The Economic Burden of AIDS in America: Increasing Access to HIV Medicines

The Economic Burden of AIDS in America: Increasing Access to HIV Medicines

Clay Porter

Eastern Virginia Medical School

Abstract

This paper examines the cost of the HIV epidemic in America and surmises the economic benefits of an early targeted roll out of treatment for minority communities. By assessing the literature on health disparities in accessing HIV/AIDS medicines and the financial toll of medical costs associated with HIV-related complications, it is determined that increased access will reduce the economic burden of the virus on both at risk communities and the health services systems they rely on.

The Economic Burden of AIDS in America: Increasing Access to HIV Medicines

There are an estimated 1.1 million individuals living with human immunodeficiency virus (HIV) infection in the United States, and about 66% of this population are not engaged in medical care (CDC, 2014). This disparity is extreme, with black and Hispanic communities, specifically men-who-have-sex-with-men (MSM), representing an overwhelming majority of those not in treatment (CDC, 2015). “Compared to white men, African-American men were more than seven times and Latin men were almost twice as likely to die from HIV-related complications (Ostrov, 2015).” This paper examines the benefits of increasing access to biomedical interventions, such as highly active antiretroviral therapy (HAART) and pre-exposure prophylaxis (PrEP), for the treatment and prevention of HIV in the United States and surmises the effects of reducing disparities in the access to HIV/AIDS medicines on the U.S. health care delivery system.  

According to the Federal HIV/AIDS Budget, with government spending estimated at 26 billion dollars (USD), it is important to evaluate the economic burden of the global AIDS pandemic, especially for those most impacted by the virus (2017). A lack of access to biomedical interventions among black and Hispanic MSM reveals disparities in the treatment of HIV and suggests that the overall cost of HIV infection and illness is disproportionately borne by this sector of the population (Hutchison et al., 2006). The question of ‘access’ is critical to understand this relationship, for the existence of medicines is not helpful unless individuals have access to them. There are many barriers to treatment that prevent individuals from obtaining the drugs they need to live healthy, productive lives; it’s not simply an issue of financing care. Applying public health principles to the HIV epidemic will reduce the barriers to treatment and help close the gap between those who are being treated for HIV in the U.S. and those left behind.

Biomedical interventions use both clinical and medical approaches to prevent the spread of HIV (Avert, 2017). This includes the use of HAART to suppress the virus among individuals living with HIV, and PrEP for preventing HIV in individuals who are HIV-negative. Together with routine testing, biomedical interventions help to reduce new HIV infections and improve health outcomes for people living with the virus (Healthy People 2020). However, not everyone is enjoying the benefits of biomedical intervention. Access to medical care in the U.S. is a serious issue; black and Hispanic MSM are less likely to remain in treatment than their white counterparts (CDC, 2015). Reducing disparities in accessing HIV/AIDS medicines and inequities in the delivery of health care are critical for achieving cost-effective HIV treatment.

The economic burden of an individual living with HIV in the U.S. is estimated at USD 385,200 over a lifetime (Hutchison et al., 2006). Despite the high cost of HAART and PrEP, studies have shown these treatments to be cost-effective because they reduce the economic burden of illness associated with AIDS-related hospitalization and death (Hutchison et al., 2006). Racial and ethnic disparities in antiretroviral therapy prescription is evidence that access to HIV treatment is a critical public health issue, that has far reaching effects on both the individuals at-risk of HIV infection and the health care facilities and services that support them (Farham, 2006).  

In this section, the overall cost of biomedical interventions and other HIV-related health care is compared to the estimated cost of illness and productivity loss for individuals not receiving care. Ethnicity-specific estimates shed light on the economic burden of HIV/AIDS and provide insight into how policy makers and community health leadership can better allocate resources. Preventing new transmissions is the most cost-effective argument in support of the value of biomedical treatment (Hutchison et al., 2006). Despite the high price of pharmaceuticals, the costs to society extend beyond the medical domain. The potential medical cost savings from avoiding or even delaying HIV infections in the U.S. are substantial (Hutchison et al., 2006). With greater success in the effective use of biomedical interventions in the treatment and prevention of HIV, the economic burden of AIDS in America will decrease coinciding (Hutchison et al., 2006).

The economic impact of HIV has been a concern since the onset of the epidemic, with most cost being associated with the price of medical treatment, rather than indirect costs such as lost productivity and premature death (Farham, 2006). However, if we surmise the value of loss due to co-morbidity and early mortality, the price of biomedical treatment compared to the economic burden of illness due to lack of care justifies an early targeted roll out of HIV/AIDS medicines (Farham, 2006). A recent study by Hutchison et al., examined differences in disease morbidity, health status, and use of medical services according to race and ethnicity, in order to assess the cost of HIV/AIDS on minority populations.  According the researchers, when the costs per incidence of infection and PrEP prescription was compared by race/ethnicity, disparities among black and Hispanic communities became evident. Productivity losses among minorities were significantly higher than for whites, while direct medical costs were lower. The study reveals that “these results are attributable to diagnosis in the later stages of disease, delays in getting into care, and less access to ART for these minority groups (Hutchison et al.)” Their analysis highlights the savings that can be achieved by increasing access to HAART and PrEP, and the benefits of universal access to HIV treatment.

HIV treatment in the U.S. depends on an individual’s access to the health care delivery system. Be it employer sponsored health insurance, changes due to the Affordable Care Act (ACA), Ryan White and the AIDS Drug Assistance Program (ADAP), Medicaid and Medicare, pharmaceutical company programs or clinic trials, there are a myriad of ways individuals are getting HIV drugs and a complex array of barriers to access them. For example, expanded access to health care insurance under the ACA, has allowed minority communities to more effectively manage health problems that have disproportionately affected them, such as HIV (Pavni, 2017). The failure of ACA repeal efforts under the Trump Administration presents additional opportunities for increased access under Medicaid, especially for minorities living in the South, where only two states have approved the Medicaid expansion (Pavni, 2017)

Improving access to HIV care is a high priority. The scientific data on the benefits of increased access to HIV treatment for people living with HIV and prevention from HIV has informed our National HIV/AIDS Strategy (HIV.gov, 2017). According to this report, there needs to be a “concerted national effort to improve health outcomes for people living with HIV by establishing seamless systems to link people to treatment and care immediately after diagnosis (HIV.gov, 2017).” Further, the Strategy calls for new efforts to reduce barriers to treatment, patient-centered care, including addressing challenges in meeting basic health needs, such as housing, which can cause individuals to leave care and treatment (HIV.gov, 2017). Under the Obama administration, fifteen million dollars (USD) was directed to the Health Resources and Service Administration (HRSA) to implement the goals of this strategy (HIV.gov, 2017). Through the “Increasing Access to HIV Care and Treatment” initiative, HRSAS provided ten mission dollars (USD) to Ryan White HIV clinics, and five million dollars (USD) to the Ryan White HIV/AIDS Program Part C grantees, who provide critical interventions at the community level (Frieden, 2017).

Equitable access to HIV/AIDS medicines is realized by applying public health principles to the epidemic. The use of biomedical interventions in the treatment and prevention of HIV depends on sustainable financing, affordability, and reliable access to the health delivery systems.  Critical investments in biomedical treatment programs will reduce HIV transmission and its economic burden on target populations. Despite this progress, most individuals living with HIV are still gay and bisexual men (MSM), particularly those a part of black and Hispanic communities. Despite advancements in surveillance strategies and data-driven interventions, biomedical approaches to treatment and prevention are not being effectively implemented (Frieden, 2017). A recent study in the New England Journal of Medicine documented the impact of increasing access to HIV medicines in two cities, San Francisco and New York City (Frieden, 2017). In San Francisco, the study reveals that increased rates of testing and direct linkage or reengagement in care for all individuals at risk of HIV infection resulted in a greater proportion of virologic suppression at the population level (Frieden, 2017).  When coupled with the use of PrEP for individuals who are HIV-negative, there was a forty percent decrease in new infections. In New York, rates of viralogic suppression have increased coinciding the individual-level support to link patients to medical care (Frieden, 2017). Together, these two examples show that both community and individual-level initiatives aimed at increasing access to HIV/AIDS treatments are beneficial to the population as a whole.

The economic benefits of universal access to HIV/AIDS medicines surpass direct medical costs, underscoring the need for systemic change in the U.S. health care delivery system that is aimed at reducing health disparities among racial and ethnic minorities, specifically black and Hispanic MSM. To ensure that everyone has an opportunity to live a healthy, productive life, regardless of their race, gender, class or sexual orientation, universal access to biomedical treatment must be cost-effective, and achieved on a non-discriminatory basis, taking into account the specific needs of the nation’s most vulnerable and marginalized sectors of the population.

Increased access to health insurance through the Affordable Care Act, together with the momentum generated by the National HIV/AIDS Strategy, have moved the nation closer to achieving virologic suppression for people living with HIV, and set the focus on treatment and early detection for all individuals at-risk of HIV infection. Increased access to HIV/AIDS medicines has led to a decrease in the rate of new infections. However more studies need to be done on the direct impact of increased access among minority populations who are at a greater risk of HIV infection. It is important that researchers provide accurate and updated information regarding the cost of HIV care to assist policy makers and stakeholders with economic planning, policy development, and resource allocation. Structural inequalities in the health care delivery system need to be addressed to create for more equitable access to HIV treatment. Increased access to biomedical interventions for at-risk populations, be it HAART or PrEP, will decrease the incidence of infection and reduce the scope of the epidemic, as well as its social and economic toll on the nation.

There is a myriad of solutions to this problem. Poverty reduction, greater access to treatment and prevention options, linkage to care and viral suppression for HIV positive individuals, biomedical interventions aimed at reducing risk behaviors are just some of the many ways to answer this community health problem. However, the most effective methods tend to be regulatory. Laws and legislation designed to address public health concerns have a high impact on the population because these new ideas can be enforced. Nongovernmental agencies do not have the power to enact policies for those outside their organization, so they tend to lead by example. In this way, creating change is difficult and time-consuming; but with the support of local authorities, such as health officials, government leadership, and elected representatives, we can expedite the processes which shape the health of our communities.

Here in Virginia, Governor Northam should use his executive authority to establish an inter-agency task force on minority health aimed at reducing barriers to HIV treatment in the public health system; and direct the Virginia state legislature to develop new competencies for educating medical providers and public officials on the specific health care needs of minority communities. New laws should require practicing physicians to undergo sensitivity trainings on sexual orientation and minority health, and mandate that medical providers make all the preventive tools available to patients without judgement. Individuals should have the right to harm reduction approaches to health care in the specific context of access to HIV treatment, be it a local health department, regional hospital, university wellness center, or primary care system; no one should be denied treatment options and medical services based on the moral-political opinions of their provider. Communities at-risk of HIV infection need to be equipped with the means to redefine the factors that affect their health, such as rolling out PrEP treatment to Virginia residents regardless of their ability to pay, or affording the MSM community with grant funding to reduce the rate of homelessness and unstable housing that contribute to the spread of infectious diseases like HIV.

Actions such as these must be enacted at the highest level and enforced across the system as whole. This kind of strong leadership will set the standards for future generations and help establish a new era in American public health history characterized by its focus on diversity in the community and the health of individuals a part of them. Access to HIV treatment in America will remain a public health crisis and the economic burden of disparities in the access to treatment will continue to take a toll on the health care delivery system and the communities they care for, if we do not act now.

Sources

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