A Comprehensive Approach to HIV Can Mitigate the US Burden, Reduce New Infections

Mitigating the burden of HIV in the United States means taking a more comprehensive approach to diagnosis, testing, and treatment of the disease, said a speaker at the National Association of Managed Care Physicians Virtual Spring Managed Care Forum.

Although the prevalence of HIV has been fairly stable in recent years, there are groups with a higher risk of infection and the United States faces a high burden between the number of new infections and the average annual cost to treat HIV with new antiretroviral therapies (ARTs).

Mitigating the burden means a more comprehensive approach to diagnosis, testing, and care, Gary Owens, MD, president of Gary Owens Associates, said during his session at the National Association of Managed Care Physicians Virtual Spring Managed Care Forum.

From 2014 to 2018, the number of HIV cases had only risen from 1.085 million to 1.173 million in people ≥ 13 years living with diagnosed or undiagnosed infection in the United States, but there is different risk for different groups. Risk is highest for Black gay and bisexual men, followed by Latino gay and bisexual men, White gay and bisexual men, and Black heterosexual women. There are also regions of the country that are more at risk. People aged 13 to 24 who live in the South are much more likely to account for a new case, representing approximately half of all new cases in this age group, according to Owens.

In general, the United States can do better. According to a Kaiser Family Foundation report, viral suppression rates in the United States (56%) are lower than they are in comparable high-income countries: United Kingdom (84%), Switzerland (84%), Sweden (83%), The Netherlands (77%), Germany (76%), Japan (75%), France (74%), Australia (74%), Austria (74%), Canada (70%), and Belgium (68%).

The early presentation of HIV has many nonspecific symptoms, such as fever, sore throat, rash, diarrhea, and headache.

“I could challenge all of us to probably name several viral illnesses, not including even COVID-19, that has overlap of many of these symptoms,” Owens said.

More than half of the individuals with early HIV infection are asymptomatic or have symptoms so minor they don’t think about them.

In the United States, there are 1.2 million individuals living with HIV, and in 2018 alone there were 36,400 new infections. In 2010 dollars, the average annual cost was $23,000 and the estimated lifetime cost of HIV treatments was $379,688, according to research by the CDC, and “obviously much more in terms of 2021 dollars."

A 2015 claims-based and actuarial study estimated that the life expectancy for a person who became infected with HIV at age 35 in 2012 was 29.5 years.1 The estimated discounted lifetime cost for this individual was $326,500, broken down as 60% for ARTs, 15% for other medications, and 25% for nondrug costs (eg, physician costs, hospital costs).

A 2020 study of costs between 2013 and 2017 for patients with HIV aged 25 to 69 years compared patients with HIV to a non-HIV population and found that the all-cause annual health care cost for the patients with HIV was almost 7 times higher.2 The study found that pharmacy utilization was a major contributor, mostly due to the high cost of antiretroviral therapy,” Owens said.

“The point is, payers, especially on the pharmacy side, are making a large annual lifetime investment, so these patients are reasonably healthy and help them live a normal life,” he said.

While early ART can decrease morbidity and prevent transmission, suboptimal engagement in care is compromising the impact these therapies can have. A 2016 study showed that, at existing levels of care engagement, there would be a projected 1.39 million new HIV infections costing $256 billion over 2 decades.3 However, enhanced testing with increased linkage to care could reduce HIV infections by 21% at a cost of $65,700 per quality-adjusted life-year (QALY) gained.

“But if you take a comprehensive approach and coupled enhanced testing, linkage to care, improved retention—so really going the full bore—you could reduce HIV incidence by 54% and mortality by almost two-thirds, 64%, and a cost-effectiveness ratio of under $50,000 per QALY,” Owens said. “What I’m really trying to point out here is it really does require a comprehensive approach.”

This is important to keep in mind, he said, because it can help payers inform a population health–based management strategy for this population, especially as the CDC has a goal to reduce new HIV infections by 75% by 2024 and by 90% by 2030.

To meet the CDC goals, payers need to put things in place to ensure there are no barriers to diagnose people with HIV as early as possible, treat people rapidly and effectively, prevent new transmissions using pre-exposure prophylaxis and syringe services programs, and respond quickly to potential HIV outbreaks to get needed prevention and treatment services to people who need them, Owens said.

“Payer engagement can really help to end this epidemic by 2030 by promptly linking individuals to care…finding innovative and effective ways to re-engage with the quarter of a million people who have the disease but are not receiving the necessary care…and then supporting those who are already in care and have not yet achieved viral suppression to achieve control of their virus,” Owen said.

References

1. Schackman BR, Fleishman JA, Su AE, et al. The lifetime medical cost savings from preventing HIV in the United States. Med Care. 2015;53(4):293-301. doi:10.1097/MLR.0000000000000308

2. Cohen JP, Beaubrun A, Ding Y, Wade RL, Hines DM. Estimation of the incremental cumulative cost of HIV compared with a non-HIV population. Pharmacoecon Open. 2020;4(4):687-696. doi:10.1007/s41669-020-00209-8

3. Shah M, Risher K, Berry SA, Dowdy DW. The epidemiologic and economic impact of improving HIV testing, linkage, and retention in care in the United States. Clin Infect Dis. 2016;62(2):220-229. doi:10.1093/cid/civ801