What Is the True Cost of the High Price of ART?

More than twice as many options for antiretroviral treatment (ART) were available in 2018 as were offered in 2012. However, not every combination medication was recommended for most people with HIV (PWH); some were only suggested for use in certain clinical situations (eg, comorbidities). In addition, this increase in choice did not translate into lower prices, something that could have increased access and adherence.

A letter published today in JAMA Internal Medicine shows the extent of the ART price increase, compared with the consumer price index, thanks to a team of researchers from Massachusetts General Hospital, the National Alliance of State and Territorial AIDS Directors, the Harvard University Center for AIDS Research, and Harvard Medical School.¹

ART is the regimen mainstay for everyone who has HIV, irrespective of infection duration. Its purpose is to slow the virus’ progression in the body, and when taken as prescribed, it accomplishes this by reducing the viral load in patients’ blood and body fluids. This keeps the immune system strong, reduces the risk of disease transmittal, and helps prevent drug resistance.^2,3 In the long term, HIV-positive individuals who adhere to ART can sustain virologic suppression, achieve CD4 cell repletion, and reduce hospitalization rates.⁴

In 2012, the average wholesale price (AWP) for an initial ART regimen for PWH ranged from $24,970 for efavirenz/tenofovir disoproxil fumarate/emtricitabine to $35,160 for darunavir/ritonavir boost/tenofovir disoproxil fumarate/emtricitabine. By 2018, the lowest price for ART had risen to $36,080 for raltegravir plus tenofovir disoproxil fumarate or tenofovir alafenamide/lamivudine, and the highest price was $48,000 for dolutegravir/ tenofovir disoproxil fumarate or tenofovir alafenamide/emtricitabine. These numbers represent an average 34% increase in AWP between 2012 and 2018,¹ which the authors note is “3.5 times faster than inflation.”

During the same period, for PWH in certain clinical situations, the mean annual cost of initial ART remained lower, at $25,930 to $39,670. There was, however, a 53% average increase in price, which is 5.6 times faster than inflation. At present, an initial ART regimen for most PWH averages more than $36,000 per patient per year, and this annual cost is only going up: The average price increase has been 6% each year since 2012.¹

These prices for ART in the United States are the highest worldwide, despite the country having the “lowest rate of HIV viral suppression (54%) compared with all other well-resourced countries, including Britain, Australia, and Canada.”¹

What can be done to remedy this situation?

Sometimes patients take it upon themselves to save money, which can be dangerous. Between 2016 and 2017, 7% were nonadherent because of the cost of their medication, and another 14% used a cost-saving measure. For both groups, their measures to reduce costs included⁵:

• Taking less medicine, 4%
• Delaying a prescription, 6%
• Asking a doctor for a lower-cost medicine, 9%
• Using alternative medicine, 2%
• Buying drugs from another country, 1%

According to the authors, “In response to mounting ART costs and prolonged survival among PWH, insurers are increasingly seeking to manage ART access through formulary design, utilization management, and cost-sharing. Slowing the trend of rapidly increasing ART costs is essential to expand and sustain access to effective individualized care and treatment for PWH and to meet ‘End the HIV Epidemic’ goals.”¹

These goals of “Ending the HIV Epidemic” include reducing new HIV infections in the United States by 75% in 5 years and 90% by 2030.⁶

References

1. McCann NC, Horn TH, Hyle EP, Walensky RP. HIV antiretroviral therapy costs in the United States, 2012-2018 [published online February 3, 2020]. JAMA Intern Med. doi: 10.1001/jamainternmed.2019.7108.

2. HIV treatment. CDC website. cdc.gov/hiv/basics/livingwithhiv/treatment.html. Accessed January 31, 2020.

3. Let’s stop HIV together/talk treatment. CDC website. cdc.gov/stophivtogether/campaigns/start-talking-stop-hiv/treatment.html. Accessed January 31, 2020.

4. Priest JL, Burton T, Blauer-Peterson C, Andrade K, Oglesby A. Clinical characteristics and treatment patterns among US patients with HIV. Am J Manag Care. 2019;25(12):580-586.

5. Rodriguez A. CDC report looks at nonadherence to HIV medications due to cost. The American Journal of Managed Care^® website. ajmc.com/newsroom/cdc-report-looks-at-nonadherence-to-hiv-medications-due-to-cost. Published December 28, 2019. Accessed February 2, 2020.

6. What is ‘Ending the HIV Epidemic: A Plan for America’? HIV.gov website. hiv.gov/federal-response/ending-the-hiv-epidemic/overview. Accessed February 2, 2020.