Costs of Living With HIV Can Be Mitigated by Rapid Initiation of ART Post Diagnosis

Christina Mattina

A trio of posters presented at the Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting show that high healthcare utilization leads to substantial costs among individuals living with HIV, but prompt initiation of antiretroviral therapy (ART) regimens after diagnosis can help contain costs in both Medicaid-covered and commercially insured patients.

In a poster describing an analysis of multistate Medicaid data combined with results of a literature review,1 researchers estimated the costs of healthcare resource utilization among patients living with HIV in the United States. These costs were comprised of costs per inpatient day and costs per emergency department (ED) and outpatient visit. Outpatient care included services from general care providers and specialists, HIV care, and procedural and social services.

In an interview with The American Journal of Managed Care®, Keith J. Dunn, PharmD, BCPS, AAHIVE, of Janssen, senior author of the 3 posters, explained that the researchers conducted the literature review in combination with the Medicaid claims data analysis “because Medicaid currently covers about 25% of patients living with HIV, so it’s certainly important to examine that population, and while we had claims data from over 21,000 enrollees living with HIV in the Medicaid database, that claims data really only comes from 6 states in this particular database. So we used the targeted literature review to compare the administrative costs identified from the Medicaid claims data with that of a more diverse population.”

From the 21,513 Medicaid claims analyzed, the researchers found that mean costs were $2035 per inpatient day, $212 per ED visit, and $85 per outpatient visit. Within the 7 US studies identified by the targeted literature review, mean costs for those 3 types of utilization ranged from $1849 to $3451, $704 to $828, and $130 to $417, respectively.

Because the literature review was not limited to Medicaid data, the authors noted that mean costs for inpatient days were similar in both Medicaid and the broader US population, but Medicaid had lower costs for outpatient and ED visits. This “could be related to changes in treatment guidelines and in the provision of healthcare services, as well as improvements in overall health” in this population, they wrote.

“Combining both sources provided a robust range of costs for [people living with HIV], which is important for decision-makers,” the authors concluded. They suggested that further research could explore the financial effects of changing treatment guidelines and use of new single-tablet regimens.

“Understanding the differences between the administrative claims data and the data in the public domain through the targeted literature review is important because when we look at costs associated with healthcare resource utilization in different data sets or clinical trials, we may be able to use the range to conduct various sensitivity analyses, as costs can vary across payer channel,” Dunn added.

Another poster explored healthcare costs of Medicaid patients with HIV, specifically focusing on how quickly they began ART after being diagnosed with HIV-1.2 Dunn defined rapid initiation as a new paradigm in which “providers start treatment prior to having full laboratory results or resistance testing records available.”

According to Dunn, the researchers looked at the economic impacts of rapid initiation because “previous studies have shown that when you start patients rapidly, they have a higher rate of retention in care, so coming back to see the doctor; improvements in virologic outcomes, like decreased time to virologic suppression; and decreased rates of morbidity and mortality.”

The 627 eligible patients were separated into 4 cohorts based on their time to ART initiation post diagnosis; 20.4% were rapid initiators (RI; ≤14 days), 36.4% were moderately rapid initiators (mRI; 15-60 days), 26.0% were moderately delayed initiators (mDI; 61-180 days), and 17.2% were delayed initiators (DI; 181-360 days).

Dunn noted that the 7-day mark is the widely accepted definition of rapid initiation in sources like the World Health Organization guidelines, but the authors’ use of the 14-day mark to define rapid initiation in this cohort was due to longer times to initiation seen among Medicaid patients.

“We actually had to change the window in which we defined rapid initiation in the Medicaid population, from 7 days to 14 days, because there were so few patients starting treatment within 7 days,” Dunn said.

Medical costs increased across all follow-up time points after diagnosis, but they were always greater among the DI group than the RI group (6 months, $9124 vs $7757; 12 months, $15,989 vs $10,836; 24 months, $27,797 vs $16,220; 36 months, $43,067 vs $23,447, respectively). DI patients had lower pharmacy costs, and the medical costs of the DI/mDI patients accounted for more than half of their total healthcare costs, whereas the RI/mRI patients had pharmacy costs that were higher than their medical costs.

By the time of follow-up at 36 months post diagnosis, the increased pharmacy costs in the RI group were offset by lower medical costs, resulting in lower total healthcare costs compared with their DI counterparts (DI, $83,157; RI, $74,093). These results highlight “the long-term economic benefits of rapid ART initiation post–HIV-1 diagnosis,” the authors wrote.

To make rapid initiation the standard of care, and potentially lower downstream spending by Medicaid, the authors suggested that future efforts should focus on “reducing barriers to treatment initiation, such as time spent waiting for test results and counseling.”

Finally, another poster looked at characteristics of and healthcare costs among commercially insured US patients with HIV who were treated within 60 days of diagnosis.3 This was among the first studies to specifically examine the financial implications of ART initiation timeliness in patients with commercial insurance, who comprise a larger proportion of the population with HIV than the Medicaid patients who are more commonly examined in similar cost-related studies.

In this study, the RI group was defined as patients who started ART therapy within 7 days of diagnosis, whereas the mRI group included those who started between 8 and 60 days after diagnosis.

Of the 6743 eligible patients, 18.3% were RI and 81.7% were mRI. Nearly three-quarters (74.3%) were started on single-tablet regimens. RI patients were more likely to start on protease inhibitor–based regimens, mRI patients were more likely to start on integrase strand transfer inhibitor–based regimens, and the groups were equally likely to start nonnucleoside reverse transcriptase inhibitor–based regimens. Total healthcare costs, defined as the sum of medical and pharmacy costs, were lower in the RI group than in the mRI group ($109,456 vs $116,870, respectively) over the 36 months after diagnosis.

The authors pointed to opportunities for improvement in ART initiation, including increasing the percentage of patients who start therapy within 7 days. They also noted that many of the RI patients used agents considered “suboptimal” due to their “low rather than high genetic barrier to resistance, demonstrating a need to optimize HIV treatment with antiretrovirals having high genetic barrier to resistance.” They suggested that “opportunities exist to educate healthcare providers about which antiretrovirals have a high genetic barrier to resistance, have fewer testing barriers, and can provide adherence benefits through their availability in single-tablet form.”

The message that rapid initiation of ART was associated with lower healthcare costs “is really important because some payers are looking at formulary management and trying to contain access to various regimens,” said Dunn.

“These findings highlight the importance of starting treatment rapidly after diagnosis and should hopefully encourage payers to provide unrestricted access to HIV treatment options that are recommended for rapid initiation per national and international treatment guidelines,” he said. “If there are active management strategies put in place like prior authorization or preferred tiering, that may result in further delayed receipt of care and also really prevent rapid initiation from taking place.”

Dunn noted that these newly published cost data will be used to inform the results of the ongoing phase 3 DIAMOND study, which is “evaluating the efficacy and safety of rapidly starting Symtuza [darunavir, cobicistat, emtricitabine, and tenofovir alafenamide], which is one single-tablet regimen that can be utilized in treatment by these patients and certain virologically suppressed patients, and in this particular study, we are looking to examine the efficacy and safety of Symtuza in patients who rapidly start treatment.”

1. Benson C, Emond B, Lefebvre P, et al. Estimating costs of health resource utilization for patients living with human immunodeficiency virus. Poster presented at: Academy of Managed Care & Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA.
2. Benson C, Emond B, Romdhani H, et al. Long-term benefits of rapid antiretroviral therapy initiation among Medicaid-covered patients with human immunodeficiency virus. Poster presented at: Academy of Managed Care & Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA.
3. Benson C, Emond B, Lefebvre P, et al. Rapid initiation of antiretroviral treatment following diagnosis of human immunodeficiency virus among commercially insured patients in the United States. Poster presented at: Academy of Managed Care & Specialty Pharmacy Annual Meeting; March 25-28, 2019; San Diego, CA.
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