Adherence & Retention
High Antiretroviral Therapy Adherence Associated with Lower Health Care Costs
Dear Colleagues
High antiretroviral therapy adherence which has been shown to be a major predictor of virological suppression, emergence of HIV drug resistance, disease progression and death, is now associated with lower health care costs in resource-limited settings.
My colleagues and I, from Johns Hopkins University, in collaboration with colleagues at the University of Cape Town, South Africa, examined the effect of antiretroviral therapy adherence on direct health care costs and found that antiretroviral therapy improves health outcomes for people infected with HIV, saving a net overall median monthly health care cost of $85 per patient. While our results make sense, it is important to be able to show the proof and discuss the possible clinical and/or public health implications. The results are featured in the January 5, 2010, issue of the Annals of Internal Medicine.
http://www.annals.org/content/152/1/18.abstract
In a cohort study of 6,833 HIV-infected adults enrolled in Aid for AIDS, a large private-sector HIV/AIDS disease management program in South Africa between 2000 and 2006. We averaged monthly direct health care costs and categorized pharmacy claim adherence in quartiles, from 1 to 4. Independent effects of patient characteristics on monthly total health care costs were assessed with health econometrics models (GLM 2-step model). We found that the cost for hospitalization increased from 29 percent to 51 percent of total costs as antiretroviral therapy adherence decreased, and this increase explained the difference in total mean monthly heath care costs from the lowest to the highest antiretroviral therapy adherence quartile.
One of the obvious implications are that effective, practical intervention strategies to promote, as well as to proactively monitor antiretroviral therapy adherence, are badly needed as they may save direct health care costs by decreasing patient’s morbidity and mortality and are likely to be cost-effective in the long-term.
Furthermore, “The cost savings are largely related to less hospital use. The threat is that budgets for hospitals are often divorced from budgets for outpatient AIDS treatment. In fragmented health systems it is difficult for the outpatient administrator to rationalize investments that lower the costs for hospitals. A broader view is necessary to improve patient care and save money,” said David Bishai, MD, PhD, co-author of the study and associate professor in the Bloomberg School’s Department of Population, Family and Reproductive Health.
The few limitations of our study are that our data originate from a private healthcare management program and may not reflect what happens in public HIV/AIDS programs. Also, we did not include indirect healthcare costs. Of note, cost-effectiveness of HAART adherence interventions was beyond the scope of this analysis and still needs to be conducted.
"The obvious next step is to determine how best to allocate resources to promote adherence and realize these benefits," according to David Bangsberg, MD, MPH, of Massachusetts General Hospital, Harvard Medical School, in Boston, and Steven Deeks, MD, of the University of California San Francisco, in an accompanying editorial that appears in the same issue of the Annals. They suggested three selected areas for intervention such as: 1) reduction of structural, economic, and stigma-related barriers; 2) Interventions such as education and counseling, telephone calls, home visits from nurses; and 3) Interventions aimed at patients with documented poor adherence due to substance abuse or psychiatric illness
We are interested to hear comments and reactions to this paper from our GHD members.
Best,
Jean Nachega, MD, PhD
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Primary source: Annals of Internal Medicine
Source reference: Nachega JB, et al "Association of antiretroviral therapy adherence and health care costs" Ann Intern Med 2010; 152: 18-25.
Additional source: Annals of Internal Medicine
Source reference: Bangsberg DR, Deeks SG "Spending more to save more: Interventions to promote adherence" Ann Intern Med 2010; 152: 54-56.
