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Antiretrovirals Pose Highest Cost in Large Swiss HIV Care Analysis
  16th European AIDS Conference, October 25-27, 2017. Milan
Mark Mascolini
Antiretroviral therapy (ART) emerged as the most expensive element of HIV care, by far, in a 2012-2013 Swiss analysis of costs for HIV-related and non-HIV comorbidities [1]. Entering care with more advanced HIV infection resulted in only marginally higher costs.
Swiss HIV Cohort Study (SHCS) investigators noted that comprehensive and representative cost data for HIV care remain scarce in Switzerland and other countries. They proposed that privacy-preserving probability matching of cohort and claims data could prove a reliable way to analyze costs of HIV care. They conducted this study aiming to analyze "direct HIV and non-HIV-related costs and resource use for in-hospital and ambulatory care of HIV-infected individuals in Switzerland." They also wanted to explore costs related to late presentation to HIV care, defined as first seeking care with a CD4 count below 350.
The analysis considered all SHCS patients on ART in 2012 and 2013. The researchers used probability matching to link this group to claims data from Switzerland's largest health insurer. They based matches on four variables: date of birth, ART in 2012 and 2013, gender, and provider. Ambulatory care costs included all services by any healthcare provider, all diagnostics, and all drugs and devices. Hospital costs reflected flat rates according to diagnostic groups, which do not reflect full costs because Swiss cantons subsidize hospitals. The researchers estimated corrected mean total costs with a semiparametric estimator that permits adjustment for censored cost data. They used generalized estimating equations to evaluate predictors of marginal costs.
The SHCS team focused on 9326 people taking ART in 2012-2013 matched to 2355 health insurance policyholders with ART claims data in those years. That process yielded 1195 patients matched to policyholders and analyzed. Among these 1195 people, 27% were female, 15% were 60 or older, 24% had an AIDS diagnosis before 2012, 24% had chronic HCV infection, and 49% started ART with a CD4 count between 100 and 350. These proportions closely reflect those of the entire SHCS.
The researchers estimated costs in Swiss francs. One Swiss franc is nearly equivalent to 1 US dollar and 0.86 Euros. Ambulatory care costs in 2012 and 2013 averaged 27,040 and 26,915 Swiss francs per person, while ART costs in those years averaged 19,913 and 19,228 Swiss francs. Outlays for ART represented 74% of ambulatory care costs in 2012 and 71% in 2013. In-hospital costs (for 300 study participants) averaged 10,263 Swiss francs in 2012 and 14,085 in 2013.
People who fell into the low-cost group (versus moderate or high cost) were more likely to be (1) 59 years old or younger, (2) male, (3) more educated, (4) light drinkers or nondrinkers, (5) without current illicit drug use, (6) with an intermediate likelihood of smoking, and (7) likely to adhere to ART. People in the low-cost group were less likely to have (1) an AIDS diagnosis, (2) psychiatric comorbidities, (3) cardiovascular events, (4) a record of virologic failure, and (5) longer HIV duration (median 6.6 versus 5.1 years).
Starting HIV care with a CD4 count below 350 did not add substantially to overall care costs in 2012 (average 29,455 Swiss francs versus 27,893 with a higher CD4 count) or 2013 (average 28,993 Swiss francs versus 27,060 with a higher CD4 count). Average differences for starting care below versus above 350 CD4 cells (and 95% confidence intervals) were 1562 Swiss francs (-471 to 3595) in 2012 and 1933 Swiss francs (206 to 3659) in 2013.
The SHCS investigators concluded that their matching of SHCS patients and insurance claims data "resulted in a highly representative sample of patients with detailed cost analysis." While ART represents the highest cost, they added, entering care late resulted in only marginally higher costs. The researchers stressed that cost profiling like that done in this study will allow researchers to isolate patient traits associated with higher costs.
1. Leon-Reyes S, Schafer J, Fruh M, et al. Cost of HIV-related and non-HIV related comorbidity in HIV infected individuals: the Swiss HIV Cohort Study (SHCS). 16th European AIDS Conference. October 25-27, 2017. Milan. Abstract PS2/7.