Antiretroviral Therapy Cost Effective in Reducing Hospital Costs and Raising Life Expectancy, Studies Show
The introduction of highly active antiretroviral therapy in the mid-1990s helped "drive down overall treatment expenditures for HIV patients" in the United States by 16% between 1996 and 1998, according to a new study sponsored by the Agency for Healthcare Research and Quality (AHRQ release, 3/14). Led by RAND Health and published in this week's New England Journal of Medicine, the study profiled 2,864 patients representative of all U.S. adults receiving HIV care in 1996, then followed them for up to 36 months, finding that the mean monthly expenditures per HIV patient on hospital and outpatient care and drug therapy dropped from $1,792 in 1996 to $1,359 in 1997. In addition, average annual expenditures fell from $20,300 per patient in 1996 to $18,300 in 1998, after adjusting for factors such as illness severity and patient deaths. Hospital care spending, then the largest category of expense, declined by 43%, although pharmaceutical expenditures rose by 33% over the same two-year period (New England Journal of Medicine, 3/15). Dr. Samuel Bozzette, an infectious disease specialist with the Veterans Affairs San Diego Healthcare System and lead author of the study, called antiretroviral drugs "a good value ... even at [high] prices," as they "save more than they cost" (Brown, Washington Post, 3/15). However, Bozzette cautioned that recent reports of drug treatment failures, coupled with study data showing that hospital expenditures were on the rise at the end of 1998, could mean that the demand for inpatient care "may be on the rebound for all HIV patient groups" (AHRQ release, 3/14).
Care and Cost Disparities for 'Underserved'
While all patient groups witnessed a decline in overall expenditures, hospital care costs remained the highest and pharmaceutical costs the lowest for "underserved" groups such as women, African Americans, patients with public health insurance and those who had not completed high school (New England Journal of Medicine, 3/15). Bozzette said the study found that "there is a clear economic consequence to unequal access to care, over and above the human costs." He explained, "Because patients in disadvantaged groups ended up in the hospital rather than on the newer drugs, their patterns of expenditure were just like those in the bad old days." AHRQ Director Dr. John Eisenberg said that his agency recently began a $45 million study aimed at finding the causes of and solutions to these disparities (RAND release, 3/14). In addition to raising questions over care disparities in the United States, the study is "likely to add to the fierce debate over how to expand access to HIV drugs for poor people and nations," AP/USA Today says. Christine Nadori, a medical officer for the international relief agency Doctors Without Borders, said the study "should spur efforts to broaden access," so that developing nations may also gain economic benefits from treating patients with antiretrovirals. Oxfam spokesperson Seth Amgott added that drug makers must continue efforts to cut anti-AIDS drug prices, saying, "A large part of the world is so poor that economic analysis won't justify something we all know is right, which is providing treatment to keep people alive" (AP/USA Today, 3/14).
Second Study Also Touts Drug Cost-Effectiveness
In a second study published in the New England Journal of Medicine, researchers from Massachusetts General Hospital and Harvard Medical School used a mathematical simulation model of HIV based on clinical data from major clinical trials and found that HIV treatment with a combination of three antiretroviral drugs (zidovudine, lamivudine and indinavir) increased life expectancy, adjusted for quality of life, from 1.53 to 2.91 years, compared to no therapy. With triple therapy, per-person lifetime costs rose from $45,460 to $77,300, and the incremental cost per quality-adjusted year of life gained was $23,000. Researchers determined a cost-effective ratio for the therapy to range from $13,000 to $23,000 per year of life gained, with the initial CD4+ cell count and drug costs "the most important determinants of costs, clinical benefits, and cost effectiveness." Among patients whose disease was less advanced, life expectancy gains were greater and the incremental costs per year of life lower with combination therapy (Freedberg et al., New England Journal of Medicine, 3/15). Dr. Kenneth Freedberg of Mass General, who directed the study, said, "There aren't a lot of things that we treat that are a lot more cost effective than this" (Ritter, Chicago Sun-Times, 3/15).
Improve Antiretroviral Availability
In an accompanying editorial, Dr. Robert Steinbrook writes that both studies "provide compelling evidence of the overall value of antiretroviral therapy for HIV infection." He adds that although "the progress against a once untreatable disease is evident," it is "limited," noting, "[O]ur goal as a society must be to reap the benefits of this progress by providing combination antiretroviral therapy to all who can be helped by it." Steinbrook highlights several tactics to improve availability of antiretroviral therapy for HIV-infected patients:
- Federal and state governments should continue to increase funding for AIDS drug assistance programs to improve the number of people that can be served.
- Government programs should negotiate with drug makers for additional price reductions and HIV drug discounts, and Medicaid should be expanded to cover more low-income individuals with HIV.
- The federal government should "link additional support for Medicaid and ADAPs to the creation of explicit standards for care" and care availability in states.
- Public health programs for HIV surveillance, testing and treatment referral should be expanded to identify those who do not know they are infected and those who know but are not receiving regular care (Steinbrook, New England Journal of Medicine, 3/15).