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FOCUS ON HIV
CARE
Betty J. Dong, Section Advisor
Programs to improve HAART adherence are cost effective
Key point: Results from a cohort study involving
6,833 patients with HIV living in South Africa showed that patients with
the highest adherence rates to highly active antiretroviral therapy
(HAART) had the lowest total monthly mean direct health care costs; this
was primarily attributed to decreased hospitalization costs.
Finer points: Jean Nachega, MD, PhD, and colleagues
conducted a cohort study to assess the association between adherence to
HAART and total monthly direct health care costs in a large HIV-infected
adult population (n = 6,833) living in South Africa and enrolled in a
HIV/AIDS managed care program (Aid for AIDS). Eligible patients were
treatment naive at enrollment and had at least 6 months of follow-up
data. Direct health care cost data were obtained from the Aid for AIDS
database and adherence data were assessed via an analysis of pharmacy
claims. Patients were classified into one of four quartiles, with
quartile 1 being the lowest adherence rates and 4 being the highest. A
similar number of patients were in each quartile: 1 (n = 1,701), 2 (n =
1,753), 3 (n = 1,647), and 4 (n = 1,732).
For the overall cohort, median age was 37 years, 61.2% were women,
and 98% were black. Patients were followed for approximately 25 months.
Total mean monthly direct health care costs were $369.7, with the
majority of this amount related to hospitalizations ($150.8). When
assessing patients by quartile, those in quartile 1 had higher mean
monthly costs ($375.6) compared with patients in quartile 4 ($313.5).
These higher costs were primarily related to increased hospitalization
costs for patients with poorer adherence rates ($190.2 for quartile 1
vs. $91.9 for quartile 4). As adherence increased, the amount spent on
HAART also increased; however, these increased costs were offset by the
reduction in hospitalization costs. In addition, crude mortality
decreased as adherence rates increased (13.2% for quartile 1 vs. 3.0%
for quartile 4).
What you need to know: Adherence to HAART is
essential to prevent viral resistance and disease progression and
improve morbidity and mortality. The current analysis supports funding
of programs that are designed to enhance adherence to HAART in a
resource-limited setting such as South Africa. The investigators
commented that programs aimed at monitoring adherence proactively can
have a substantial impact on patient outcomes. They wrote that
additional funding for adherence programs and funding designed to reduce
the cost of HAART would help enhance adherence rates for patients with
minimal resources such as the current cohort.
An accompanying editorial by David Bangsberg, MD, MPH, and Steven
Deeks, MD, commented that the full benefits of enhanced adherence were
underestimated in the analysis because the investigators did not include
the societal benefits of restoring health and economic productivity.
These authors recommended community-level interventions such as local
access to free HAART and patient-level interventions such as education,
counseling, and telephone/electronic reminders to enhance adherence in a
resource-limited setting such as Africa.
What your patients need to know: Tell patients who
are prescribed HAART about the importance of adhering to their
prescribed regimen. If patients are having trouble adhering to the
regimen because of pill burden, bothersome adverse events, or financial
difficulties, encourage them to discuss these issues with their
prescriber and to never stop therapy on their own.
Posted by Carli Richard (crichard@aphanet.org)
March 10, 2010
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