Model of care for HIV infection in Ireland

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Brennan, Aline
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University College Cork
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Background Highly active anti‐retroviral therapy (HAART) has completely transformed the clinical course of HIV. HIV is now considered a chronic disease, with patients living for decades on treatment. It is anticipated that health services will be placed under increasing pressure as the prevalence and age profile of the HIV population increases. A deeper understanding of the specific factors driving the use and cost of HIV care in Ireland is needed to allow quantification of future resource needs as well as the identification of potentially cost‐effective service delivery modifications. This thesis investigates the current use and direct cost of hospital care by HIV patients, and explores some of the patients and clinic level factors influencing the cost of HIV care in Ireland. Methods The total number of patients in care annually as well as the changing age profile of patients over time was estimated using routine data on the number of notified cases and general mortality in combination with published estimates of HIV related deaths. Current resource use and costs of care in 2012 were estimated from two studies carried out in the HIV centre located in Cork University Hospital. The first study estimated the total cost of outpatient HIV care using micro‐costing, including data on HAART use and cost. The second study used data extracted from the finance department of Cork University Hospital to identify and describe the pattern of use and non‐drug cost of all hospital services (including inpatient episodes, non‐ID outpatient appointments and emergency department attendances) by HIV patients in 2012. A national estimate of the cost of ambulatory HIV care in 2012 was then generated adjusting the estimated unit costs of outpatient visits, for variation in service delivery across the six centres providing adult HIV care in Ireland in 2012 and using national anti‐retroviral sales data. Results The number of HIV patients accessing HIV care was estimated to be 3,820 in 2012, with 18% of patients aged ≥50 years. Assuming the rate of new diagnosis remains stable we estimated that the number of patients in care will have increased by 40% to 4,607 by 2020 and that the proportion of patients aged ≥50 years will have increased to 30%. HAART is the overwhelming driver of the cost of outpatient HIV care. Treatment costs accounted for 90% of the total cost of outpatient HIV care estimated in the micro‐costing study. Patient factors associated with increased total outpatient HIV costs on multivariate analysis were younger age (< 50 years), female gender and being on HAART but not suppressed. When categories of costs were examined separately older patients were found to have both significantly lower HAART costs as well as HIV outpatient visit costs while female patients only had significantly higher HAART costs. On analysis of non‐drug hospital costs (i.e. including inpatient admissions, non‐ID outpatient appointments and emergency department attendances) low CD4 count and treatment status were significant, but no demographic factors were identified. A small number of patients (2%) with very low CD4 counts incurred a disproportionate amount of inpatient (61%) and total hospital non drug costs (31%). Extrapolating from the micro‐costing estimates and taking into account variation in service delivery across centres, we estimate that the annual non‐drug cost of providing ambulatory HIV care in Ireland in 2012 was €1,127 per patient or €4.31 million, and that including HAART, the cost to the health service provider in 2012 was approximately €50 million. Discussion The age profile of HIV patients in care is increasing in Ireland at a similar rate as in other developing countries. However, in contrast to what has previously reported in the literature, older patients in our study did not appear to incur increased total costs compared to their younger counterparts. The main reason for this was that the older patients were on less expensive treatment regimens, and HAART cost is the main driver of total cost of outpatient HIV care. Exactly why this was is unclear, but regimen choice is influenced by many health‐system (e.g. drugs available, clinician preference etc) as well as patient factors (treatment history, resistance, patient preference etc). There was also no difference identified in the non‐drug cost of care for older patients. This may have been due to the patients themselves being possibly younger and/or healthier than in other published studies, but may also be due to a lack of co‐ordinated routine screening for age‐related comorbidities in HIV patients in Ireland, as well as the cost estimates being based on data collected in a single centre which did not include costs incurred in other hospital, community and primary care settings. As the increasing age and total number of patient increases demands on HIV services it is imperative that measures to improve service efficiency are evaluated in terms of both clinical outcomes and costs. Interventions such as increased screening to reduce the number of patients diagnosed with advanced disease and increased use of generics have the potential to generate cost‐savings, however a nationally co‐ordinated approach is needed to drive such changes while ensuring the current standard of care is maintained.
HIV , Epidemiology , Health services research , Costing
Brennan, A. 2016. Model of care for HIV infection in Ireland. PhD Thesis, University College Cork.