VA study shows increase in cost of HIV drug therapy
Study notes increased use of antiretrovirals
A recent study by the U.S. Department of Veterans Affairs (VA) shows a 434% increase in the cost of antiretroviral drugs prescribed for HIV/AIDS patients between 1992 and 1998.1
The study period encompasses several years before protease inhibitors and highly active antiretroviral therapies became widely used in the United States. It’s the first large-scale study to document the increased usage of antiretrovirals.
When the costs of all HIV drug prescriptions, including prophylaxis and medications for opportunistic infections, are compared between 1992 and 1998, the increase is 222%, from $21.9 million in 1992 to nearly $71 million in 1998. The VA study also notes another trend of anti re troviral drugs taking a larger portion of the HIV medication expense pie. While the cost of antire troviral drugs represented 47% of the total pharmacy costs for HIV patients in 1992, by 1998, antiretrovirals accounted for 78% of the total drug costs for HIV patients.
Outpatient clinic visits by HIV patients rose between 1992 and 1998, while hospital admissions dropped during the same period. The specific numbers will be released later this year as part of a published study, says Abid Rahman, PhD, an epidemiologist and chief investigator of the VA study.
VA facilities treat between 16,000 and 17,000 HIV/AIDS patients each year, making it the largest single provider of HIV medical services. VA medical centers provide free medical care and prescriptions to all eligible veterans.
"We are committed to providing state-of-the-art and the best quality care, and have a track record of doing so since the earliest days of the HIV epidemic," Rahman says.
For example, the VA’s HIV program provides all needed services, including the latest federally approved therapies and diagnostics. It also includes national clinician education on current treatment guidelines and case management of HIV-infected veterans.
The VA’s general policy is to consider adding a new drug to its national formulary one year after it has been approved by the U.S. Food and Drug Administration (FDA). However, antiretroviral drugs for HIV have been added to the national formulary more quickly. They are added based on recommendations by the VA HIV/AIDS Technical Advisory Group. Once they are added, they’re placed on a systemwide computer package that lists the drugs in every VA facility’s pharmacy database.
"We did a detailed analysis of the quantity of prescriptions and their costs," Rahman says. "The number of antiretroviral prescriptions filled increased by 546% from 1992 to 1998, reflecting the increased use of combination antiretroviral therapies in more and more veterans with HIV infection, as recommended by consensus guidelines."
The study shows that the largest increases in antiretroviral prescriptions began in 1996 after national consensus recommendations called for earlier use of the drugs. By 1998, the nucleoside analogues, protease inhibitors, and non-nucleoside reverse transcriptase inhibitors accounted for about one-third of the 741,406 total prescriptions filled for HIV patients. Their costs represented more than three-quarters of the total HIV drug costs in 1998.
The study gives the VA a better understanding of how its resources are allocated for HIV/AIDS care, Rahman says. "The allocation of resources for patients is an important area for us, and we want to understand from a policy-making perspective if the cost is increasing."
The VA is the largest single provider of HIV services in the United States, and the data used in the study came from the VA’s Immunology Case Registry (ICR) or HIV registry, the largest clinical HIV database in the world. The ICR contains access to complete medical records, including diagnoses, utilization, pharmacy, and laboratory data on more than 45,000 HIV patients in the VA system.
The VA’s HIV registry of HIV patients groups people into four categories of disease progression. They are:
• HIV-positive people with CD4 cell count greater than or equal to 500 per cubic millimeter;
• HIV-positive people with a CD4 cell count of 200-499 per cubic millimeter;
• HIV-positive people with a CD4 cell count of less than 200 per cubic millimeter;
• AIDS patients with AIDS-defining illnesses.
The registry never moves patients from a higher and more severe category to a lower or less severe disease category.
The VA divides all its patients into two categories according to allocation of services and cost of services. Those in the basic care group are patients whose costs are typically $3,000 to $4,000 per year. Care for patients in the complex care group can cost 10 times that amount, and HIV patients are in the complex care category.
Despite the increased cost of providing HIV care, the disease’s total cost ranks somewhere in the middle of all diseases that the VA treats.
Reference
1. Rahman A, Kendall S, Deyton L, et al. Trends in antire troviral drug utilization for HIV/AIDS patients treated at U.S. Department of Veterans Affairs (VA) medical centers. Abstract presented at the Third International Conference on Healthcare Resource Allocation for HIV/AIDS and Other Life-Threatening Illnesses. Vienna, Austria; Oct. 11-13, 1999.
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