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  53rd ICAAC Interscience Conference on
Antimicrobial Agents and Chemotherapy
September 10-13, 2013, Denver CO
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Second- and Third-Line ART Cost 24% and 41% More Than First Line in US
  53rd ICAAC, September 10-13, 2013, Denver
Mark Mascolini
Second-line antiretroviral therapy (ART) costs 24% more per year than first-line therapy in the United States, and third-line therapy costs 41% more than first-line therapy, according to a large insurance claims-based analysis [1]. Monthly costs for people who begin care with a CD4 count below 100 are 92% higher than costs for people who start with more than 350 CD4s.
The cost of HIV care in the United States has not been thoroughly studied. Researchers from Pharmerit International, Pfizer, and the Medical University of South Carolina conducted this study to address that need. They created two cohorts with data from the MarketScan Commercial Claims and Encounters Database covering 2007-2011 and the MarketScan Lab Database Covering 2007-2010. The first cohort, called the incident treatment cohort, tracked 9931 people through first, second, and third lines of antiretroviral therapy. Members of this cohort were at least 18 years old and did not have hepatitis. The second cohort, called the CD4 analysis cohort, included 486 treated people with CD4 data, which consisted of 1503 CD4 measurements.
The incident treatment cohort averaged 41.1 years in age, 82.4% were men, and most lived in the South (50.3%), followed by the West (17.4%), Northeast (15.2%), North Central (14.7%), and unknown regions (2.4%). One in 5 cohort members (20.3%) had an AIDS-defining condition. Most people in this cohort (58.7%) started treatment with a nonnucleoside, usually efavirenz in Atripla (49.5%), followed by a protease inhibitor (28.7%), an integrase inhibitor (6.0%), multiple third agents (6.3%), and a CCR5 antagonist (0.3%).
Unadjusted costs per person-year were $33,674 for first-line therapy, $39,191 for second line, and $39,882 for third line. The cost of antiretroviral therapy represented the biggest expense with all three lines of therapy: 54.4% for first line, 52.2% for second line, and 47.8% for third line. Other calculated costs were outpatient care, emergency room use, inpatient care, nonantiretroviral drugs, and lab costs. The proportion of spending on nonantiretroviral drugs rose from 6.6% with first-line therapy to 7.5% with second line and to 13.2% with third line.
Kaplan-Meier estimates of switching regimens within 12 and 24 months of starting were lowest for people starting a CCR5 antagonist (3.7% and 3.7%), followed by efavirenz-based regimens (11.7% and 17.2%), integrase inhibitor regimens (11.6% and 20.9%), nonefavirenz nonnucleoside regimens (13.2% and 25.0%), protease inhibitor regimens (17.4% and 27.8%), and multiple third-agent regimens (29.8% and 41.4%). Overall, more than 20% of cohort members switched regimens within 2 years.
Statistical analysis to compare costs by line of therapy adjusted for prior AIDS, sex, age, region, type of health plan, and Charlson Comorbidity Index. In this analysis, second-line therapy cost 24% more than first-line therapy (P < 0.001) and third-line therapy cost 41% more (P = 0.006). Adjusted costs per person-year were $28,861 for first-line therapy, $35,805 for second-line therapy, and $40,804 for third-line therapy.
The CD4 analysis cohort averaged 47.8 years in age and 76% were men. Almost everyone in this cohort, 95.5%, lived in the Northeast. Unadjusted costs per person-month were highest for people with an initial CD4 count at or below 100 ($5573). Cost per month then dropped sharply for people starting treatment with more CD4 cells, but with little difference between the four CD4 brackets analyzed: 100 to 200 CD4s ($2508), 201 to 350 CD4s ($2425), 351 to 500 CD4s ($2820), and more than 500 CD4s ($2571).
The CD4-based cost analysis adjusted for prior AIDS, sex, age, type of health plan, any antiretroviral use before CD4 measurement, and Charlson Comorbidity Index. In this analysis starting treatment with more than 350 CD4s cost $2526 per person-month. Starting with 100 to 350 CD4s cost about the same ($2378, P = 0.264), while starting with fewer than 100 CD4s cost almost twice as much ($4860, P < 0.001).
These "real-world data," the researchers conclude, "demonstrate that second-line and third-line antiretroviral treatments are significantly more expensive than first-line treatments" and that "direct medical costs increased significantly with CD4 counts less than 100 cells/uL."
1. Solem CT, Snedecor SJ, Khachatryan A, et al. Burden of illness in a US commercially-insured HIV population: treatment patterns and costs. 53rd ICAAC, September 10-13, 2013, Denver. Abstract H-662.