The Care of HIV-Infected Adults in the United States
Jan 1, 1998
Good News and Bad News
The good news about HIV care in the United States is that treatment costs are not prohibitive—the average cost per patient equals about $20,000 a year. Although these costs represent a growing burden on the public sector, they are still smaller than the costs of treating some other major diseases. The bad news, however, is that one-half to two-thirds of American adults infected with HIV do not get regular care, and even fewer receive the most advanced anti-HIV therapy.
These are the main findings in the initial report from the HIV Cost and Services Utilization Study (HCSUS), the first comprehensive effort to collect information about a nationally representative sample of people receiving care for HIV infection. Sponsored by the Agency for Health Care Policy Research, the study is being led by RAND in conjunction with a consortium of private and public research institutions.
The report is based on data from the study's opening round of interviews with 2,864 patients randomly selected to accurately represent the study's "reference population"—adults in the contiguous 48 states with known HIV infection who received medical care during the first two months of 1996. The study excluded adults treated at military, prison, and emergency room facilities and also excluded children. The interviews sought information primarily on the nature and costs of care, as well as on patient characteristics.
The study team found that 231,400 adults were treated during the first two months of 1996. Based on this figure, the team estimated that about 335,000 HIV-infected American adults saw a doctor at least once every six months in 1996. However, about one-half to two-thirds of all infected adults (estimated to number between 650,000 and 900,000) did not receive regular medical care. These individuals were primarily in the early stages of the disease. Fifty-nine percent of patients met the Centers for Disease Control case definition for AIDS, the most advanced stage of HIV infection.
Care settings. Seventy percent of patients received care from office-based physicians and community hospitals and clinics, and the remaining 30 percent received care from major teaching hospitals.
Costs. The cost of treating patients in the reference population was about $5.1 billion annually. This figure is based on data from the first two months of 1996. The authors extrapolated from this figure to estimate that total spending for HIV-infected adults who received medical care at least once every six months in 1996 was about $6.7 billion (approximately $20,000 per patient), or less than 1 percent of all direct personal health care expenditures in the United States. That number is "not inordinate," according to the study, considering that HIV infection accounts for about 7 percent of the total potential years of life lost in the United States.
The most expensive cost component was hospital care, but the costs of pharmaceuticals rose sharply during the course of the study period and were more than double the amount spent on outpatient care (see figure). The authors expect spending on pharmaceuticals to increase further as care providers make more-extensive use of new HIV treatments.
Pharmaceutical use. The study also found that only about half of patients under care had used advanced, highly active ("antiretroviral") HIV treatments, although their use grew dramatically during the study reporting period.
Patients receiving care for HIV infection differ from the general U.S. population in several ways. They are disproportionately young, male, black, poor, unemployed, and underinsured:
These characteristics prevailed despite the fact that the educational level of HIV patients was roughly the same as that of the general population, with slightly less than half reporting some college education.
The authors draw two basic implications from their findings: Given that up to two-thirds of HIV patients are not receiving regular treatment, the health care system needs to do a better job of getting HIV-infected individuals into care. Second, the system needs to provide more-effective means of financing that care, particularly for the increasingly affected poor and minority communities.
The next phases of the HCSUS study will examine in more detail the issue of disparities in access to care across socioeconomic and racial groups, as well as the impact of variations in insurance coverage, the extent of mental health and substance abuse disorders among HIV patients, and the extent to which HIV is becoming resistant to the new antiretroviral drug therapies.
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