Day Four of Good News: HIV Therapy

Today’s Managing Health Care Costs Indicator is 2.8 million

Click on image to enlarge. Source 

When I was in medical school, we still didn’t know what caused AIDS.

When I was in my residency, the HIV virus had been identified, but we were at best able to treat associated infections and cancer.  AZT (zidovudine) was licensed in 1987 – the year I finished my residency.   Everyone I cared for with HIV disease during my training died – most within a year of diagnosis. Some died the very hospitalization of their diagnosis.  When I moved into practice, treatment was improved a bit, but AIDS still had a 100% mortality.

Highly active antiretroviral therapy is one of the miracles of my medical lifetime.  I now frequently see patients who have had HIV for years and even decades. They have to take pills –and the pills are expensive. The pills have some dreadful side effects, too.  But the incidence of pneumocystis pneumonia and Kaposi’s Sarcoma and brain lymphomas and ophthalmologic fungal infections has plummeted.  People with HIV are living meaningful and productive lives with their disease – a huge medical success.

In the early years of highly active antiretroviral (HAART) therapy, the cost of caring for HIV patients declined. We were diagnosing people earlier, and while we spent a lot on medications, we spent far less on hospitalizations than we had in the terrible early days of the HIV epidemic. It’s estimated that HAART has saved 2.8 million years of life – and prevented 2900 cases of HIV infection of infants at birth.

But this is a blog on managing health care costs, and at $14,000 HAART is hardly cheap.  However, there is more evidence this year that treating HIV is a good bargain.

It turns out that HAART dramatically decreases the rate of transmission of HIV. Look at the chart at the top of this post. There are finally fewer global cases of HIV in 2009 than in 2008.  HIV might have peaked –and it’s this cocktail of antiretroviral medicines that have likely made the difference.

It’s rare to have medicines so expensive serve as a viable public health intervention. This is one of those heartening examples. HAART for HIV infection is a great example of how progress in medical care can yield future societal benefits and even cost savings.

Penny Wise: Cutting HIV Prevention and Treatment Programs

Today’s Managing Health Care Costs Indicator is $11,388

That’s how much it costs per patient in the AIDS Drug Assistance Program (ADAP) program  -- which purchases HIV medications for those without health insurance.  Much of this is funded through the federal government – although ADAPs are administered through each state.

The Washington Post and NPR reported this spring about growing waiting lists for ADAP –over 8000 people in May.  South Carolina’s preliminary 2011 budget would have eliminated its HIV prevention and treatment programs altogether.  Some states like Virginia were bumping patients off the ADAP program if their T cell count rose.  Florida  has the largest HIV drug waiting list, and is considering decreasing the income threshold for eligibility to under $22,000 per year.

That might seem fair, to restrict access to those who are  poorest or sickest, but it’s a terrible clinical idea.  Intermittent use of anti-HIV medications is more likely to lead to drug resistance. Also, those on effective anti-HIV medication are substantially less likely to transmit the disease. 

The Boston Globe  reported yesterday that a federal cut of $4.3 million, about a quarter of the anti-HIV budget, will lead to discontinuation of condom distribution programs, outreach to gay men, and community case workers who work directly with HIV patients.   The federal government is shifting its investment from prevention and from states with low transmission rates to testing and treatment and states with higher transmission rates.

Cutbacks in HIV prevention are likely to be costly in the future – public health interventions are far more cost-effective than treating preventable cases later.  Cutting back on drug treatment is a special tragedy.    Highly Active Anti-HIV therapy (HAART) is one of the medical miracles witnessed by my generation of physicians.  Patients with HIV once uniformly died 18-36 months from initial diagnosis. They went blind from cytomegalovirus, they were pockmarked with Kaposi’s Sarcoma, and they were breathless from pneumocystis pneumonia.  They spent weeks or months in the hospital, suffering from wasting and from central nervous system lymphomas.  

All that now seems like the Dark Ages.  The dread disease that was a rapid death sentence in 1994 is now a chronic disease – a bad one – but one that is treatable and where patients can live normal lives (and remain working and paying taxes) for decades.  

We should not restrict access to life-saving HIV drugs.