Very late HIV diagnosis incurs very high healthcare costs in Netherlands

Even without including antiretroviral therapy (ART), the financial cost of treating someone who starts HIV treatment very late in the course of their disease is almost 250% higher over five years than that of a person who starts ART early, a Dutch study found.

About This Study

“Characteristics and short- and long-term direct medical costs among adults with timely and delayed presentation for HIV care in the Netherlands” was published online on Feb 8, 2023, in PLoS One. The lead author is Stephanie Popping, M.D., Ph.D., of Erasmus Medical Center in Rotterdam, the Netherlands.

Key Research Findings

The Netherlands requires everyone to pay for a basic health insurance package , and HIV treatment is provided at 27 specialized clinics, which feed data into the national ATHENA cohort. The current study draws on this data.

The goals of this research were to evaluate the costs of HIV-care based on time of presentation for care. In addition, the researchers wished to identify other factors contributing to higher costs for 5 years after ART initiation.

Results were based on 1,223 PLWH who started ART in 2013 and had five years of follow-up data. Most were men across all three categories of starting care: timely presentation (CD4+ count > 350 cells/µL, 844 participants), late presentation (CD4+ count 200-350 cells/µL or AIDS-defining condition, 273 participants), very late presentation (CD4+ count < 200 cells/µL, 179 participants). Other demographic characteristics varied by category, with PLWH starting treatment late being older, more likely of non-Dutch origin, and more likely to have acquired HIV through heterosexual contact than those starting ART early.

The higher cost of treatment for people who started ART late was mostly driven by non-ART expenses, such as co-medications or hospitalizations. During the first year on treatment, those who presented very late to care were inpatients for an average of 8.3 days compared to 0.38 days for those who had a timely presentation. Over the course of five years, non-ART costs for late presenters were 56% higher than for timely presenters, and such costs for very late presenters were 246% higher than for timely presenters.

Discussion Highlights and Implications for Practice

The researchers pointed out that presenting later for HIV care is often driven by a low perceived risk for HIV (particularly among cisgender heterosexuals and the elderly), lack of HIV awareness, or stigma. They suggest that improving HIV awareness among older adults and their health care providers, routinely testing for HIV in people who seek care for certain conditions, distributing “free and easy” HIV self-tests, partner notification, and large-scale testing events could help diagnose PLWH earlier.

Financial savings when people start ART on a timely basis could be used to implement novel HIV screening and testing programs, the authors suggested. Beyond improving the health of PLWH and saving money, they also noted that early diagnosis and treatment would reduce HIV transmissions overall, and prevent the worst health care outcome: death.

By Barbara Jungwirth