For HIV-positive patients, delayed treatment a costly decision

"We know that it's important clinically to get people into care early because they will stay healthier and do better over the long run," says Kelly Gebo, M.D., M.P.H., an associate professor of medicine in the Division of Infectious Diseases at the Johns Hopkins University School of Medicine and the study's senior author. "But now we know it's also more costly to the health care system for potentially decades and a serious drain on our limited health care dollars."

Gebo says her team's findings highlight the importance of motivating people who are at risk to seek HIV testing and of reducing the time between the first positive HIV test and the first visit to an HIV clinic for care.

Patients with HIV are living longer and healthier lives, thanks to advances in antiretroviral therapy, but those successes may erode when some wait too long into the course of their disease to get treatment -- whether because they don't know they are infected with HIV, aren't sure how to access the health care system or have competing needs like mental health or substance abuse issues.

Dr. Gebo and her team's research, published in the December issue of the journal Medical Care, reviewed medical records of 8,348 patients at nine HIV clinics across the United States between 2000 and 2007. They found that more than 43 percent of patients were considered late entrants into the health care system, presenting at a clinic with extremely weakened immune systems, characterized by having CD4 counts below 200. CD4 cells are keys to a healthy immune system -- healthy people have counts between 800 and 1,000. When CD4 cells are damaged, as they are by HIV, counts can fall dramatically, making patients more susceptible to infection and certain types of cancer.

Low CD4 counts "make it more likely that patients are going to have complications and more likely that their CD4 counts won't ever recover to normal levels even with antiretroviral treatment," Gebo says. Previous studies have shown that those who come to care late in the course of their disease have shorter survival and benefit less from antiretroviral therapy.

Gebo and her colleagues found that the average difference in cumulative treatment expenditures between early and late presenters ranged from $27,275 to $61,615 higher over the course of the first seven to eight years of treatment. Costs are higher for the late presenters because they tend to be sicker than early presenters, particularly the first year of treatment -- and the cost gap doesn't shrink over time, she says. Late presenters are hospitalized more often, need to be put on costly antiretroviral therapy and antibiotics, and often must be treated for other diseases that have been exacerbated by a weakened immune system.

The study was supported by the Agency for Healthcare Research and Quality and the National Institutes of Aging and Drug Abuse. Richard D. Moore, M.D., M.H.Sc., a professor of general internal medicine at Johns Hopkins, also contributed to the research.