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Researchers examine use of highly active HIV medications and their effects on costs and access to care

Highly active antiretroviral therapy (HAART) has improved immune system functioning (evidenced by increased CD4 cell count) and survival in patients infected with the human immunodeficiency virus (HIV) that causes AIDS. HAART also reduces by nearly 2 months the time that HIV-positive patients spend in the hospital, according to a recent study of a nationwide network of HIV clinics. A second study found that differences in the use of HAART based on insurance status have narrowed since 1996. Both studies were supported in part by the Agency for Healthcare Research and Quality (HS07809). The studies, which are summarized here, were led by Richard D. Moore, M.D., M.H.Sc., of Johns Hopkins University School of Medicine.

HIV Research Network. (2002, May). "Hospital and outpatient health services utilization among HIV-infected patients in care in 1999." Journal of Acquired Immunodeficiency Syndromes 30(1), pp. 21-26.

This study involved data on 5,255 patients who were treated at nine U.S. HIV primary and specialty care clinics during 1999. For patients who received HAART, hospital time averaged 265 days per 100 patients compared with 320 days per 100 patients who did not receive this type of combination drug therapy. In contrast, HAART patients made more clinic visits for outpatient care than non-HAART patients. Thus, HAART not only improves patient health, but also reduces HIV-related health care costs, since hospital care is more expensive than outpatient care.

Seventeen percent of the patients were hospitalized sometime during the year, with hospital time even more strongly affected by CD4 cell count than HAART. Hospital days averaged 165 per 100 patients with a CD4 cell count of more than 500 cells/mm3 compared with 840 days per 100 patients with CD4 count of less than 50/mm3 (very advanced HIV disease). Clinic visits also increased at lower CD4 counts. Both hospital days and clinic visits increased with higher HIV RNA level (number of copies of HIV in the blood), an indicator of the severity of HIV infection.

Mean monthly health care spending per patient averaged $423 for hospital care and $168 for outpatient care. Compared with previous studies, these figures suggest that the costs of HIV care may have leveled off since the advent of HAART in the late 1990s. However, the authors note that data from the past few years will be needed to confirm this conclusion.

Keruly, J.C., Conviser, R., Moore, R.D. (2002, May). "Association of medical insurance and other factors with receipt of antiretroviral therapy." American Journal of Public Health 92(5), pp. 852-857.

Patients infected with HIV who were uninsured or insured by State Medicaid programs were less likely than those with private insurance to receive HAART in early 1997. However, insurance-related differences in receipt of HAART narrowed significantly by 1999, according to this study. Thus, it appears that effective but expensive medical care can be made available to all patients if socioeconomic barriers are removed, suggests Dr. Moore.

The researchers assessed the associations of sociodemographic factors and medical insurance with receipt of HAART in two periods (April 1996 through March 1997, and April 1997 through March 1999) using data on 959 patients enrolled in the Johns Hopkins HIV clinic after April 1, 1996. Most of the patients were male (70 percent), black (78 percent), and had intravenous drug use as the major risk behavior for HIV transmission (47 percent). In period 1, HAART was more likely to be used in patients who were commercially insured than in other payer groups. However, differences between payers narrowed in period 2.

After January 1, 1998, use of HAART significantly increased for Medicaid and uninsured patients compared with commercially/privately insured patients, and it increased nonsignificantly for people who had partial coverage. Although whites were more likely than minority patients to receive HAART in period 1, these differences narrowed in period 2. However, substance abusers and those who missed scheduled visits were still less likely to receive HAART in period 2. Care providers may have viewed these patients as unable to adhere to the rigorous medication schedule and followup visits needed to monitor HAART.

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