EMBARGOED by the New England Journal of Medicine for 5 pm EST March 14, 2001


Spending on treatment for HIV patients fell by a sixth during the 18 months following the introduction of highly active combination antiretroviral therapy in early 1996. A 43 percent decrease in hospital inpatient care and smaller but significant reductions in the use of outpatient care more than compensated for the increased costs of the newer pharmaceuticals.

Not all benefited equally from these medications, however. For most patients, 75 to 90 percent of spending went for outpatient drug therapy and clinic visits. For under-served groups, such as blacks, women and those with public rather than private health insurance, hospital costs remained the largest treatment cost item.

These are the latest results from an HIV Cost and Services Utilization Study (HCSUS), the first large-scale effort to collect information on a nationally representative sample of persons receiving care for AIDS and HIV disease. The report, which was led by the non-profit RAND organization and published in the March 15, 2001 issue of The New England Journal of Medicine, shows that average expenditures per HIV patient declined from $1,792 per month in 1996 to $1,359 in 1997 before rising slightly to $1,410 in 1998. Average annual per patient treatment costs declined from $20,300 to $18,300 after adjustments for illness severity, patient deaths and other factors.

“There are two broadly important messages in these findings,” observes lead author

Samuel A. Bozzette, M.D., a UCSD infectious diseases specialist and HCSUS co-principal investigator. “The first is that use of these newer drug therapies decreased the total cost of care despite their high unit cost. In other words, expensive new technologies may not be that costly from an overall societal perspective. The second point, perhaps even more critical, is that there is a clear economic consequence to unequal access to care, over and above the human costs. Because patients in disadvantaged groups ended up in the hospital rather than on the newer drugs, their patterns of expenditure were just like those in the bad old days.”

HCSUS is sponsored by the federal Agency for Healthcare Research and Quality (AHRQ) and also supported by the Health Resources and Services Administration and other components of the U.S. Department of Health and Human Services. Conducted by RAND in conjunction with a consortium of private and public research institutions, the research project periodically interviewed a randomly selected sample initially consisting of 2,864 adults representing all HIV patients in the contiguous United States.

“This is a good news-bad news study,” said the director of AHRQ, Dr. John M. Eisenberg. “The good news is that highly active combination antiretroviral therapy reduced the need for expensive hospital inpatient care among HIV patients as a whole; the bad news is that it didn’t affect disadvantaged groups to the same degree.” Dr. Eisenberg added that AHRQ recently launched a $45 million program to examine the causes of disparities in health care and to look for solutions.

The authors caution that the slight upward trend in hospital expenditures detected towards the end of the study period warrants close observation. “If it is sustained,” they observe, it “probably reflects the aggregate effect of treatment failures due to viral resistance or drug intolerance” and “stands as a warning that the service capacity lost with the closing of HIV wards might be needed again.”

Bozzette is affiliated with RAND, the UCSD School of Medicine and the Veteran Affairs San Diego Healthcare System. The other principal investigator of the project, Dr. Martin F. Shapiro, is with RAND and the University of California, Los Angeles. Co-author Dana P. Goldman and the majority of the other members of the research team are with RAND, which is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.

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Media contact: Jess Cook

UCSD Health Sciences Communications Health Beat