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Earlier HIV Treatment Is More Cost Effective

Testing and treating people with HIV early in the course of disease is more cost-effective than waiting until they develop serious immune deficiency, according to study findings published in the December 2010 issue of Medical Care. Late care remains common, however -- people who accessed care after their CD4 count had fallen to 200 cells/mm3 (the criteria for AIDS) accounted for more than 40% of patients treated at urban centers over the past decade.

There is an ongoing debate about the best time to start antiretroviral therapy (ART). Some experts argue that starting treatment soon after HIV diagnosis could both improve individual health and reduce viral transmission, while others point to concerns such as side effects and increased cost.

John Fleishman from the Agency for Healthcare Research and Quality and colleagues estimate direct medical care expenditures for HIV patients according to their disease status when they first accessed care. Late entry into care was defined as having an initial CD4 T-cell count of 200 cells/mm3 or less, intermediate entry as 201-500 cells/mm3, and early entry as > 500 cells/mm3. The intermediate group was further divided into those with CD4 counts above or below 350 cells/mm3, the U.S. treatment guidelines ART initiation threshold at the time the analysis was performed.

The study included 8348 people who enrolled to receive HIV primary care between 2000 and 2006 at 10 clinics participating in the HIV Research Network. The investigators reviewed medical records collected from 2000 through 2007. They estimated costs per outpatient visit and inpatient day, as well as monthly medication costs for antiretroviral drugs and opportunistic illness (OI) prophylaxis and cost of lab tests.

Results

• CD4 cell counts at the time of entry into care were distributed as follows:
  • Late entry (< 200 cells/mm3): 43.1%;
  • Low intermediate (200-350 cells/mm3): 21.4%;
  • High intermediate (351-500 cells/mm3): 16.8%;
  • Early entry (> 500 cells/mm3): 18.7%.
• The number of years during which patients received care after enrollment did not differ significantly across initial CD4 count groups.
• People who presented for care late were more likely to die during follow-up, with a mortality rate of 14.04%, compared with rates of 6.22%, 3.92%, and 3.84% in the other CD4 count groups (low to high).
• During the first year of care, the average cumulative cost for a late presenter was $37,104, compared with $9,829 for an early presenter.
• During the fifth year of care, the corresponding costs were $30,598 for late presenters versus $92,213 for early presenters.
• By the seventh year, the average late entry cost was $135,827 versus $49,105 for early entry.
• Differences in average cumulative treatment cost -- that is, the savings if the late entries had started early -- ranged from $27,275 to $61,615.
• Even after 7 to 8 years in care, the cost difference between people who accessed care early versus late remained "substantial."

"Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages," the study authors concluded. "Successful efforts to link patients with medical care earlier in the disease course may yield cost savings."

"Continuation of higher expenditures over time among late presenters is consistent with recent longitudinal data demonstrating that late entry into care is associated with a less robust reconstitution of the immune system," they explained in their discussion. "To the extent that patients with severely compromised immune systems are surviving longer, early entry into care could help to prolong patients at a relatively less costly disease stage, and thereby reduce aggregate expenditures."

The acknowledged, however, that with longer follow-up late presenters might have shorter survival than early presenters, in which case cumulative expenditures for the latter group could become larger as people live longer.

Investigator affiliations: Agency for Healthcare Research and Quality, Rockville, MD; Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

Reference

JA Fleishman, BR Yehia, RD Moore, and others. The economic burden of late entry into medical care for patients with HIV infection. Medical Care 48(12): 1071-1079 (Abstract). December 2010.