A Look Back at the Cost of HIV/AIDS Care -- Then and Now
Samuel Bozzette, MD, PhD, of Rand Corporation and the University of California at San Diego, reviewed the direct medical costs of HIV/AIDS care in the United States. The review broke down the data into 3 eras:

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  Start of the epidemic to the Ryan White Care ACT (RWCA) (1981-1990)
  
  
  
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  RWCA to highly active antiretroviral therapy (HAART) (1990-1996)
  
  
  
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  HAART to the present (1996-2006)
  

Era 1 (1981-1990): Start of Epidemic to RWCA
This period was defined by "chaos and cost."

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  Patients had an average of 3 hospitalizations per year and extensive need for acute and chronic care.
  
  
  
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  The per-patient cost estimates diminished over time, but total costs increased (Table 1).
  

Table 1. Cost of AIDS Care Over Time in the First Era: 1981-1990

Cost Estimates	1985	1990
Per-patient cost	$147,000/13 mo	$80,000/12 mo
Total cost	$630 million	$8500 million

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  The period was characterized by lack of financial commitment, large variation in coverage, deficiency in providers, and deficiency in infrastructure (hospitals, clinics, laboratories, and drugs).
  

Era 2 (1990-1996): RWCA to HAART
The RWCA passed in 1990 to provide emergency assistance with Title I (eligible metro area grants based on formula), Title II (state formula grants including AIDS Drug Assistance Programs [ADAP]), and Title III (direct grants and other programs such as SPNS (Special Projects of National Significance).

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  Federal spending in 1995: $5.1 billion including $2.5 billion from Medicare/Medicaid.
  
  
  
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  Pharmacy costs come to dominate in this period and account for 50% of total treatment cost; treatment is highly effective.
  
  
  
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  Cost per patient declines in era 2, then increases in era 3
  
  
  
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  Lifetime costs increase "reasonably" from $13,000 (era 2) to $23,000 (era 3) per quality-adjusted life-year (QALY).
  
  
  
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  Approximate per-person costs per month totaled $1500 in 1999, comprising $600 in hospital costs, $700 for antiretroviral drugs, and $180 for OPD (outpatient costs, including lab tests).
  
  
  
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  Mortality decreased from approximately 52,000 in 1995 to 16,000 in 2001.
  
  
  
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  The number of people living with HIV infection increased from about 165,000 in 1993 to 360,000 in 2001.
  
  
  

Table 2. Federal Funding of HIV Care -- 1995-2004 (in $US Billions)

Type of Funding	1995	2000	2004
Medicaid	1.5	3.3	5.4
Medicare	1.0	1.7	2.6
Ryan White Care Act	0.6	1.6	2.0
Other	0.6	0.8	0.9
Total	3.7	7.4	11.0

In terms of total federal funding, the budget for FY94 was $18.5 billion budget, which was categorized as with $11.0 billion (59%) for care, $3.0 billion (16%) for research, $1.8 billion (9%) for housing assistance, $1.9 billion (10%) for "international," and $0.9 billion (5%) for prevention.

Reports from 2006 based on data collected in earlier time periods show the following costs of care:

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  Chen and coworkers: Annual cost is $13,885 with CD4+ cell count > 350 cells/microliter (mcL) increasing to $36,533 for CD4+ cell count < 50 cells/mcL (based on a 2001 analysis).
  
  
  
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  Gebo and coinvestigators: Annual cost in consortium of 19 centers in United States showed a mean cost of $21,869 with CD4+ cell count > 500/mcL increasing to $57,565 with CD4+ cell count < 50 cells/mcL (based on a 2003 analysis).
  
  
  
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  Goldie and colleagues report a cost of $55/month in Cote d'Ivoire when drug costs are $300/year.
  

Summary

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  Costs of HIV care continue to rise
  
  
  
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  Drugs are increasingly the dominant cost
  
  
  
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  Many economic issues are unexplored, including indirect costs, returns on primary and secondary prevention, and returns on comprehensive quality improvement, continuity, and recruitment efforts
  

References

1. 
   Chen RY, Accortt NA, Westfall AO. Distribution of health care expenditures for HIV-infected patients. Clin Infect Dis. 2006;42:1011-1013. Abstract
   
2. 
   Gebo K, Fleishman J, Conviser R, et al. Contemporary costs of HIV health care in the HAART era. Program and abstracts of the 13th Conference on Retroviruses and Opportunistic Infections; February 5-8, 2006; Denver, Colorado. Abstract 537.
   
3. 
   Goldie SJ, Yazdanpanah Y, Losina E. Cost-effectiveness of HIV treatment in resource-poor settings -- the case of Cote d'Ivoire. N Engl J Med. 2006;355:1141-1153. Abstract