Long-Term Impact of Highly Active Antiretroviral Therapy on HIV-Related Health Care Costs

Highly active antiretroviral therapy (HAART) for HIV has been associated with marked decreases in death rates, opportunistic infections (OIs) and hospitalizations among AIDS patients receiving treatment. Since it is currently recommended that patients take at least three medications, and access to the medications is limited because the cost of prescribed annual treatment ranges from $10,000 to $15,000, the researchers examined the long-term impact of HAART on HIV-related health care costs over a period of time.

The researchers compared the records of monthly health care use by HIV-positive men at the Dallas Veterans Affairs Medical Center (DVAMC), which provides comprehensive inpatient and outpatient care to approximately 300 HIV-positive individuals. Data were collected for the period between Jan. 1, 1995 and June 30, 1998, which were then divided into four intervals (10-11 months each). Data included the number of infectious diseases clinic visits, emergency room visits, other medical and surgical clinic visits and the number of hospital days. According to the authors, "Per diem costs were estimated to be $328 for an outpatient visit (exclusive of antiretroviral treatment costs) and $1,228 for a hospital day." The researchers calculated the monthly costs for inpatient and outpatient HIV care and extracted monthly costs of antiretroviral medications "directly from the Immunology Case Registry" at the DVAMC. After collecting average cost information for hospital care and drug treatment, the researchers assessed the cost-effectiveness of HAART "by determining the monthly cost of achieving a viral load less than 500 copies/ml per patient and a viral load less than 5000 copies/ml per patient," the authors wrote.

The researchers found that the mean monthly hospitalization and associated inpatient costs "decreased and remained low 2 years after the introduction of protease inhibitors (37 hospital days per 100 patients). Total cost decreased from $1,905 per patient per month during the first quarter to $1,090 per patient per month in the third quarter but increased to $1,391 per patient per month in the fourth quarter. Antiretroviral treatment costs increased throughout the entire observation period from $79 per patient per month to $518 per patient per month." Although hospitalization and outpatient services costs decreased, "pharmacy costs increased dramatically so that the total pharmacy cost exceeded either the inpatient or outpatient costs during the last 11 months that we collected data," wrote the authors. "Thus, there was a large shift in the cost of caring for HIV-infected patients from the inpatient area to the pharmacy." The researchers noted that their "data also suggest that HIV-related health care costs will continue to increase. . . . In the future, a significant proportion of our patients will fail antiretroviral therapy. They will then be treated with more intensive salvage regimens, which will undoubtedly increase the pharmacy costs. In addition, the number of hospitalizations may begin to increase and further drive up total HIV-related health care cost."

The researchers suggested that the "impact of protease inhibitor therapy on overall HIV cost deserves further investigation. . . . The savings that we observed were primarily due to the decrease in hospital admissions. Similarly, hospitals with low inpatient HIV costs or high outpatient HIV costs may not observe the dramatic savings that we found because of the inverse relation between inpatient and outpatient costs. In addition, our data suggest that the cost savings may be transitory and that costs will continue to rise. Finally," they recommended, "formal evaluations of the cost-effectiveness of HAART should be performed."

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