lowest and highest uptake scenarios, respectively. CONCLUSION: In conclusion, DTG/3TC with its comparable efficacy and lower drug acquisition costs, has the potential to offer significant cost savings to US healthcare payers for the initial treatment of treatment naive patients and as a treatment switching option for virologically suppressed patients. DISCLOSURES: This study was funded in full by ViiV healthcare, Brentford, UK. Medical writing to support this study was also funded in full by ViiV Healthcare, Brentford, UK. Butler, Hayward, and Jacob are employees of HEOR Ltd, the company performing this study funded by ViiV Healthcare. Anderson is an employee of GlaxoSmithKline and owns shares in the company. Punekar, Evitt, and Oglesby are employees of ViiV Healthcare and own stocks in GlaxoSmithKline.