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Weighing Management Strategies for HIV Medication Safety, Cost


While medical advances have improved lifespan and quality of life for patients with HIV, there are still opportunities for strategies that address both medication safety and costs.

Thanks to significant medical advances, such as antiretroviral therapy (ART), HIV is now considered a chronic disease, and the United States is seeing an aging HIV population with improved quality of life, as well as improved medication safety profiles and tolerability. But at the same time, costs for these patients are significant, according to a session at the Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting.

Compared with people without infection, people living with HIV have aggregate costs that are $10.7 billion higher due to outpatient, emergency department, home care, and medication costs. Across these factors, medications account for the majority of spending for HIV, with patients having an average lifetime medical cost of $326,500, explained Adana Oragwu, PharmD, BCPS, AAHIVP, infectious disease clinical pharmacy specialist, Kaiser Permanente Georgia.

“We now have more individuals with access to healthcare, and the cost for HIV is not decreasing,” said Oragwu. “So, what strategies can we implement to overcome increasing healthcare costs?”

In addition to management strategies to contain these costs, there are also opportunities for ensuring patient safety, explained Desola Davis, PharmD, BCPS, BCACP, clinical pharmacy specialist, drug utilization, Kaiser Permanente Georgia.

Davis started with opportunities that arise when new medication safety information becomes available. She used the example of dolutegravir, which was found have an increased risk of neural tube defects in infants born to women on the drug at the time of conception from preliminary data of a Botswana-based study. As a result, guidelines were updated to offer guidance for clinicians using the drug in that patient population. The guidelines now recommend against using the drug in pregnant women within 12 weeks of conception or in women of childbearing age who can’t use effective contraception or are contemplating pregnancy at the time.

Recent data have also shown that tenofovir alfenamide (TAF) and TAF-containing products have a lower risk of bone and kidney toxicities compared with tenofovir disoproxil fumarate (TDF) equivalents. As a result, guidelines have been adjusted to recommended TAF products over TDF equivalents.

As Davis moved on to cost-management opportunities, it became clear that these strategies were not as straightforward. When thinking of containing costs, the first opportunity that likely comes to mind is the use of generics.

It’s been estimated by a simulation study1 that that use of 1 generic medication in an ART regimen could save over $500 million in the first year, use of 2 generic medications in a regimen could save $560 million, and use of 3 generic medications could save $920 million. However, while the cost savings is appealing, there are barriers to use of these generics. For example, the simulation study found that a 3-pill regimen of generics led to a higher risk of virologic failure.

Also, while 1 drug in a multidrug single-tablet regimen might have a generic alternative on the market, if the other drugs are still on patent, the patent life of the brand medication is extended. The most notable example of this is Truvada, which is commonly used for pre-exposure prophylaxis but is also approved for the treatment of HIV. While TDF is available as a generic, emtricitabine is not.

With no generic single-tablet regimen available, incorporating a generic medication into a patient’s treatment would mean a multi-tablet regimen, which would create increased pill burden and likely impact medication adherence.

Davis also noted that, at this point, the cost of HIV regimens is not universal, and some organizations might look at their budget and determine that using generics would not have enough of an impact for them to switch from the brand-name drug.

Oragwu rounded up the session by highlighting a management strategy we hear of often that demonstrates improved patient outcomes with no caveats: medication adherence.

When patients with HIV effectively adhere to their medication regimen, they have improved immune function and viral suppression, decreased medication resistance, decreased morbidity and mortality, and decreased overall healthcare costs.

Highlighting an adherence initiative from Kaiser Permanente Georgia, Oragwu explained that using the organization’s HIV registry embedded in the electronic medical record, they create reports that identify patients who are overdue for their medication refill and reach out either through a letter or email or through a phone call from a certified pharmacy technician.

Launched in October 2018, preliminary data showed a 2% improvement in undetectable viral load, more patients linked back into care, and opportunity for optimization of regimens based on what patient feedback.


Walensky R, Sax P, Nakamura Y, et al. Economic savings versus health losses: the cost-effectiveness of generic antiretroviral therapy in the United States [published online January 15, 2013]. Ann Intern Med. doi: 10.7326/0003-4819-158-2-201301150-00002.

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