The Economic Benefit of Preventing HIV

In May 2014, the CDC released guidelines for pre-exposure prophylaxis (PrEP) for individuals considered high risk for HIV infection: those in relationships with HIV positive partners, those engaged in high-risk sexual behavior, and those with ongoing intravenous drug use. The recommendations include daily Truvada, an antiretroviral drug, and follow-up visits with STI/HIV testing and lab work every 3 months. These guidelines represent a significant investment estimated at $13,000 annually without insurance just for the medication.

A recent Medical Care study examined the effect of PrEP by analyzing the lifetime cost savings of preventing one HIV infection. This study asserts that prevention of infection will yield significant cost savings.

However, the study has several limitations. First, the study fails to consider the costs associated with pre-exposure prophylaxis. The study estimates an increase of 13% in medical costs for those that are HIV uninfected not accounted for by the annual cost associated with PrEP ($13,000 yearly). This would significantly reduce the predicted lifetime cost-savings.

Second, there a risk of increased resistance associated with PrEP, especially if Truvada is given to persons with ongoing systemic HIV infection. Although this is somewhat mitigated by regular HIV testing while on prophylaxis, there is a chance of having a negative HIV antibody test, while still positive for HIV RNA. This could theoretically increase costs as other, possibly more costly, antiretroviral therapy will need to be considered for treatment.

More importantly, there are a myriad of social, psychological, and emotional implications associated with preventing an HIV infection, which the study acknowledges are areas for further research and may represent even further benefit of PrEP.

The study proposes, and I would agree, an urgent need for generic antiretroviral medications. With generic medications, there is a significant reduction in costs per HIV infected patient.

While the study fails to construct an economic argument in favor of PrEP, the social and public health implications of preventing HIV infection and transmission are innumerable. Policies targeting all economic and social contributions to HIV infection instead of simply medicating them would be ideal.

commentary by Sharmistha Dev, MD MPH

Abstract

OBJECTIVE: Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States.

METHODS:We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD). RESULTS:The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided. CONCLUSIONS: The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment. PMID: 25710311.

Schackman, BR et al. Med Care. 2015; 53(4):  293-301.