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The American Journal of Managed Care December 2019
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Clinical Characteristics and Treatment Patterns Among US Patients With HIV
Julie L. Priest, MSPH; Tanya Burton, PhD; Cori Blauer-Peterson, MPH; Kate Andrade, MPH; and Alan Oglesby, MPH
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Clinical Characteristics and Treatment Patterns Among US Patients With HIV

Julie L. Priest, MSPH; Tanya Burton, PhD; Cori Blauer-Peterson, MPH; Kate Andrade, MPH; and Alan Oglesby, MPH
It is important to take into account individual complexities such as comorbidities and pill burden when selecting antiretroviral therapy regimens for individuals living with HIV.
ABSTRACT

Objectives: Describe the clinical characteristics and treatment patterns of patients with HIV-1 who have commercial or Medicare health insurance in the United States.

Study Design: Retrospective cohort study.

Methods: Administrative claims for adult commercial and Medicare health plan enrollees with evidence of HIV-1 and antiretroviral therapy (ART) between January 1, 2007, and March 31, 2017, were assessed. Current and previous complete ART regimens were identified using a claims-based algorithm. Results were stratified by treatment status and insurance type.

Results: Of 18,699 eligible patients, 5027 (27%) had no previous ART regimens; 15,275 (82%) had commercial insurance. Mean age was 47.5 years. Common comorbidities included hyperlipidemia, cardiovascular disease, hypertension, depression, and anxiety. The mean number of ART regimens was 1.43, with 31% of patients having 2 or more regimens. Mean (SD) daily pill burden was higher in patients with more than 1 ART regimen over time (5.7 [6.0] pills) or with Medicare insurance (9.2 [8.0] pills) than in patients with no previous ART (1.9 [4.4] pills) or with commercial insurance (3.7 [4.7] pills). Overall, 60% of patients achieved 90% or greater adherence to their ART regimen and 16% had a prescription filled for any contraindicated medication to an ART during their regimen.

Conclusions: This descriptive study demonstrated that people living with HIV enrolled in Medicare have a significant amount of comorbidities and total pill burden. Although advancements in ART have significantly improved life expectancy and quality of life for people living with HIV, it is important to take into account individual complexities such as comorbidities and pill burden when selecting ART regimens.

Am J Manag Care. 2019;25(12):580-586
Takeaway Points

Although advancements in antiretroviral therapy (ART) over the past few decades have significantly improved life expectancy and quality of life in patients with HIV, this retrospective cohort study:
  • Identified that people in the United States living with HIV, particularly those living longer with HIV and who are enrolled in Medicare, experience a high level of comorbidities and total medication burden
  • Demonstrated the complexity of people living with HIV in terms of overall disease burden and the need for individualized considerations for healthcare providers to select the most appropriate ART regimen to ensure long-term treatment success
HIV is a chronic viral infection that attacks CD4 T lymphocytes (T cells) and weakens the ability of infected patients to fight other infections and diseases. HIV represents a significant healthcare burden in the United States. As of 2016, more than 1 million Americans had received an HIV diagnosis and were living with HIV, and there were 15,807 deaths among people with HIV due to any cause that year.1 Although the rate of new HIV diagnoses has been declining since 2012, the number of Americans with newly diagnosed HIV was 38,739 in 2017.2

If left untreated, HIV can develop into AIDS.3 However, due to advances in antiretroviral therapy (ART), people living with HIV can achieve prolonged disease-free survival, sustained virologic suppression, CD4 cell repletion, and reduced rates of hospitalization if they maintain high adherence to their ART regimen.4-6 As a result, rates of HIV-related morbidity and mortality have been dramatically reduced, and HIV is now a largely manageable chronic disease.4,7,8 At the time of this study, an ART regimen consisted of a 3-drug combination of 2 nucleoside reverse transcriptase inhibitors (NRTIs) with either an integrase strand transfer inhibitor (INSTI), a nonnucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (PI).9

Although people living with HIV are now less likely to experience acute, life-threatening complications of HIV, there are still challenges to consider when managing a chronic disease that persists for decades. For example, people living with HIV have an increased risk of developing a range of comorbidities such as cardiovascular disease (CVD), cancer, kidney disease, liver disease, neurocognitive disease, and osteoporosis.10-12 Many of these comorbidities are associated with increasing age10,13 but may also result from an increased life span and resultant cumulative exposure to ART.10,14 The complex challenge of managing HIV with ART for life involves maintaining long-term control of HIV viral replication while simultaneously managing tolerability, toxicity, and drug-drug interactions, which can lead to reduced adherence.

The aim of the present study was to examine the demographics, clinical characteristics, and treatment patterns of people living with HIV using ART in the United States.

METHODS

Study Overview

This was a retrospective cohort study using administrative claims data for commercial and Medicare Advantage (herein referred to as Medicare) health plan enrollees with evidence of HIV in the Optum Research Database (ORD) between January 1, 2007, and March 31, 2017 (study period) (Figure 1). Informed consent and institutional review board approval were not needed because of the deidentified nature of the retrospective claims data source.

Data Source

Data sourced from the ORD included medical claims, pharmacy claims, socioeconomic status, and enrollment data. Medical claims or encounter data were collected for all types of provided services, including specialty, preventive, and office-based treatments, and complied with insurance industry standards. Pharmacy claims covered all outpatient prescriptions filled and covered by the health plan. Socioeconomic data came from various individual- and population-level databases.


 
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