If your company operates in a developing country, AIDS is your business. While Africa has received the most attention, AIDS is also spreading swiftly in other parts of the world. Russia and Ukraine had the fastest-growing epidemics last year, and many experts believe China and India will suffer the next tidal wave of infection. Why should executives be concerned about AIDS? Because it is destroying the twin rationales of globalization strategy-cheap labor and fast-growing markets--in countries where people are heavily affected by the epidemic. Fortunately, investments in programs that prevent infection and provide treatment for employees who have HIV/AIDS are profitable for many businesses--that is, they lead to savings that outweigh the programs' costs. Due to the long latency period between HIV infection and the onset of AIDS symptoms, a company is not likely to see any of the costs of HIV/AIDS until five to ten years after an employee is infected. But executives can calculate the present value of epidemic-related costs by using the discount rate to weigh each cost according to its expected timing. That allows companies to think about expenses on HIV/AIDS prevention and treatment programs as investments rather than merely as costs. The authors found that the annual cost of AIDS to six corporations in South Africa and Botswana ranged from 0.4% to 5.9% of the wage bill. All six companies would have earned positive returns on their investments if they had provided employees with free treatment for HIV/AIDS in the form of highly active antiretroviral therapy (HAART), according to the mathematical model the authors used. The annual reduction in the AIDS "tax" would have been as much as 40.4%. The authors' conclusion? Fighting AIDS not only helps those infected; it also makes good business sense.
*BC Centre for Excellence in HIV/AIDS †Faculty of Health Sciences, Simon Fraser University ‡Division of AIDS, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
Treatment options and therapeutic guidelines have evolved substantially since highly active antiretroviral treatment (HAART) became the standard of HIV care in 1996. We conducted the present population-based analysis to characterize the determinants of direct costs of HAART over time in British Columbia, Canada.
We considered individuals ever receiving HAART in British Columbia from 1996 to 2011. Linear mixed-effects regression models were constructed to determine the effects of demographic indicators, clinical stage, and treatment characteristics on quarterly costs of HAART (in 2010$CDN) among individuals initiating in different temporal periods. The least-square mean values were estimated by CD4 category and over time for each temporal cohort.
Longitudinal data on HAART recipients (N = 9601, 17.6% female, mean age at initiation = 40.5) were analyzed. Multiple regression analyses identified demographics, treatment adherence, and pharmacological class to be independently associated with quarterly HAART costs. Higher CD4 cell counts were associated with modestly lower costs among pre-HAART initiators [least-square means (95% confidence interval), CD4 >?500: 4674 (4632-4716); CD4: 350-499: 4765 (4721-4809) CD4: 200-349: 4826 (4780-4871); CD4
Southern Alberta HIV/AIDS Clinic and the Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB. Harmut.Krentz@CalgaryHealthRegion.ca
Determining the direct cost of providing medical care to patients with HIV/AIDS is important for both short-term and long-term decision-making and for appropriate resource allocation. We aimed to categorize and measure the direct costs of medical care provided to the entire HIV-positive population receiving care in southern Alberta between 1995 and 2001.
We collected all patient-specific direct costs including the cost of pharmaceutical drugs (HIV and non-HIV drugs), outpatient care (including physician costs and laboratory testing), inpatient (in-hospital) care and home care (acute, long-term, palliative) from primary sources for all patients between April 1995 and April 2001. We determined cost per patient per month (PPPM) adjusted to 2001 Canadian dollars.
Since 1995, the direct cost of providing medical care to patients with HIV/AIDS has increased primarily as a result of increased antiretroviral drug costs both in absolute and in PPPM terms. Mean PPPM expenditures increased from 655 Canadian dollars in 1995/96, that is, before the use of highly active antiretroviral therapy (HAART), to 1036 Canadian dollars in 1997/98 when HAART was widely used. During the following 3 years, mean overall PPPM costs remained stable. Antiretroviral drugs accounted for 30% (198 Canadian dollars PPPM) of the total cost in 1995/96 increasing to 69% (775 Canadian dollars PPPM) in 2000/01. Inpatient, outpatient and home care costs decreased in both percentage and cost PPPM between 1995/96 and 2000/01 from 26% to 10%, 27% to 14% and 8% to 3% respectively.
The cost of providing medical care to HIV-positive patients continues to increase, although the burden of costs is distributed differently from before the introduction of HAART, with the costs of drug therapy offsetting the costs of inpatient care and home care. Careful consideration of all aspects of direct costing data is needed when any health economic policy issues are examined.
Notes
Cites: N Engl J Med. 2001 Mar 15;344(11):817-2311248159
Cites: AIDS Patient Care STDS. 2001 Jan;15(1):25-911177585
Cites: J Med Syst. 2001 Feb;25(1):73-8011288483
Cites: J Acquir Immune Defic Syndr. 2001 May 1;27(1):14-911404515
The aim of this study was to estimate the cost-effectiveness of atazanavir/ritonavir (atazanavir/r) versus lopinavir/ritonavir (lopinavir/r) in treatment-naïve human immunodeficiency virus-1 (HIV-1) patients in Sweden for whom efavirenz is not suitable.
A Markov model was developed to predict the lifetime outcomes of atazanavir/r and lopinavir/r in terms of quality-adjusted life years (QALYs) and total costs. The model was structured to focus on treatment lines--how patients progress from first- to second-, and then to third-line treatment. Model inputs were derived directly from clinical trials, such as the CASTLE study (a 96-week head-to-head trial in first-line therapy), and from the Framingham risk-equation. The analysis was conducted from a payer perspective and included extensive scenario and probabilistic sensitivity analyses.
The model predicted atazanavir/r to save 0.16 (95% confidence interval (CI) 0.00 to 0.33) QALYs and reduce total costs by -202,896 SEK (95% CI -332,156 to -81,644 SEK) over a lifetime horizon. Probabilistic sensitivity analyses showed that atazanavir/r had a 100% probability to be cost-effective at a willingness to pay of 200,000 SEK per QALY.
The results indicate that atazanavir/r is cost-saving and more effective compared to lopinavir/r for patients who have previously not been exposed to antiretroviral drugs in Sweden.
Cost effectiveness of darunavir/ritonavir 600/100 mg bid in protease inhibitor-experienced, HIV-1-infected adults in Belgium, Italy, Sweden and the UK.
Two phase II trials (POWER 1 and 2) have demonstrated that darunavir co-administered with low-dose ritonavir (DRV/r) provides significant clinical benefit compared with control protease inhibitors (PIs) in highly treatment-experienced, HIV-1-infected adults, when co-administered with optimized background therapy (OBR).
To determine whether DRV/r is cost effective compared with control PIs, from the perspective of Belgian, Italian, Swedish and UK reimbursement authorities, when used in treatment-experienced patients similar to those included in the POWER 1 and 2 trials.
An existing Markov model containing health states defined by CD4 cell count ranges (> 500, 351-500, 201-350, 101-200, 51-100 and 0-50 cells/mm³) and death was adapted for use in four European healthcare settings. Baseline demographics, CD4 cell count distribution and antiretroviral drug usage reflected those reported in the POWER 1 and 2 trials. Virological/immunological response rates and matching transition probabilities over the patient's lifetime were based on results from the POWER trials and published data. After treatment failure, patients were assumed to switch to a tipranavir-containing regimen plus OBR. For each CD4 cell count range, utility values and HIV-related mortality rates were obtained from the published literature. National all-cause mortality data and published data on the increased risk of non HIV-related mortality in HIV-infected individuals were taken into account in the model. Data from observational studies conducted in each healthcare setting were used to determine resource-use patterns and costs associated with each CD4 cell count range. Unit costs were derived from official local sources; a lifetime horizon was taken and discount rates were selected based on local guidelines.
In the base-case analysis, quality-adjusted life-year (QALY) gains of up to 1.397 in Belgium, over 1.171 in Italy, 1.142 in Sweden and 1.091 in the UK were predicted when DRV/r-based therapy was used instead of control PI-based treatment. The base-case analyses predicted an incremental cost-effectiveness ratio (ICER) of €11,438/QALY in Belgium, €12,122/QALY in Italy,€10,942/QALY in Sweden and €16,438/QALY in the UK. Assuming an acceptability threshold of €30,000/QALY, DRV/r-based therapy remained cost effective over all parameter ranges tested in extensive one-way sensitivity analyses. Probabilistic sensitivity analysis revealed a 95% (Belgium), 97% (Italy), 92% (Sweden) or 78% (UK) probability of attaining an ICER below this threshold.
From four European payer perspectives, DRV/r-based antiretroviral therapy is predicted to be cost effective compared with currently available control PIs, when both are used with an OBR in treatment-experienced, HIV-1-infected adults who failed to respond to more than one PI-containing regimen.
Cost effectiveness of darunavir/ritonavir 600/100 mg bid in treatment-experienced, lopinavir-naive, protease inhibitor-resistant, HIV-infected adults in Belgium, Italy, Sweden and the UK.
Using data from the phase IIb POWER trials, darunavir boosted with low-dose ritonavir (DRV/r; 600/100 mg twice daily; bid)-based highly active antiretroviral therapy (HAART) was shown to be significantly more efficacious and cost effective than other protease inhibitor (PI)-based therapy in highly treatment-experienced, HIV-1-infected adults. Furthermore, in the phase III TITAN trial (TMC114-C214), DRV/r 600/100 mg bid-based HAART generated a superior 48-week virological response rate compared with standard-of-care lopinavir/ritonavir (LPV/r; 400/100 mg bid)-based therapy in treatment-experienced, lopinavir-naive patients, and in particular those with one or more International AIDS Society - USA (IAS-USA) primary PI resistance-associated mutations at baseline. These patients had a broader degree of previous PI use/failure (0 - = 2) than the POWER patients.
To determine whether DRV/r 600/100 mg bid-based HAART is cost effective compared with LPV/r-based therapy, from the perspective of Belgian, Italian, Swedish and UK reimbursement authorities, when used in treatment-experienced patients similar to TITAN patients with one or more IAS-USA primary PI mutations at baseline.
An existing Markov model containing health states defined by CD4 cell count ranges (>500, 351-500, 201-350, 101-200, 51-100 and 0-50 cells/mm³) and an absorbing state of death was adapted for use in the above-mentioned healthcare settings. Baseline demographics, CD4 cell count distribution, antiretroviral drug usage, virological/immunological response rates and matching transition probabilities were based on data collected during the first 48 weeks of therapy in the modelled subgroup of TITAN patients and the published literature. After treatment failure, patients were assumed to switch to a follow-on combination regimen. For each health state, utility values and mortality rates were obtained from the published literature. Data from local observational studies (Belgium, Sweden and Italy) or the published literature (UK) were used to determine resource-use patterns and costs associated with each CD4 cell count range. Unit costs were derived from official local sources; a lifetime horizon was taken and discount rates were chosen based on local guidelines.
The base-case analysis predicted quality-adjusted life year (QALY) gains of 0.785 in Belgium, 0.608 in Italy, 0.584 in Sweden and 0.550 in the UK when DRV/r-based therapy was used instead of LPV/r-based treatment. The estimated base-case incremental cost-effectiveness ratios (ICERs) were €6964/QALY gained in Belgium, €9277/QALY gained in Italy, €6868 (SEK69,687)/QALY gained in Sweden and €14,778 (£12?612)/QALY gained in the UK. Assuming a threshold of €30,000/QALY gained, DRV/r-based therapy remained cost effective over most parameter ranges tested in extensive one-way sensitivity analyses. The variation of immunological response rates and the time horizon were identified as important drivers of cost effectiveness. Probabilistic sensitivity analysis revealed a greater than 70% probability of achieving an ICER below this threshold in all four healthcare settings.
From the perspective of Belgian, Italian, Swedish and UK payers, DRV/r 600/100 mg bid-based HAART is predicted to be cost effective compared with LPV/r 400/100 mg bid-based therapy, when used to manage treatment experienced, lopinavir-naive, PI-resistant, HIV-infected adults with a broad range of previous PI use/failure.
To estimate the cost-effectiveness ratio of highly-active antiretroviral therapy (HAART) in Canada.
A before-and-after analysis to calculate incremental cost of life year gained (LYG) between 1991 and 1995 (pre-HAART period) and between 1997 and 2001 (HAART period) for non-AIDS and AIDS groups (CDC stage of HIV infection).
For two Quebec HIV hospital clinics, mean inpatient (IP) days, outpatient (OP) visits and direct health care costs per patient-year (PPY) were calculated. Cox's proportional hazards models calculated disease progression, stratified by study periods and adjusted for gender, age at cohort entry, sexual orientation, injecting drug use and baseline CD4 cell count.
For non-AIDS patients, mean IP days was 1.6 (pre-HAART period) compared with 0.8 PPY (HAART period); mean OP visits increased from 2.8 to 5.5 PPY. Total cost was US$ 4265 (pre-HAART period) and US$ 9445 PPY (HAART period) of which 66 and 84%, respectively were spent on antiretroviral drugs. Median progression time was 6.3 years in the pre-HAART period compared with 12.5 years in HAART period (log rank chi = 270, P
To report on the cost of medical care for HIV-infected patients stratified by CD4 cell count for a regional population over a 9-year period, and to examine the effect of reporting costs of HIV care only or only in antiretroviral therapy (ART)-experienced patients.
Retrospective costing analysis on all HIV-infected patients within the Southern Alberta Cohort from April 1997 to April 2006. Costs for all drugs (ART/non-ART), in-patient (HIV/non-HIV) and out-patient care were obtained from primary sources. Costs were aggregated by patient's CD4 cell count and ART exposure and presented as mean cost per patient per month (PPPM) in 2006 Canadian dollars.
The number of patients and annual costs increased by 74% and 69%, respectively. Overall mean PPPM costs increased slightly from $1082 in 1997/1998 to $1159 in 2005/2006. PPPM costs for patients with CD4 counts 500, 201-500 and 76-200 cells/microL remained relatively stable at $979, $1057 and $1294, respectively. In-patient hospitalization costs account for most of the cost increases. Reporting costs using only ART-experienced patients would overestimate total costs by 2-9%. Costs for only HIV care were 10-24% lower than total care costs.
Care costs have remained relatively stable for most HIV patients except those with CD4 counts
To assess the effectiveness and cost-effectiveness of treating HIV-infected injection drug users (IDUs) and non-IDUs in Russia with highly active antiretroviral therapy HAART.
A dynamic HIV epidemic model was developed for a population of IDUs and non-IDUs. The location for the study was St. Petersburg, Russia. The adult population aged 15 to 49 years was subdivided on the basis of injection drug use and HIV status. HIV treatment targeted to IDUs and non-IDUs, and untargeted treatment interventions were considered. Health care costs and quality-adjusted life years (QALYs) experienced in the population were measured, and HIV prevalence, HIV infections averted, and incremental cost-effectiveness ratios of different HAART strategies were calculated.
With no incremental HAART programs, HIV prevalence reached 64% among IDUs and 1.7% among non-IDUs after 20 years. If treatment were targeted to IDUs, over 40 000 infections would be prevented (75% among non-IDUs), adding 650 000 QALYs at a cost of USD 1501 per QALY gained. If treatment were targeted to non-IDUs, fewer than 10 000 infections would be prevented, adding 400 000 QALYs at a cost of USD 2572 per QALY gained. Untargeted strategies prevented the most infections, adding 950 000 QALYs at a cost of USD 1827 per QALY gained. Our results were sensitive to HIV transmission parameters.
Expanded use of antiretroviral therapy in St. Petersburg, Russia would generate enormous population-wide health benefits and be economically efficient. Exclusively treating non-IDUs provided the least health benefit, and was the least economically efficient. Our findings highlight the urgency of initiating HAART for both IDUs and non-IDUs in Russia.
