Population Management and Cost Containment in HIV

Peter L. Salgo, MD: You’re talking about not managing, which means that you’re worried the cost is going to spiral out of control. But how big an issue is this? How many folks are we talking about? How many people in this country do we know have HIV, and how many are being treated? What’s the number?

Michael Sension, MD: I’ve heard estimates of about 1.1 to 1.2 million people living with HIV in the United States, and approximately 75% to 80% know they have it.

Jeffrey Dunn, PharmD: That’s the issue. It’s how many people know and how many are being treated. It’s that pool, and what are we doing to address those people? From our perspective, we don’t know. We just base it on claims data. I’ll reiterate. I’ll stop saying this, but again, this is a top 5 or 6 category in terms of cost.

Peter L. Salgo, MD: It is. But you’ve already mentioned, you’ve all mentioned, that if we get everybody—I’m going to put a number on the table for lack of any other—a million-and-a-half folks and if we treat them, really sit on this disease, and get these people treated and their viral count goes to 0, your cost is going to go to 0 in a generation or 2. Not a bad idea, or is it?

Jeffrey Dunn, PharmD: No, it’s a great idea. I don’t think anybody is going to sit here and say that’s not a legitimate goal that we should have. I will just say though, that getting there is going to be costly. So, are there better ways to get there? We just need to be thinking about that, that’s all I’m saying. Because realistically, employers and health plans and everybody who is purchasing insurance now has to pay for what’s going on. They’re not paying for what’s going on 50 years down the road.

Michael Sension, MD: I think that what you’ve articulated is happening on a public health level. Across the board and across many states now, there’s a push to have what’s called “opt-out testing,” where instead of you needing special consent to have an HIV test, it’s a part of the general consent to care. So, at every point of contact with the health care system, there’s an opportunity to identify people who otherwise would not know that they have HIV.

Peter L. Salgo, MD: It sounds to me, for lack of a better word, that this has become destigmatized to the point where it’s just part of the medical landscape. Maybe not completely, but it’s hidden in that direction compared to where it was in the 1980s. Today we say, “All right, so he’s HIV-positive, but his viral count is 0 and his T4 cell count is OK, so let’s go.” Is that what you’ve seen?

Michael Sension, MD: We’ve made strides forward in that, but I think we have a long way to go still. I think that would really be destigmatized if insurers and third-party payers would also take that approach and say, “We won’t increase somebody’s insurance rates based upon their HIV status or being HIV-positive, particularly if they’re taking care of themselves.”

Elly Fatehi, PharmD, BCPS: You can’t do that under the current regulations. That would be a preexisting condition, which is not allowed. But I come from New York City, and in New York City our health plan is under the state and we have this whole epidemic initiative. Our goal is to treat everybody that is infected with HIV to get viral load undetectable and to prevent transmission. From our state’s perspective, everybody who’s infected should have insurance, whether it’s Medicaid or commercial, and start treatment as soon as possible

Jeffrey Dunn, PharmD: No argument.

Peter L. Salgo, MD: Here’s what I see coming through the door in my ICU (intensive care unit), and this is from the perspective of the residents and interns who are kids. They haven’t had this history. They present the patient: “Well, he’s got hypertension, he’s a diabetic, and he’s got HIV but he’s on these drugs and his viral count is 0. So, now let’s talk about what’s wrong with him.” That was inconceivable a generation ago, and it’s where we’re headed, I think. You don’t sound convinced.

Elly Fatehi, PharmD, BCPS: No, no, I agree with you 100%.

Jeffrey Dunn, PharmD: Yes, 20 years ago if somebody had HIV, you weren’t worried about their diabetes.

Peter L. Salgo, MD: Well, we were.

Jeffrey Dunn, PharmD: You were, but nowadays it’s different. We’ve made a lot of progress. It’s fantastic. We’re all on the same page in terms of the goal. I’m just saying that I think it’s unfair. Long-term, it’s to the detriment of society and to the patient if we don’t have some discussions around the cost component.