Aggressive HIV treatment cost-effective

Drug cocktails cost less than other interventions

Ten years ago, treatment for HIV could only buy patients a little more time before they entered the downward spiral of illness. Some decision makers at the time questioned whether it was worth it to pay for such treatment. But in the last two years, combination therapies - commonly called drug cocktails - have dramatically improved HIV care to the point that researchers say early aggressive treatment is not only good for the patient but also for the pocketbook.

"There is a sense that we have stopped that spiral down, if not indefinitely than certainly for much longer than ever before," says Calvin J. Cohen, MD, research director of the Brookline, MA-based Community Research Initiative of New England, which does clinical trials on HIV therapeutics. "We and others have done analyses of the cost-effectiveness of more expensive interventions vs. treating minimally, and at this point it's fair to say the effective treatment of HIV fortunately turns out to be a cost-effective approach."

To prove his point, Cohen recently did a literature survey of current research on the clinical and financial benefits associated with protease inhibitor-containing regimens for the HIV Phys icians Strategic Treatment Initiative, a medical education program sponsored by The University of Alabama School of Medicine in Birmingham. (For details on how to get a copy of the program, which includes 29 charts and graphs based on various studies, see address at the end of this article.) Highlights include the following:

· Early treatment preserves immune function and may lower the probability that drug resistance will develop.

· Careful evaluation of the patient's actual adherence (dietary requirements, daily routine, attitude) is key to cost control and maintaining viral load reduction.

· In terms of HIV cost per year of life saved, drug cocktails are more cost-effective than many other common medical interventions such as screening mammography.

· The cost per year of life saved for HIV drug cocktails is between $10,000 and $20,000, Cohen says, compared to around $30,000 for screening mammograms and $110,000 for coronary bypass surgery.

Avoiding other problems

Another key point to consider is the ability of drug cocktails to prevent the opportunistic infections that plague patients when HIV goes unchecked. You'd have to pay $10,000 for one year of an aggressive regimen with maximum potency, Cohen says, but thatmuch less than the cost of treating other illnesses that could occur. One medication alone for treatment of cytomegalovirus retinitis, a common complication of AIDS, costs $15,000 a year. Full treatment for the condition could cost upwards of $100,000. And of course, you have the human cost of quality of life for patients, as well as a possible inability to work and need for disability payments.

"We have enough information now to inform us that when we spend our resources on combination therapy that not only do the patients do better, but it's also a good use of dollars," Cohen says. "For the amount of money you spend to treat HIV, you're also preventing illnesses that in themselves have high costs."

Drug cocktails have become the standard of care for HIV in the United States, but there's debate on which combinations to use, when to start them, which patients should be eligible, and how to pay for them. Cohen advocates early aggressive treatment for anyone with HIV. "I think any HIV-positive patient deserves treatment. There's no such thing as a good amount of HIV," he says. "It's more cost-effective to do a complete cocktail and get it right the first time than it is to deal with resistance or other illnesses down the road."

Research has shown that patients who don't comply with their medication schedules dramatically reduce the future effectiveness of drug cocktails and may unwittingly make themselves resistant to other HIV medications. Missing a medication even once can make the virus resistant forever to that drug and to other drugs in that class.

Kenneth Freedberg, MD, associate professor of medicine at Boston Medical Center, Boston University School of Medicine, says the cost-effectiveness of the drugs hinges on successful adherence, monitoring, and ongoing care. "If you're hypertensive and you miss an occasional dose of your blood pressure medication, it won't help but it probably won't hurt you much either," he says. "With HIV, if people take the drugs occasionally, it may be worse than not taking them at all. You can develop a resistant virus and then a year later, if you become motivated to start treatment again, the drugs might not work. It's critically important people understand the seriousness of the medications."

Freedberg points out that the research on the cost-effectiveness of drug cocktails is new enough that the implications on long-term costs aren't clear. But it appears that even if the drugs don't actually save money in the long run, they still provide a good value. "They improve survival and quality of life at a reasonable cost compared to other things we do with medical resources," Freedberg says. "You spend a lot of money, but you get a lot of benefit from them."

Most private insurers pay for drug cocktails, Freedberg says, but there are inconsistencies with the state-funded AIDS Drug Assistance Programs. Some states pay for cocktails; others pay for certain combinations or none at all. "It is a question of trying to convince policy-makers that they should provide these medications and for physicians to understand how best to use them," Freedberg says. "The drugs work, but not all people have access to them."

Cohen says HIV drug cocktails should be considered highly in the evaluation of the cost-benefit ratios of different medical treatments. "Medicine is at a point where we can do more than we have money to pay for. In HIV, that issue is critical because of the fast-paced and life-threatening nature of the illness. There's not much time to wait."

[To get a copy of the HIV Physicians Strategic Treatment Initiative educational program on cost-effective HIV care, contact The Alliance for Scientific Affairs and Publications Inc., Five Sylvan Way, Suite 100, Parsippany, NJ 07054. Telephone: (973) 898-9600. For other information, contact:

· Calvin J. Cohen, MD, research director, Com mun ity Research Initiative of New England, 320 Washington St., Suite 3, Brookline, MA 02445.

· Ken Freedberg, MD, associate professor of medicine at Boston Medical Center, Boston University School of Medicine, 91 E. Concord St., Suite 200, Boston, MA 02118. Telephone: (617) 534-7443.]