Bay Area Reporter - April 12, 2001
Matt Sharp, Survive AIDS Writers Pool

These are the first large-scale studies to conclude that HIV drugs are cost effective. One of the studies performed at the RAND Health Institute in Santa Monica examined the expenditures for 2,864 patients receiving care for HIV. The study followed patients for up to 36 months beginning in early 1996. The researchers found that health care costs declined to $18,300 in 1998 compared to $20,300 in 1996. Mean expenditures per month were down from a baseline amount of $1,792 to $1,359 in mid-1997. Use of HAART (highly active antiretroviral therapy) was independently associated with reduction in expenditures. The bottom line is that there was a significant degree of cost savings over time with the use of antiviral drugs.

The second study published in the NEJM came from the Division of General Internal Medicine and the Partners AIDS Research Center at Massachusetts General Hospital and Harvard Medical School. The study used a complicated mathematical analysis estimating clinical benefits and cost effectiveness. In other words, the researchers looked at the ratio of benefits and cost effectiveness, to the increases in life expectancy in a large federally funded AIDS clinical trial. They showed in their analysis that treatment with triple drug regimens is a cost effective use of resources.

How do these studies reflect the reality of HIV treatment today? As usual the issue is access. Even though the studies prove that HIV drugs are cost effective, they can only help if they are used. Not surprisingly, the RAND study showed that drug costs were lower and hospital costs were higher among underserved groups, including blacks, women, and patients without private insurance. And clearly, the costs of treatment are still completely out of bounds, especially in developing countries where AIDS treatment is merely a dream.

Despite this study, access and availability will continue to be a major problem here in the U.S. and in developing countries. In the states, combination therapy costs approximately $10,000 to $15,000 a year. Unfortunately, a disproportionate number of people with HIV are poor or lack insurance thus increasing the demand for governmental aid. Until the drug costs come down, a strain on public assistance programs will continue regardless of how much proof there is that drugs save in care costs. Cost effectiveness is important with our burdened health care system, however a more important finding of these studies is the fact that the drugs are not getting to everyone who needs them.

An editorial in the NEJM where these studies were published proposed strategies to improve availability of HIV medications. Of course first and foremost is that state and federal programs must increase funding of ADAP programs. ADAP and Medicaid are not perfect solutions because of their financial and eligibility requirements. The programs vary from state to state and do not cover everyone that they are intended to serve. However, anti-HIV medications have improved formularies many times at the expense of coverage of drugs for opportunistic infections and other complications of HIV therapy itself.

Secondly, government programs already purchase drugs at a discount from pharmaceutical companies but should push for deeper reductions. Lower costs obviously mean that more drugs can be purchased with increasingly tight budgets.

According to the NEJM editorial, Medicaid is the largest health insurance program for people with AIDS, providing treatment to 50 percent of adults and 90 percent of children. But the program is woefully inadequate and needs to expand coverage to cover more low-income people with HIV and cover those who have yet to develop symptoms.

An old saying says an ounce of prevention is worth a pound of cure. These studies prove that preventing HIV replication through therapy can cut costs, but until the pharmaceutical industry drastically lowers prices, and the health care system dramatically improves, we will continue to see people left out of the promise of HIV treatment. More importantly, until drugs are made available to the majority of people with HIV in the world, cost effectiveness studies won't mean spit.
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