Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

984 Abstracts 44241-44245

12th World AIDS Conference

482*/44241 Expansion of US Medicaid system to cover HIV
drugs will prevent thousands of deaths and AIDS
diagnoses, and is affordable
James G. Kahn1, B. Haile1, S.W. Chang2. Center for AIDS Prevention Studies,
UCSF Inst. for Health Pol Stud., UCSF, Box 0936, San Francisco, CA; 2HJ
Kaiser Family Foundation, Menlo Park, USA
Objectives: To assess the health and federal fiscal implications of expanding
Medicaid, the US insurance system for the poor, to cover HIV care for those
without access to HIV medications.
Design: Computer spreadsheet modeling of HIV disease progression, treatment costs, and financing.
Methods: We compared projected outcomes with and without an expansion,
over 5 years. The expansion assessed is for all individuals lacking medical insurance for antiretroviral medications and with income below $10,000 per year (125%
of poverty for a single person). It covers medications and outpatient care. The
analysis incorporates estimates of the number of people living with HIV infection
by disease stage; current access to antiretroviral therapy, insurance status, and
income; likelihood of qualifying for and enrolling in the expansion; a natural history
model of HIV disease progression, calibrated to cohort studies; the efficacy of
combination antiretroviral therapy in reducing HIV disease progression, based on
clinical studies; the costs of HIV medications and care; and federal government
costs for the expansion.
Results: An estimated 37,100 individuals would enroll in the expansion, 83%
pre-AIDS and 17% with AIDS. Over 5 years, there are 5,200 fewer deaths with the
expansion than without. 6,700 fewer individuals with early HIV disease progress
to an AIDS diagnosis or early death. The expansion increases total life years by
14,500 over the 5 years. Total federal costs for the expansion itself are $1.3 billion
over 5 years; these are offset by decreased federal expenditures of $765 million:
Medicaid, due in part to slowed progression to AIDS ($385 million), AIDS Drug
Assistance Program ($240 million), and other programs ($140 million). Federal
budget neutrality, currently required to approve Medicaid waivers to states, can
be achieved by an 18% reduction in Medicaid prices for HIV drugs. Despite this
price reduction, total spending for HIV drugs increases by $175 million.
Conclusion: This analysis suggests that expansion of the US Medicaid system to provide wider access to combination antiretroviral therapy would prevent
thousands of deaths and AIDS diagnoses, leading to 14,500 more years of life for
persons with HIV disease over 5 years. The program is affordable from a federal
perspective, with budget neutrality achievable if the expansion is accompanied
by an 18% reduction in HIV drug prices for Medicaid.
44242 Should plasma PCR be used to target CMV prophylaxis in
AIDS patients? Insights from a cost-effectiveness
evaluation
A. David Paltiel1, S.J. Goldie2, C.J. Cohen3, M.C. Weinstein2, K.A. Freedberg4.
1 Yale School of Medicine 60 College Street New Haven CT 06520,; 2Harvard
School of Public Health, Boston; 3Community Research Initiative, Brookline;
4Boston Medical Center, USA
Background: To explore the circumstances under which targeted CMV prophylaxis, using PCR screening to identify patients at greatest risk, might be clinically
and economically justifiable.
Methods: We developed a mathematical, state-transition, simulation model to
estimate the cost-effectiveness of three alternative CMV-prevention strategies in
patients with CD4 < 50/1tL who receive otherwise standard care: (1) no CMV
prophylaxis; (2) targeted CMV prophylaxis (where a single PCR test is performed
when CD4 is first observed below 50 cells//1L and patients with positive results
receive oral ganciclovir (GCV)); (3) general oral GCV prophylaxis (no PCR test is
performed) for all patients. Data for the model were derived from the Multicenter
AIDS Cohort Study (MACS), randomized clinical trials of CMV prophylaxis, and
the AIDS Costs and Services Utilization Survey (ACSUS). Baseline estimates
included monthly risk of CMV (1.86% overall, 5.04% if PCR-positive), efficacy of
GCV (49% reduction in CMV risk), PCR test costs (US$200), and the monthly
cost of oral GCV ($1,300).
Results: With no CMV prophylaxis, the average patient with a beginning CD4
count of 201-300/jiL has total lifetime costs of approximately $43,200 and lives
4.02 quality-adjusted life-years (QALYs). With targeted CMV prophylaxis, costs
and survival increase to approximately $46,200 and 4.05 QALYs, respectively.
General CMV prophylaxis, wherein all patients receive prophylaxis, costs $55,700
and confers 4.06 QALYs. These results are sensitive to the incidence of CMV and
the relationship between CMV viral load and predisposition to disease. Results
are not sensitive to the price of oral GCV or to reasonable variation in patient
quality of life assessments.
Conclusions: Relative to no CMV prevention, targeted CMV prophylaxis using
PCR testing confers additional QALYs at an incremental cost of $95,000. The cost
per additional QALY that results from further extension of GCV prophylaxis to all
patients (regardless of CMV viral load) is $938,000. We conclude that, compared
to alternative uses of HIV patient care resources, universal CMV prophylaxis does
not appear to be cost-effective. Targeted prevention based upon PCR findings

does warrant consideration.

44243_ Early treatment with highly active antiretroviral therapy
(HAART) is cost-effective compared to delayed treatment
John Hornberger1, J.E. Aledort2, N. Roth2, M. Eging2, G.R. Rose3,
W.E. Arnold3. 1Roche, Stanford University, 3401 Hillville Avenue, Mailstop
A3-122, Palo Alto, CA 94304-1397; 2Roche Pharmaceuticals, Nutley, NJ;
3Treatment Access Expansion Project, Washington, DC, USA
Background: Recent US Department of Health and Human Services guidelines
recommend HAART in asymptomatic patients based on HIV RNA, CD4 count,
prognosis for disease-free survival, and patients' willingness to accept therapy.
This study examines the potential clinical and economic consequences of early
HAART.
Methods: To assess optimal timing of HAART initiation, a Markov model was
used to simulate outcomes in a cohort of 10,000 asymptomatic HIV+ patients.
Data were obtained from clinical trials and from published reports of the Multicenter AIDS Cohort Study, US HIV/AIDS medical costs, and published quality-of-life
estimates. Patients were assumed to change HAART regimens if an earlier regimen failed. Endpoints were measured according to the guidelines of the US
Panel on Cost-Effectiveness in Health and Medicine. Two policy objectives were
compared: (1) initiating HAART early when CD4 is 200-500 or HIV RNA > 10,000
versus (2) initiating HAART late when patients develop an AIDS-defining event
(ADE) or have CD4 < 200.
Results: By 5 years, 15% of patients initiating HAART early are estimated to
develop an ADE compared to 29% if treatment is delayed. By 10 years, 42%
of patients with early HAART develop an ADE compared to 51% for delayed
treatment. Early HAART prolongs patients' survival (adjusted for quality of life) by
6.2%. Although HAART is expected to delay the cost of treating AIDS in the near
term, the overall costs to society in the long term could increase slightly by about
5.0% due to increased patient survival. The cost-effectiveness of early HAART in
asymptomatic patients is $23,700 per quality-adjusted year of life saved.
Conclusions: Early HAART is predictive of delayed progression to ADEs and
prolonged survival. The cost-effectiveness of starting HAART early is well within
the range of many accepted medical therapies routinely reimbursed by public and
private payers.
484*/44244 Implicit valuation of a blood exclusion decision
Edward H. Kaplan. Yale School of Management Box 208200, New Haven, CT
06520-8200, USA
Background: In 1996, it was revealed that blood donations from Ethiopian immigrants to Israel were routinely discarded, without informing the donors, for fear
that such donations would contaminate Israel's blood supply with HIV infection.
Following the revelation of this policy, 10,000 of Israel's 60,000 Ethiopian immigrants demonstrated in protest, 70 persons were injured, and Israel was subjected
to considerable criticism. This study estimates the number of infectious donations
prevented by Israel's Ethiopian blood ban, and conducts an implicit cost-benefit
analysis of this blood exclusion decision.
Methods: The number of infectious donations averted is estimated as the
product of the number of attempted antibody negative donations by Ethiopian
immigrants, and the false negative screening rate. The false negative rate is estimated as the product of HIV incidence among would be Ethiopian donors, and the
mean duration of the window period from HIV infection until the development of
HIV antibody. Total costs of $1.5 million (reflecting medical and non-medical costs
of HIV) are charged for each infectious donation. Together these assumptions
serve to overstate the effectiveness of the Ethiopian blood ban.
Results: At most one infectious donation every ten years was prevented by
the Ethiopian blood ban. For the ban to prove cost-beneficial, the social costs
imposed on Israeli society from this ban would have to be less than $150,000
annually, or only $2.50 per Ethiopian immigrant per year.
Conclusions: The social costs Israel suffered on account of the Ethiopian
blood ban were considerable while the public health benefits Israel achieved
were slim. For example, the medical costs alone associated with the 70 injuries
reported above might compete with the benefits of preventing one infectious
donation every 10 years. Contrasting the social costs of this blood ban against
the meager public health benefits derived, Israeli society may not have been well
served by excluding Ethiopian donors.
481*/44245 The affordability of antiretroviral therapy in
developing countries: What policymakers need to
know
Steven Forsythe. Pembroke Place, Liverpool England L3 5QA, England
Objective: To assist policymakers in developing countries and international
donors by providing an outline of economic information needed to make a decision regarding the purchase of drugs needed to provide triple combination therapy
(TCT).
Methodology: The following presentation: 1) reviews existing experiences of
policymakers in developing countries regarding the purchase of drugs needed for

TCT, 2) identifies issues that would need to be addressed and data that would be
required order to make more informed decisions regarding this issue, 3) develops
a cost-benefit model that could be utilised in designing an economic research
project evaluating the economic costs and benefits of TCT and 4) uses data from
Costa Rica to develop a preliminary assessment of this economic model.
Results: A review of experiences with this issue reveals that there are growing
political, legal and budgetary pressures for countries to make tenable decisions