HIV Treatment as Prevention Saves Money Over Long Term (Dr. Bohdan Nosyk)

Expanding treatment as prevention is not only cost-effective over the long term, but when productivity gains are considered, it is cost-saving, a new study indicates.

In British Columbia, the only Canadian province that has adopted complete access, expanding antiretroviral therapy could save up to $65.5 million by 2035, said lead author Bohdan Nosyk, PhD, from the British Columbia Centre for Excellence in HIV/AIDS, who is St. Paul's Hospital CANFAR Chair in HIV/AIDS Research at Simon Fraser University in Vancouver, British Columbia.

The $65.5 million savings is the result of the difference between a 100% probability of accessing antiretroviral therapy and a 50% probability. At 75% probability, the savings would be $25.1 million by 2035, the study shows.

Dr Nosyk and colleagues studied HIV incidence, prevalence, mortality, costs (in 2010 Canadian dollars), and quality-adjusted life-years in British Columbia from 1997 — after strategies focused on finding people infected with HIV and treating them were implemented — to 2010. These data were compared with scenarios of reduced access.

In their analysis, the team projected potential costs to the province during the next 25 years, using mathematical models.

“We compared what actually happened in BC to scenarios in which we didn't expand treatment as much as we could have. We found that even fairly small increases in access to treatment were highly cost-effective,” Dr Nosyk told Medscape Medical News. And because getting more people on treatment keeps them alive and employed longer, the increases led to cost savings.

“What makes this study unique is that we built it for British Columbia, using the most extensive data anybody has anywhere,” Dr Nosyk explained. Because the projections are based on what has already happened in British Columbia, they are an accurate representation of how many patients will drop out or not adhere to treatment, he said.

The findings, published online today in the Lancet HIV, will be discussed during a treatment as prevention workshop tomorrow at the 8th International AIDS Society (IAS) Conference.

Productivity gains and reduced hospitalization costs will account for the biggest savings, Dr Nosyk reported. He pointed out that the study results are conservative because capturing data over only a few years does not account for the snowball effect of people not getting infected and then not infecting others.

Some Factors Difficult to Model

This study makes the case that universal antiretroviral therapy makes economic sense, writes Anton Pozniak, MD, from Chelsea and Westminster National Health Service Foundation Trust and Imperial College in London, United Kingdom, in a comment accompanying the published results. However, he notes, some factors are difficult to model over time.

For instance, “economic models might,” he says, “fail to account for the changes in acquired resistance and the effect that might have on treatment and infectivity.”

He adds that the goal of universal antiretroviral therapy is to wipe out AIDS, but without a cure, the model would have to consider that patients would need to be continuously receiving treatment until all have died.

“This is well beyond the 25 years studied by Nosyk and colleagues,” he explains, “and, with current life expectancy estimates, is more likely to be longer than 60 years.”

The study was performed to answer a question posed by the British Columbia Ministry of Health about potential cost savings, Dr Nosyk said.

The standard for expanding access seems to be different for HIV than for other diseases. Cost-effectiveness alone, which has already been demonstrated, should be enough to expand access, he said.

Clinical benefit has also been well documented. In a study conducted after free and widespread access to antiretroviral therapy was rolled out in British Columbia, HIV-related mortality decreased from 6.5 to 1.3 per 100,000 people (80% decrease;P = .0115) ( PLoS One. 2014;9:e87872). In addition, new HIV diagnoses decreased from 702 to 238 cases (66% decrease; P  =  .0004).

British Columbia was the epicenter of the initial HIV/AIDS epidemic in Canada, but the rate in that province is now lower than it is in most other Canadian provinces. This “reduction is at least partly attributed to universal coverage of drug and other healthcare costs for people with HIV/AIDS and rigorous efforts to scale-up access to antiretroviral therapy,” Dr Nosyk explained.

“Will a message of cost savings further the discussion? Maybe it will,” Dr Nosyk said. “Should it further the discussion? No.”

The team plans to use the models they built to test different kinds of interventions in this analysis to increase testing and treatment uptake, reduce the rate of treatment dropout, and assess the effect of increasing access to harm-reduction benefits.

This study was funded by the British Colombia Ministry of Health, which funded the Seek and Treat for Optimal Prevention of HIV/AIDS pilot project, and the National Institute of Drug Abuse at the US National Institutes of Health. Dr Nosyk and Dr Pozniak have disclosed no relevant financial relationships. Some of Dr Nosyk's coauthors report receiving grants from the British Columbia Ministry of Health and the US National Institutes of Health, and support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and ViiV Healthcare, and GlaxoSmithKline.

Marcia Frellick reports.