Alberta researchers warn about increasing costs of HIV care
3 September 2014 - As mentioned in the previous CATIE News bulletin, the cost of care increases as people age. This is no different for HIV-positive people. Policy planners and health authorities need to begin to estimate future costs of care as HIV-positive people grow older.
In this CATIE News article, we explore a report from southern Alberta about the rising costs of HIV care.
The Southern Alberta HIV Clinic in Calgary is the major specialist clinic in the region that deals with infectious diseases. It provides centralized services, including HIV care and treatment and laboratory tests. All of these are free of charge for patients because of universal health care.
Researchers at the clinic launched a study to assess changing costs of care for their HIV-positive patients. Data were captured between January 1999 and January 2011. The research team classified older patients as those who were over the age of 50.
During the course of the study, the number of people using the clinic's services increased from 708 to 1,454. The researchers found that the proportion of patients older than 50 years at different points in time was as follows:
- 1999 - 10% of patients were older than 50 years
- 2011 - 25% of patients were older than 50 years
According to the researchers, this change in the distribution of older people was "driven mostly by the aging of those with long-standing HIV infection rather than newly diagnosed [participants]." Overall, older participants accounted for about 10% of newly diagnosed cases of HIV.
The changing face of HIV
Here are some other changes that occurred over the course of the study:
- The proportion of male patients decreased from 88% to 76%.
- The proportion of patients classified as men who have sex with women (MSW) increased from 16% to 37%.
- The proportion of patients who were people of colour increased from 20% to 38%.
All of these changes were statistically significant.
According to researchers, older patients were more likely than younger patients to have the following profile:
- acquired HIV through sex with another man
- self-identify as white
Focus on health
Overall, the proportion of patients with an AIDS-related illness increased slightly from 18% in 1999 to 22% in 2010. However, older people were more likely to have experienced an AIDS-related illness by 2010 (29%) than younger people (20%).
Older people (51%) were more likely to have sought care when their CD4+ count fell below the 200 cell/mm 3 mark compared to younger people (32%).
Regarding co-existing health conditions (also called co-morbidities), older people tended to have more (about four) compared to younger people (about two).
Older people were less likely to smoke (26%) than younger people (40%). Nearly equal proportions of older and younger patients (11%) disclosed that they had injected street drugs in the past.
Use of ART increases
Over the course of the study, the proportion of patients who used potent combination anti-HIV therapy (commonly called ART or HAART) increased, as follows:
- 1999 - 61% were taking ART
- 2010 - 74% were taking ART
Researchers noted that older people were more likely to be taking ART (90%) compared to younger people (70%).
The costs of HIV care
Given the many trends with older patients in this study, it is not surprising that caring for older people costs more. This is generally the case for HIV-negative people.
In 1999, about 10% of patients were over the age of 50 and accounted for 12% of total costs. By 2010, 25% of participants were over the age of 50 and accounted for 31% of total costs.
About 80% of these costs were driven by the use of ART. Researchers found that older patients tended to require complex and somewhat more costly regimens than their younger counterparts.
The Alberta researchers suggested that the following factors might have played a role in increasing costs:
- Thanks to ART, older people are living longer and require treatment for longer periods.
- Older people are more likely to have used several different combinations of anti-HIV drugs because of side effects associated with earlier regimens and in some cases HIV's ability to resist treatment. These are perhaps two factors that explain why older people have needed more complex regimens as they aged.
- Due to the presence of co-morbidities and their treatments, older people may need "more modern and expensive ART to minimize drug interactions or reduce pill burden," according to the researchers.
- Older patients tended to be more adherent to their anti-HIV drug regimens than younger patients. However, at the time of HIV diagnosis, older participants were more likely to have low CD4+ cell counts and may have required more complex (and therefore more costly) regimens.
There are at least three reasons why the Alberta study likely underestimates the true costs of care, as follows:
- The study reported only on HIV-related costs. Other studies have reported that HIV-positive people may increasingly require hospitalization and medications for complications unrelated to HIV.
- The study only included hospitalizations after the first 30 days of diagnosis. However, the Alberta researchers noticed that the diagnosis of HIV is "often linked to a hospital admission."
- The researchers only analysed data from patients who remained alive at the end of the study. They did not analyse data from patients who moved to another location or with whom they had lost contact. Other researchers have found that the cost of care rises significantly in the year prior to an HIV-positive person dying. Therefore, not including the cost of care for patients who had died during the study is yet another reason why costs were underestimated.
For the future
The Alberta study is a very important first step in alerting health authorities about the rising costs of care for HIV-positive people. The changes being seen in Alberta with an aging population of HIV-positive people are likely occurring in other regions of Canada and other high-income countries. Policy planners and health authorities need to be aware of this and need to fund more complex studies to fully capture the costs associated with comprehensive care and treatment of HIV-positive people as they age. By doing so, health authorities can be prepared for an aging HIV-positive population and can increase funding for clinics so they can continue to provide high quality care and save lives.
-Sean R. Hosein
Krentz H, Gill M. Increased costs of HIV care associated with aging in an HIV-infected population. HIV Medicine . 2014; in press.
From Canadian AIDS Treatment Information Exchange (CATIE). For more information visit CATIE's Information Network at http://www.catie.ca
Source: CATIE: CANADIAN AIDS TREATMENT INFORMATION EXCHANGE