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.

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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.

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Rationing Health Around The World

The World, a public radio show cohosted by the BBC and the Boston NPR station, had a four part series on rationing health care  around the world last week.  The radio shows as well as the web material help demonstrate how hard it is to distribute scarce health resources. 

The series starts in South Africa, where committees in hospitals determine who gets dialysis and who doesn’t.  These committees started by considering “social worth,” but have moved to prioritizing those who would be good candidates for kidney transplants, and who could therefore get off dialysis quickly.  If you’re a drinker, or if you’re overweight – well, dialysis could save your life, but it won’t. 

The series moves on to the UK, lauded by health policy experts around the world, where the National Institute for Clinical Excellence (NICE) assesses comparative effectiveness and determines how much the National Health Service (NHS) will spend to save a quality adjusted life year (QALY).  Right now the number is south of $50,000.  If a new drug might help you but would cost more, it isn’t covered.  NICE has been successful at pressuring drug companies to lower prices in exchange for access to the NHS market – but its authority to do so expires in 2012.  It’s hard to feel good about denying a drug that could save someone’s life.

Next stop is Zambia, which can’t afford HIV drugs for all the HIV patients.  The country has long had poor governance, and has a shortage of health personnel and medicines.  The main method of rationing in Zambia is the queue.  People have to wait a half day for a brief clinician appointment, and another half day for the pharmacist to fill a prescription. Those who cannot wait – perhaps because they are employed or have young children – go without life saving medications.

The final installment is a visit to India, where a resourceful pediatrician faced a shortage of ventilators during an influenza epidemic.  She fashioned homemade continuous positive airway pressure machines from a few dollars of readily available supplies, and saved  many dozens of lives.  This is an example where disruptive innovation made an enormous difference.  The homemade machines weren’t nearly as good as ventilators for these critically ill children.  But the makeshift machines were better than nothing, and the physician improved them “on the fly” during the epidemic.

These stories point out that rationing is painful – and it’s not restricted to poor countries.   We already ration care in the US by rationing access.  It’s not easy for a Medicaid patient to find a dentist or a specialist in many states, as Medicaid pays very low rates.  We might give FDA approval to a $90 a month medicine for cancer, but few eligible patients who don’t have generous insurance coverage will benefit from these medicines.  In Arizona, Medicaid beneficiaries are dying because the state will not fund evidence-based transplantations. 

We’ll be having more distributive justice conversations in the US, because we won’t be able to afford uniform access to all health care innovations as they are currently priced.  The best way to minimize the number of times we refuse to offer useful therapy to patients is to lower the cost of interventions, but we’ll still face a demand for more health care than we can afford.

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