Adherence Interventions a Cost-Effective Option to Boost Viral Suppression Rates Among US Youth With HIV

The rate of viral suppression among US youth aged 13 to 24 with HIV (YWH) hovers between 12 and 26%, representing an important clinical and public health challenge.

There is an urgent need for alternative adherence interventions for this population in order to boost the numbers.

To explore ways to do this, a group of investigators from Massachusetts General Hospital, Johns Hopkins, Harvard T.H. Chan School of Public Health, and more constructed and evaluated hypothetical intervention models as part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. The results were presented in a poster at the Annual Conference on Retroviruses and Opportunistic Infections (CROI 2020).

The research team simulated a cohort using published data and the Cost-Effectiveness of Preventing AIDS Complications-Adolescent model, which included YWH ages 13-24. The mean CD4 was 654/μL (SD 276), and cohort-level viral suppression was 59% (RNA <50c/mL)><50 c/mL0.

Two strategies were applied: 1) standard-of-care, and 2) a 12-month adherence intervention (AI), which increased cohort-level viral suppression 10% compared with standard-of-care at 12 months and cost $100/month/person.

For the purposes of the model, it was assumed that all YWH were in care and on ART for the first 12 months in both arms.

Outcomes included opportunistic infections (OIs), life expectancy (LE), primary HIV transmissions averted during the intervention, HIV-related costs, and incremental cost-effectiveness ratios (ICERs, $/year-of life saved [YLS]; threshold ≤$100,000/YLS; discounted 3%/year).

At 12 months, AI reduced OIs and transmissions by 15% and 19%, respectively, compared with standard-of-care.

“Discounted LE for [standard-of-care] vs. AI was 21.9 vs. 22.3 years. Discounted lifetime cost/person was $599,700 for AI and $599,500 for SOC,” investigators determined. “AI was +$200/person vs. SOC, a difference largely driven by added intervention costs (+$1,200) and ART (+$3,500); these costs were partially offset by savings from averted transmissions (-$3,800), less costly HIV-related care (-$300), and fewer OIs (-$200) and deaths (-$200).”

Compared with standard-of-care, AI was more cost-effective ($490/YLS).

Anne Neilan, MD, MPH, an infectious disease specialist at Massachusetts General Hospital, and presenting author on the poster, discussed the context of the results in an interview with Contagion^®.

“Efforts to improve virologic suppression, even a small amount in youth, can have a substantial impact over a lifetime,” she said.

“The greatest contributor to lifetime costs is the cost of antiretroviral therapy. One of the reasons why…the model projected that adherence interventions will be cost-effective is that the intervention-specific costs were less than 1% of a patient's overall HIV-related lifetime costs,” Neilan continued. “So, as we modeled it…a drop in the bucket compared to the cost of antiretroviral therapy. I think efforts to reduce drug costs and improve access to generics could also further improve the value of adherence intervention, so I think that is another important takeaway.”

The poster, “Can adherence interventions be cost-effective among youth with HIV?,” was virtually presented Monday, March 9, 2020, at CROI 2020.