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Financial Stress: Impact on HIV Adherence, HCV and Prescribing Patterns

October 30, 2012

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Money and Access

Co-payments such as dispensing fees are not unique to Australia. In Canada, some pharmacies waive such payments and some provincial and territorial health plans as well as private insurers cover all or part of such fees. Also, the cost of medicines to treat catastrophic illnesses such as HIV and hepatitis C virus (HCV) infection is generally covered by Canada's provinces and territories, though specific coverage of particular drugs may come with restrictions that can vary from one province or territory to another.

A 2007 survey of 5,723 Canadians found that about 10% reported non-adherence to prescription medicines because of drug costs. People most likely to report non-adherence to medicines because of cost generally had the following profile:

  • poor health
  • low income
  • no drug payment insurance

Issues Related to Hepatitis C Virus


In 2008, researchers in Halifax, Nova Scotia, interviewed 50 participants with HCV infection. They found that participants took a range of prescribed medicines to treat multiple conditions, including the following:

  • mental health issues, particularly anxiety and depression
  • higher-than-normal blood pressure
  • inflammation

Nearly 60% of participants were concerned about financial stress and their ability to pay for prescribed medicines. Participants developed a variety of strategies to cope, including borrowing money, delaying the purchase of drugs and asking their health care provider for a cheaper substitute for an expensive drug. Some participants were uncomfortable discussing cost issues with their physician and instead sought such discussions with their pharmacist.

Many participants also purchased supplements and complementary therapies, which increased their financial stress.

Cost and Adherence in HIV-Negative People

A recent American study in HIV-negative people who did not have severe mental health conditions or engage in substance use found that adherence to medications for chronic conditions such as cardiovascular disease and diabetes was affected by out-of-pocket costs. In the same study, researchers stated that they found "robust evidence that reduced out-of-pocket expenses improved medication adherence across clinical conditions."

Changes to Therapy -- the London Experience

The UK has been experiencing a severe recession for several years. As a result of rising health care costs and overall budget cuts, health spending is under significant financial stress. In 2010, the cost of ART for the 30,000 HIV-positive people living in London was approximately £170 million ($267 million). Each year there are approximately 1,800 new HIV-positive people, so costs will rise. The local health commissioners (who oversee health care spending) brought together key stakeholders, including clinicians and patient advocates, and created a subgroup tasked with reducing the cost of buying ART. Whatever course of action the subgroup took had to be in line with HIV treatment guidelines and the results should not negatively impact the health of patients. The following fundamental principles guided the decisions of the subgroup:

"The freedom of the individual clinician to prescribe the most appropriate drug for the patient and full involvement of the person living with HIV in treatment decision-making processes [was] confirmed as [a fundamental principle]."

The subgroup created a multidisciplinary team of doctors, health commissioners, pharmacists, public health workers and patient advocates to meet with pharmaceutical companies. This team invited companies to submit bids for providing discounted ART. The winning bid resulted in doctors and patients considering using following drugs when initiating ART:

  • nukes: Kivexa -- a fixed-dose formulation of abacavir + 3TC
  • protease inhibitors: atazanavir (Reyataz) + ritonavir (Norvir)

These drugs will be supplied at reduced cost for two years. During this time, spending will be audited to assess savings, estimated to be between £8 million and £10 million (between $13 million and $16 million). Also, auditing of health outcomes of HIV-positive patients will be done to ensure that quality of care is maintained.

Other Ideas for Reducing Costs

In the UK, a group of researchers has published a paper with ideas of how the cost of HIV treatment may be further cut. They proposed two broad themes:

  • substituting generic formulations of medicines once the patent on the branded formulation has expired
  • simplifying treatment by reducing the number of drugs in a regimen; specifically, relying on combinations that use a combination of ritonavir plus another protease inhibitor called darunavir (Prezista). Such greatly simplified combinations are called protease inhibitor monotherapy.

Most trials of protease inhibitor monotherapy using either ritonavir-lopinavir (in Kaletra) or darunavir-ritonavir have enrolled carefully selected participants who had little or no history of treatment failure. Furthermore, participants are usually very motivated and highly adherent. All this is to say that treatment simplification to protease inhibitor monotherapy will not be suitable for every HIV-positive patient.

In general, protease inhibitor monotherapy regimens do not have the same effectiveness as currently recommended combinations of ART.

Another issue with HIV treatment simplification is that of the health of the brain and spinal cord -- the central nervous system (CNS). HIV-infected cells of the immune system reside within the CNS. Some anti-HIV drugs have difficulty penetrating the CNS, and simplified therapy raises a concern of insufficient suppression of HIV in the CNS. So care needs to be taken when considering or using such regimens, particularly their long-term impact on neurocognitive health. Perhaps for these and other reasons, protease inhibitor monotherapy is not generally recommended in major HIV treatment guidelines. An upcoming CATIE News bulletin will explore recent reports of injury to brain cells detected in some HIV-positive people who were using protease inhibitor monotherapy.

The Looming Future

The International Monetary Fund (IMF) has predicted a period of slow economic growth for many countries in the short-term and medium-term. This means that financial stress at the individual and institutional level may become an increasing concern. Researchers who aim to assess adherence to HIV or HCV therapy need to take financial stress into account in future studies, particularly when such studies are done in high-income countries. At the institutional level, agencies that subsidize the cost of HIV treatment (and other medicines) will increasingly be seeking a reduction in costs. Doctors and pharmacists may also need to take financial stress into account when prescribing medicines.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication CATIE News. Visit CATIE's Web site to find out more about their activities, publications and services.
See Also
6 Reasons Why People Skip Their HIV Meds
Word on the Street: Advice on Adhering to HIV Treatment
More HIV Treatment Adherence Research


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