Cost Saving Interventions to Offset Expenses With ART Use
Objectives Combination antiretroviral therapy (cART) has become the main driver of total costs of caring for persons living with HIV (PLHIV). The present study estimated the short/medium-term cost trends in response to the recent evolution of national guidelines and regional therapeutic protocols for cART in Italy.
Methods We developed a deterministic mathematical model that was calibrated using epidemic data for Lazio, a region located in central Italy with about six million inhabitants.
Results In the Base Case Scenario, the estimated number of PLHIV in the Lazio region increased over the period 2012–2016 from 14 414 to 17 179. Over the same period, the average projected annual cost for treating the HIV-infected population was €147.0 million. An earlier cART initiation resulted in a rise of 2.3% in the average estimated annual cost, whereas an increase from 27% to 50% in the proportion of naïve subjects starting cART with a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen resulted in a reduction of 0.3%. Simplification strategies based on NNRTIs co-formulated in a single tablet regimen and protease inhibitor/ritonavir-boosted monotherapy produced an overall reduction in average annual costs of 1.5%. A further average saving of 3.3% resulted from the introduction of generic antiretroviral drugs.
Conclusions In the medium term, cost saving interventions could finance the increase in costs resulting from the inertial growth in the number of patients requiring treatment and from the earlier treatment initiation recommended in recent guidelines.
The widespread adoption in clinical practice of combination antiretroviral therapy (cART) has produced a substantial increase in the survival of persons living with HIV (PLHIV), and has also provided good value for money as shown in a number of cost-effectiveness studies.
Longer survival has resulted in a rise in lifetime costs at the individual level, as well as in the total annual costs of treating an HIV-infected population. Costs for antiretroviral (ARV) drugs have also increased, to the point that they account for most (about 70%) of the overall direct costing budget. Therefore, clinical prescription practices regarding the use of ARV drugs have become crucial determinants of the total costs for treating PLHIV in resource-rich countries.
Accumulated evidence suggests that starting treatment earlier in the course of HIV disease may reduce AIDS- and non-AIDS-associated morbidity and mortality, and may decrease the risk of sexual transmission of infection, with a potential impact on the future course of the epidemic. Based on this evidence, several guidelines now recommend also offering cART to patients with a lower level of immunosuppression, and the strategy of treating all individuals diagnosed with HIV infection, regardless of CD4 cell count, has recently gained momentum. The sustainability for health care systems, even in resource-rich countries, of the increasing cost of care that may be associated in the short to medium term with these changes in the policy of ARV use is yet to be investigated in detail.
A series of treatment strategies, including simplification to nonnucleoside reverse transcriptase inhibitors (NNRTIs) co-formulated in a single tablet regimen (STR) and to protease inhibitor/ritonavir-boosted (PI/r) monotherapy, have been proposed to curb the increase in treatment costs while retaining individual benefits, and some local health authorities in charge of health care budgets have already issued recommendations to reconcile national guidelines with the objective of ensuring affordable and high-quality care for PLHIV.
The objective of the present study was to analyse short/medium-term cost trends in response to the evolution of clinical practices in HIV care, in order to provide data useful for health policy makers in optimizing the allocation of scarce resources for managing HIV disease. To this end, we examined, using a mathematical model, the impact of guidelines issued in 2011 on the costs of treating an HIV-infected population over the period 2012–2016 in an Italian region, with a focus on costs of ARV drugs.
Abstract and Introduction
Abstract
Objectives Combination antiretroviral therapy (cART) has become the main driver of total costs of caring for persons living with HIV (PLHIV). The present study estimated the short/medium-term cost trends in response to the recent evolution of national guidelines and regional therapeutic protocols for cART in Italy.
Methods We developed a deterministic mathematical model that was calibrated using epidemic data for Lazio, a region located in central Italy with about six million inhabitants.
Results In the Base Case Scenario, the estimated number of PLHIV in the Lazio region increased over the period 2012–2016 from 14 414 to 17 179. Over the same period, the average projected annual cost for treating the HIV-infected population was €147.0 million. An earlier cART initiation resulted in a rise of 2.3% in the average estimated annual cost, whereas an increase from 27% to 50% in the proportion of naïve subjects starting cART with a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen resulted in a reduction of 0.3%. Simplification strategies based on NNRTIs co-formulated in a single tablet regimen and protease inhibitor/ritonavir-boosted monotherapy produced an overall reduction in average annual costs of 1.5%. A further average saving of 3.3% resulted from the introduction of generic antiretroviral drugs.
Conclusions In the medium term, cost saving interventions could finance the increase in costs resulting from the inertial growth in the number of patients requiring treatment and from the earlier treatment initiation recommended in recent guidelines.
Introduction
The widespread adoption in clinical practice of combination antiretroviral therapy (cART) has produced a substantial increase in the survival of persons living with HIV (PLHIV), and has also provided good value for money as shown in a number of cost-effectiveness studies.
Longer survival has resulted in a rise in lifetime costs at the individual level, as well as in the total annual costs of treating an HIV-infected population. Costs for antiretroviral (ARV) drugs have also increased, to the point that they account for most (about 70%) of the overall direct costing budget. Therefore, clinical prescription practices regarding the use of ARV drugs have become crucial determinants of the total costs for treating PLHIV in resource-rich countries.
Accumulated evidence suggests that starting treatment earlier in the course of HIV disease may reduce AIDS- and non-AIDS-associated morbidity and mortality, and may decrease the risk of sexual transmission of infection, with a potential impact on the future course of the epidemic. Based on this evidence, several guidelines now recommend also offering cART to patients with a lower level of immunosuppression, and the strategy of treating all individuals diagnosed with HIV infection, regardless of CD4 cell count, has recently gained momentum. The sustainability for health care systems, even in resource-rich countries, of the increasing cost of care that may be associated in the short to medium term with these changes in the policy of ARV use is yet to be investigated in detail.
A series of treatment strategies, including simplification to nonnucleoside reverse transcriptase inhibitors (NNRTIs) co-formulated in a single tablet regimen (STR) and to protease inhibitor/ritonavir-boosted (PI/r) monotherapy, have been proposed to curb the increase in treatment costs while retaining individual benefits, and some local health authorities in charge of health care budgets have already issued recommendations to reconcile national guidelines with the objective of ensuring affordable and high-quality care for PLHIV.
The objective of the present study was to analyse short/medium-term cost trends in response to the evolution of clinical practices in HIV care, in order to provide data useful for health policy makers in optimizing the allocation of scarce resources for managing HIV disease. To this end, we examined, using a mathematical model, the impact of guidelines issued in 2011 on the costs of treating an HIV-infected population over the period 2012–2016 in an Italian region, with a focus on costs of ARV drugs.
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