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Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (2005)

Chapter: Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs

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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Appendix A
Technical Appendix: Estimating the Impact and Cost of Expanded HIV Care Programs

INTRODUCTION

The charge given the Committee on Public Financing and Delivery of HIV Care is to develop policy recommendations that would “mitigate the discontinuities and inefficiencies of current public funding systems” that support services for people living with HIV and “eliminate resulting disparities in access to care by filling identified financing and service gaps.” The Committee was specifically directed to consider as an option (including determining the expected costs, savings, and overall financial impact of) modifying Title XIX of the Social Security Act (Medicaid) to create an eligibility category based on HIV infection.

To guide its deliberations, the Committee developed estimates of the likely impact (financial and on the health of the HIV-infected population) of alternative policy options. This appendix presents the methods and data the Committee used to model the impact of different financing options, and the results. Because of time constraints, the analysis was focused on the two financing options believed by the Committee to provide the best opportunity for meeting the goals it identified for a desirable system of care. Both of these options create an entitlement to care for those diagnosed with HIV who meet established income eligibility requirements. One option, the HIV Comprehensive Care Program (HIV-CCP), is a public insurance program funded entirely by the federal government and administered by the states. The other option, Optional Medicaid Eligibility Group with Increased Federal Match (Enhanced Medicaid), is a modification to the Medicaid program that provides for an enhanced federal match (70 percent on aver-

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

age) to states that extend eligibility to individuals in the early stages of HIV disease. Both options are described in detail in Chapter 5. For brevity, “the Committee” is replaced by “we.”

METHODS

The approach to the analysis was to pose and then answer three broad questions for each option:

  • What are the likely health benefits of implementing an alternative approach to public financing of HIV care in terms of mortality and life expectancy? In other words, what incremental gains in health does an additional investment in HIV care buy?

  • What is the cost effectiveness of implementing an alternative approach?

  • What is the cost of implementing the proposed alternative approach?

MODELING OVERVIEW

To answer these questions, we conducted an analysis that involved five steps:

  1. Estimate the number of people not currently receiving highly active antiretroviral therapy (HAART) who are likely to begin HAART with alternative methods for financing care.

  2. Estimate the cost and health implications over 10 years of each financing option, including the anticipated gain in life expectancy (adjusted for quality of life) and reduced mortality (premature deaths averted) among those who participate in the programs.

  3. Estimate the cost per quality-adjusted life-year (QALY) gained associated with enrollment in each financing option and compare the estimates to other investments in health.

  4. Estimate the short-term (first-year) cost implications for each public payer.

  5. Compare the results for each option to one another.

Our approach was to gauge the potential increase in HAART use associated with a policy to expand access to HIV care by estimating how many individuals are currently in need of HAART and, of those, how many do not receive HAART. We refer to the number of people who need but do not receive HAART as the “HAART use deficit.” Our estimates of current HAART use are based primarily on data collected between 1996 and 1998, the beginning of the HAART era, which presents a limitation to our analysis.

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

There is also data from 2000, however, that suggest that antiretroviral therapy (ART) (but not HAART) was used by about two-thirds of individuals with AIDS. This, along with unpublished data from a Kahn (2002) study on HAART use combined with ART use, suggests overall HAART use of approximately 45 percent. Recognizing that HAART use may have grown in the interim, especially for individuals with late-stage AIDS, we used a higher value of estimated HAART use (64 percent) based on an AIDS diagnosis by the 1987 definition.

We then estimated the number of people who would receive HAART assuming implementation of a proposed change in public financing of HIV care. This estimate was based on program eligibility and enrollment, as well as the association of insurance status and ancillary services covered with HAART use. Current and anticipated HAART use were then compared to calculate the incremental gain in HAART use expected as a result of the creation of a new entitlement to care.

We used a disease state-transition (Markov) model of HIV disease progression adapted from Kahn et al. (2001) to estimate the health and financial impact of providing greater access to HAART. This model portrays a population of individuals with HIV disease classified into five increasingly severe disease states: asymptomatic with a CD4 cell count >500, asymptomatic CD4 200–500, symptomatic CD4 200–500, AIDS by the 1993 definition only (including CD4 < 200), and AIDS by the 1987 clinical definition. The model specifies transition probabilities between disease states and to death, per time period. These probabilities are derived from published empirical studies. The model thus predicts how the mix of HIV disease states evolves over time for the specified infected population. The transition probabilities are reduced for individuals on HAART, based on a structured review of HAART clinical trials which used disease progression or surrogate markers as endpoints. Thus, increased insurance coverage, such as with HIV-CCP, slows disease progression by increasing the likelihood of HAART use.

The original model produced three clinical outcomes. New AIDS diagnoses represent the progression from any pre-AIDS state to AIDS (by the CDC’s 1993 definition). Deaths include all causes, as generally reported. Life years are cumulative years of life for all HIV-infected individuals, unadjusted for quality of life. The model was updated by the Committee to calculate QALYs, based on the most recent reviews of the utility of HIV health states. The model also calculates the costs of providing HIV medical care, by assigning to each individual in each time period a set of costs reflecting the Committee’s estimates of the costs of HIV medical care by severity of illness (see separate section on costs).

We also estimated the health and cost implications of ancillary services provided by one financing option (HIV-CCP). This financing option has a

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

benefit package that includes case management, mental health care, and treatment of substance abuse. For each service, we estimated from previously reported estimates the unmet need, the costs of meeting that need, and, for the latter two, expected increases in quality of life.

We estimated the cost per QALY for each option using the standard cost–utility ratio. The numerator includes societal costs for medical care and ancillary services under each financing alternative, minus the same costs with current financing. In the denominator is the gain in QALYs as compared with the current situation.

We estimated the first-year financial impact on the budgets of the federal government, collectively on the budgets of the states, and on the cost of care for the uninsured. This was done based on how services are currently financed, expected increases in cost, and specified changes in federal matching rates.

Finally, we compared the financing options on key outcome measures. This comparison indicated the incremental differences in costs, health gains, and cost per health gain. All costs are adjusted to 2002 using the medical component of the United States consumer price index. All future costs and health outcomes are discounted to 2002 using a discount rate of 3 percent per year.

FINANCING OPTIONS

We defined three financing options: maintaining the system as it currently exists, a federally funded eligibility expansion with a comprehensive benefit package (HIV-CCP), and a state-option eligibility expansion with 70 percent federal match (Enhanced Medicaid). Descriptions follow of the three options that focus on characteristics that we explicitly modeled.

The “current” option is based on the most recent and representative data, as described in the Inputs section. To facilitate adjustment of costs for specific services for the alternative financing options, we characterized current costs by type of service. The services included HAART, viral resistance testing, HIV monitoring labs, outpatient visits (adjusted for specifically listed outpatient services), other medications, inpatient care, emergency care, substance abuse treatment, mental health care, case management, dental care, obstetrics/gynecology, home health/visiting nurse care, and prevention counseling. Although the list is extensive, we did not include services such as housing, food, transportation, child care, and legal advocacy, which can also be necessary depending on the circumstances of the individual. Utilization was set to levels reported in current literature (primarily the HIV Cost and Services Utilization Study [HCSUS]), and other sources as well, reflecting the current mix of insurance and associated benefits packages.

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

The HIV-CCP option is a highly incentivized expansion in eligibility, accompanied by a 100 percent federal financing match, a strengthened benefit package, and higher outpatient reimbursement rates. Eligibility is based on having an income that is below 250 percent of the federal poverty level (FPL)—$22,150 for an individual in 2002. Enrollment is assumed to be high due to incentives to both providers (higher reimbursement) and patients (better benefits and better paid providers). The benefits package is richer than current average Medicaid benefits because unrestricted coverage of three key ancillary services (case management, mental health, and substance abuse treatment) is included. Outpatient reimbursement is increased 20 percent as compared with Medicaid to be comparable to Medicare, plus 5 percent on average for Centers of Excellence.

For the HIV-CCP, increases in utilization are in three areas. First, there is an increase in ancillary services, due to improved coverage. Second, some individuals who were previously out of care enter into regular care. Third, HAART use (and viral resistance testing) increases because being insured is associated with higher HAART use. We assume that because of enhanced reimbursement, HAART use will equal that seen with private insurance. HAART use further increases because of the improved coverage of ancillary services, which have been independently associated with higher HAART use. Because these services largely help to address problems associated with poverty, and because low income is independently associated with lower HAART use, we refer to these gains as partially alleviating the poverty effect.

The Enhanced Medicaid option is a state-discretion expansion in Medicaid eligibility, accompanied by a 70 percent federal financing match, with no change in benefits or reimbursement. Eligibility is also based on having an income below 250 percent of the FPL. Enrollment is lower than with the HIV-CCP entitlement due to much lower incentives to providers and patients. Increases in utilization are just for individuals who begin to use HAART (and viral resistance testing) as a result of becoming insured. Without enhanced reimbursement, HAART use among enrollees is assumed to equal that reported for Medicaid.

INPUTS

We conducted extensive literature searches to identify inputs for this model of HIV disease and health services use, and consulted with a number of experts. For most inputs, data were available that directly provided input values or could be readily adapted for that purpose. All cost data were adjusted to 2002 dollars using the medical care consumer price index. For those inputs lacking data, we relied on expert judgment, including discussion within the Committee, and chose values that tended to understate the

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

impact of the modeled policies. Due to uncertainty in inputs, we specified uncertainty ranges and conducted sensitivity analyses.

The following discussion is divided into four categories: HIV population characteristics, HAART use, HIV clinical services and costs, and effects of financing options. The text parallels Table A-1.

HIV Population and Characteristics

According to Fleming et al. (2002), approximately 950,000 individuals are infected with HIV. Among those infected, Fleming further estimates that approximately 670,000 are aware of infection. Of these, approximately 360,000 have AIDS (CD4 < 200, or AIDS-defining condition). Based on data from in-care populations, we assume that 150,000 of these have AIDS by clinical criteria and 210,000 by CD4 < 200 (Bozzette et al., 1998). As individuals are more likely to be aware of HIV infection later in disease (e.g., if infected for longer and/or symptomatic), we assumed a greater number of aware individuals in each more severe disease state.

Information regarding income level and insurance status of HIV-infected individuals was obtained from HCSUS, a national probability sample of people with HIV in care. According to Bozzette et al. (1998), the majority (72 percent) of those with HIV are low income (household income < $25,000). Among these low-income individuals, nearly 25 percent are uninsured and 61 percent rely on Medicaid or Medicare. In contrast, of those with incomes > $25,000, most (78 percent) rely on private insurance (Bozzette et al., 1998).

Information regarding disease stage and insurance status was also obtained from HCSUS (not shown in table). Individuals with clinical AIDS are about two-thirds as likely to have private insurance as are asymptomatic individuals, and are correspondingly more likely to have Medicaid. This reflects the impoverishing effects of severe AIDS as well as the AIDS disability requirement for HIV-associated Medicaid eligibility.

HAART Use and Need

Estimates of the current prevalence of HAART use are drawn from a number of sources. Studies of HIV-infected populations (AIDS and HIV non-AIDS) in New York State and in three metropolitan areas used local data sources (HIV/AIDS surveillance, lab reporting, Medicaid and AIDS Drug Assistance Program [ADAP] billing claims) from 2001 in a framework endorsed by the Health Resources and Services Administration (HRSA) to estimate participation in HIV care (Kahn, 2002). Studies of Medicaid and ADAP populations were conducted for 1998 in four heavily HIV-affected states (Kahn et al., 2002). Additional older estimates provide

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-1 Analysis Inputs

HIV Population

Baseline Estimate

Sources

Infected

950,000

Fleming et al., 2002

Aware

670,000

Fleming et al., 2002

HIV Population Characteristics

Baseline Estimate

Sources

By clinical stage (among aware)

CD4 > 500

0.08

Bozzette et al., 1998;

CD4 499—350

0.15

Expert Judgment

CD4 349—200

0.24

 

CD4 199—50

0.31

 

CD4 < 50

0.22

 

By income level

Proportion <$25,000

0.72

Bozzette et al., 1998

Proportion >$25,000

0.28

 

By insurance status, among aware

Proportion Medicaid, other public (including Medicare)

0.50

Bozzette et al., 1998; Expert Judgment

Proportion uninsured

0.25

 

Proportion private

0.25

 

HAART Use

Baseline Estimate

Sources

Current use

Total current antiretroviral (ARV) use

230,000

Kahn, 2002; Kahn et al., 2002; Moorman et al., 1998; Palella et al., 1998

By clinical stage

ARV current use (CD4 50–200)

0.40

Kahn, 2002; Kahn et al., 2002; Moorman et al., 1998; Palella et al., 1998

By income

odds ratio (OR) getting ARV if < $25,000

0.60

Andersen et al., 2002

By insurance status

OR getting ARV if uninsured

0.74

Andersen et al., 2002

OR getting ARV if Medicaid alone

0.83

 

OR getting ARV if Medicare—other

0.82

 

OR getting ARV if HMO insurance

0.90

 

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

HIV Clinical Costsb

Use

Cost per person year (ppy)

Sources

HAART (CD4 50–200)

 

$9,222

Schackman et al., 2002; Expert Judgment

Other medicines

1.00

$3,980

Aldridge et al., 2002; Bozzette et al., 2001

Prevention counseling

1.00

$272

Holtgrave et al., 2002

Monitoring labs

1.00

$682

Schackman et al., 2002

Outpatient medical

1.00

$1,629

Bozzette et al., 1998; Bozzette et al., 2001; Shapiro et al., 1999

Sexually transmitted disease, tuberculosis, and hepatitis screening

1.00

$14

IOM, 1997; Gable et al., 1996; HepNet

Hepatitis C

InfoCenter, 2003

Inpatient medical

1.00

$4,246

Bozzette et al., 1998; Bozzette et al., 2001

Emergency department

0.33

$846

Bozzette et al., 1998

Dental

1.00

$513

Bozzette et al., 1998; Capilouto et al., 1991

Obstetrics/gynecology

0.20

$446

Bozzette et al., 1998

Home health/visiting nurses

0.20

$5,000

London et al., 2001; MetLife, 2002

 

Baseline Use

Gain in Use Due to Improved Coverage

OR for ARV Use

Cost ppy

 

Substance abuse treatment

0.075

0.075

1.700

$6,193

Ashman et al., 2002; Burnam et al., 2001; Conover and Whetten-Goldstein, 2002; Finkelstein and Tiger, 2002; Lo et al., 2002; Marx, 2002; Messeri et al., 2002; Sherer et al., 2002; Strathdee et al., 1998; Zaric et al., 2000

Mental health

0.220

0.09

1.400

$1,380

Ashman et al., 2002; Burnam et al., 2001; Lo et al., 2002; Messeri et al., 2002; Sambamoorthi et al., 2000; Sherer et al., 2002; Turner et al., 2001

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

 

Baseline Use

Gain in Use Due to Improved Coverage

OR for ARV Use

Cost ppy

 

Case management

0.600

0.15

1.500

$826

Katz et al., 2001; Lo et al., 2002; Magnus et al., 2001; Marx, 2002; Messeri, 2002; Sherer, 2002

Federal Matching Rates for Medicaid

 

 

 

 

Sources

Florida

58.83

 

 

 

DHHS, 2003

Georgia

59.60

 

 

 

 

Illinois

50.00

 

 

 

 

New York

50.00

 

 

 

 

Texas

59.99

 

 

 

 

Effects of Financing

Baseline Estimate

Sources

Proportion eligible

Publicly insured/in care

0.92

Expert Judgment

Publicly insured/not in care

0.975

Expert Judgment

Uninsured/in care

0.53

Expert Judgment

Uninsured/not in care

0.50

Expert Judgment

Enrollment rates

Publicly insured/in care

0.90

Expert Judgment

Publicly insured/not in care

0.40

Expert Judgment

Uninsured/in care

0.90

Expert Judgment

Uninsured/not in care

0.30

Expert Judgment

If enrolled, in care

Publicly insured/in care

1

Expert Judgment

Publicly insured/not in care

0.75

Expert Judgment

Uninsured/in care

1

Expert Judgment

Uninsured/not in care

0.75

Expert Judgment

Enrollment rate adjustment,

Enhanced Medicaid program

0.667

Expert Judgment

Health Effects

Baseline Estimate

Sources

Utility deficit due to advanced disease

0.12–0.24

Tengs and Wallace, 2000

Utility change (drop) for being on HAART

–.03

Expert Judgment

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Health Effects

Baseline Estimate

Sources

Utility gain for being on HAART (symptom reduction)

0.06–0.13

Expert Judgment; see text

Utility adjustment for receiving substance abuse treatment

0.1

Zaric, 2000; Expert Judgment

Utility adjustment for receiving mental health treatment

0.05

Simon et al., 2001; Wang et al., 2002; Expert Judgment

Increase in Service Utilization

Substance abuse treatment

0.075

Zaric, 2000; Expert Judgment

Mental health treatment

0.09

Simon et al., 2001; Wang et al., 2002; Expert Judgment

Case management

0.15

Expert Judgment

nationally representative data of individuals in care (Bozzette et al., 1998) and individuals in private and public HIV specialty clinics (Moorman et al., 1998; Palella et al., 1998). Based on these data, we estimated that 230,000 individuals are on HAART, including 40 percent of those with a nadir CD4 count between 50 and 199.

To determine the association of HAART use with income level and insurance status used data from HCSUS (Andersen et al., 2000). Though this data is from 1996, somewhat more recent nationwide data (from 1997–1998) and analyses of data from the state and local levels suggest the persistence of income and insurance effects found by Andersen et al. (Bhattacharya et al., 2003; Goldman et al., 2003; Kahn, 2002; Kahn et al., 2002; Goldman et al., 2001; Hsu et al., 2001). Low-income individuals (family income < $25,000) were less likely to be on HAART (odds ratio [OR] = 0.6). The odds of being on HAART also varied by insurance status, from 0.74 among those with no insurance, to 0.83 among Medicaid recipients, to 0.90 among those with health maintenance organization (HMO) insurance (reference group is those with private fee-for-service insurance) (Andersen et al., 2000).

We defined HAART need based on HIV disease stage. All those with AIDS “need” HAART. Although there are many legitimate reasons not to provide HAART when someone has AIDS, and many patients may decline HAART, clinical guidelines suggest offering and using HAART. Among

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

those with HIV disease with a CD4 count of 200 to 350 (often symptomatic), we assume that half need HAART, consistent with the guidelines’ suggestion for flexibility in this range. For those even earlier in disease, we define need as the small percentage estimated to be currently using HAART, which at that stage is not recommended (DHHS, 2003).

HIV Clinical Services and Costs

To determine HAART costs, estimates were reviewed from HCSUS data, state and territorial ADAPs, and the 1999 Red Book average wholesale price (AWP). We used the last of these, further adjusted to reflect Medicaid drug pricing (15 percent below average manufacturer price, which is 20 percent below AWP on average) (Schackman et al., 2002; DHHS, 2000). Thus, we estimated total per-person annual cost of HAART to be $9,222.

According to Committee estimates, individuals with HIV need a number of clinical services. Among individuals who have developed AIDS (CD4 < 199), in addition to benefiting from HAART, we estimate that all need the provision of medications beyond HAART as appropriate, such as opportunistic infection prophylaxis (DHHS, 2003). We also estimate that all individuals with HIV, regardless of disease stage, need prevention counseling, monitoring labs, inpatient and outpatient medical care, sexually transmitted disease (STD) screening and treatment, and dental care (100 percent need for each).

Among a smaller proportion of individuals with HIV, there is a need for additional clinical services. Based on estimates from HCSUS data, we estimate that a third of individuals with HIV need coverage for emergency department visits. Furthermore, we estimate that a fifth would benefit from obstetrics/gynecology services, home health/visiting nurses (according to data from HCSUS), and food services (based on data from a San Francisco study). A small percentage would also benefit from transportation services (also based on the data from San Francisco).

Utilization of case management, substance abuse treatment, and mental health treatment was estimated from published estimates of unmet need for care. We estimated an increase from 15 to 30 percent in use of substance abuse services among injection drug users (IDUs), who constitute half of individuals with HIV/AIDS, based on published data (Sherer et al., 2002) and expert judgment, including Committee member experience with offering substance abuse treatment to IDUs. We estimated an increase of 9 percent in mental health treatment, representing an estimated 18 percent unmet need and a 50 percent likelihood of seeking needed care (Burnam et al., 2001; Expert Judgment). We estimated a 15 percent increase in case management, based on expressed unmet need (Sherer et al., 2002). Costs for

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

these services range from $852 per person per year for case management (Messeri et al., 2002) to $5,250 for treatment of substance abuse (Finkelstein and Tiger, 2002; Zaric et al., 2000).

In addition, we estimate that several of the services outlined would lead to a greater chance of receiving HAART. The provision of substance abuse treatment is associated with an OR for receiving HAART of 1.7 (Ashman et al., 2002; Messeri et al., 2002; Strathdee et al., 1998). Similarly, the receipt of mental health treatment is associated with a greater chance of receiving HAART (OR of 1.4) (Ashman et al., 2002; Magnus et al., 2001; Messeri et al., 2002), and case management services are associated with an OR for receiving HAART of 1.5 (Katz et al., 2001; Magnus et al., 2001; Messeri et al., 2002).

These estimates were formed based on a number of sources, including HCSUS data, data collected from HRSA’s Client Demonstration Project sites (specifically, data on people living with HIV/AIDS collected from service providers in a delimited geographic area), an ongoing longitudinal study of HIV-infected individuals living in New York City, databases from a multiservice program in New Orleans, and a cohort study of IDUs in British Columbia.

Federal Matching Rates for Medicaid

We used the 2003 federal matching rates for Medicaid programs in five states—Florida, Georgia, Illinois, New York, and Texas—to estimate the cost of the Medicaid expansion options that were considered (DHHS, 2003).

Effects of Financing on Program Participation

The effects of financing mechanisms on insurance status and access to care depend on how many individuals are eligible for the program and what proportion chooses to enroll. We used HCSUS data on insurance status and income level to estimate the number of individuals who would be eligible for the program (Bozzette et al., 1998).

To determine the number of eligible persons who would enroll in the program, we attempted to find enrollment data on comparable public insurance programs. We found, however, that there were no public programs comparable to the recommended program, and little enrollment data exist from any public program. As a result, we relied on our consensus expert judgment as the basis for this assumption. We assumed that those currently in care, either publicly insured or uninsured, are highly motivated to seek care and that 90 percent of them would choose to enroll in the new program. Of those not currently in care who are publicly insured or

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

uninsured, we assumed that much lower proportions would enroll in the new program—40 percent and 30 percent, respectively.

To estimate the enrollment rate for the Enhanced Medicaid program, we further reduced those numbers by a third to reflect the added barriers of a Medicaid program, such as lack of provider participation and the absence of benefits that might draw people into care. Again relying on expert judgment, we assumed that of those who enroll, 100 percent of those in care prior to enrollment would remain in care, but that just 75 percent of those who enroll and are not currently in care would enter care.

Health Status Effects of HIV Disease, HAART, and Ancillary Services

Using the quality of life adjustments from Tengs and Wallace (2000), we estimated a utility deficit for advanced disease of 0.12 to 0.24, depending on severity of illness. Because HAART is a complex regimen with multiple side effects, we used the Committee’s expert judgment to assign a utility drop of –0.03 for being on HAART. To adjust for the symptom relief of HAART, we assigned a utility gain in the range of 0.06 to 0.13 for taking HAART, reflecting the product of efficacy (i.e., relative reduction in clinical events) and the utility deficit (above).

We used expert judgment to assign a utility gain of 0.1 for receiving substance abuse treatment and an increase in service utilization of 0.075 (Zaric et al., 2000). To determine the utility and service utilization adjustment for mental health treatment, we identified the health utility gain (0.4) from receipt of effective treatment for depression reported in Simon et al. (2001), and adjusted for estimates of the timeliness of care seeking, the imperfect effectiveness of mental health treatment, and the delay of symptom alleviation with effective treatment (Expert Judgment; Wang et al., 2002).1 Thus, we conservatively estimate a utility gain of 0.05 for those seeking mental health care and an increase in service utilization of 0.09 as a result of receiving mental health treatment. Finally, we used expert judgment to estimate an increase of 0.15 in service utilization for receiving case management services.

1  

“Service utilization” is defined as the prevalence of use of the specified service during one year, i.e., the percent of the population of interest using this service at least once. This is multiplied by the mean annual cost per user to estimate mean annual cost per person in the population of interest.

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

RESULTS

HAART Use Deficit

The estimates are based on an initial finding that there are 950,000 individuals living with HIV and that 670,000 individuals are aware of their HIV status, of whom 25 percent (167,500) are uninsured and 50 percent (335,000) are insured through a program financed with public dollars (Table A-2). Among those individuals who are aware that they are infected, we estimate that 69 percent (463,069) are in need of combination antiretroviral therapy and that slightly fewer than half in need of HAART (230,000 individuals) receive antiretroviral medications, leaving a deficit in HAART use of 233,069 for this cohort. We believe that an additional 82,000 individuals who are infected but unaware of their HIV status are also in need of HAART.

HIV-CCP HAART Use Gain

For the purpose of estimating the benefits and costs of its proposals, we assumed that the creation of a health care entitlement would not increase enrollment in care or HAART use among individuals who are unaware of their HIV status or who have private insurance. Of the estimated 502,500 individuals who are infected and aware of their HIV status, and who are either uninsured or have public insurance, 80 percent (400,975) would be eligible to enroll in the HIV-CCP program. The Committee estimates that 71 percent (285,503) of those eligible would enroll and receive care, that 78 percent (222,681) of those individuals enrolled and in care should be on HAART, and that 82 percent (181,848) in need of HAART would receive antiretroviral therapy paid for by the program.

We also estimate that there would be 106,849 individuals (uninsured or publicly or privately insured) who would not enroll in the program but would be on HAART. Therefore, the Committee predicts that the total number of individuals on HAART would be likely to rise from 230,000 to 288,697 with implementation of the HIV-CCP program, reducing the number of individuals in need of, but not receiving, HAART by 58,697 individuals (Table A-3). Of those 58,697 we estimate that less than two-thirds (57 percent) will receive HAART as a result of gaining access to insurance coverage or higher provider reimbursement (leading to a greater willingness to accept publicly insured patients). The remainder of those newly receiving HAART in the program will do so because of the enabling effects of ancillary services such as substance abuse and mental health treatment and case management (Table A-4). Almost all (98 percent) of enrollees starting HAART are symptomatic or have AIDS. Specifically, 34 percent have AIDS by the clinical

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-2 Estimate of Need for HAART, Current HAART Use, and HAART Use Deficit Given Existing System of Public Financing and Delivery of HIV Care

Population

Estimate by Subpopulation

Estimate Total

Infected with HIV

 

950,000

Aware of HIV status

 

670,000

Care status of those aware of HIV status

 

In care

 

470,000

 

Not in care

 

200,000

Insurance and care status of those aware of HIV

 

Private (31%)

 

 

In care

117,500

 

 

 

Not in care

50,000

 

 

Public (47%)

 

 

In care

235,000

 

 

 

Not in care

100,000

 

 

Uninsured (22%)

 

 

In care

117,500

 

 

 

Not in care

50,000

670,000

Those aware who need HAART by insurance and care status

 

Private

 

 

In care

88,821

 

 

 

Not in care

26,285

 

 

Public

 

 

In care

191,187

 

 

 

Not in care

56,579

 

 

Uninsured

 

 

In care

77,317

 

 

 

Not in care

22,881

463,070

Those aware and in care who receive HAART by insurance status

 

Private

62,350

 

 

Public

123,024

 

 

Uninsured

44,626

230,000

Those aware who need but do not receive HAART by insurance and care status (HAART use deficit)

 

Private

 

 

In care

26,471

 

 

 

Not in care

26,285

 

Public

 

 

In care

68,162

 

 

 

Not in care

56,579

 

 

Uninsured

 

 

In care

32,691

 

 

 

Not in care

22,881

233,069

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-3 Increase in HAART Use Anticipated Given Implementation of HIV-CCP

Population

Estimate by Subpopulation

Estimate Total

Eligible

 

 

Public

 

 

Currently in care

216,200

 

 

 

Currently not in care

97,500

 

 

Uninsured

 

 

Currently in care

62,275

 

 

 

Currently not in care

25,000

400,975

Enroll, if eligible

 

 

Public

 

 

Currently in care

194,580

 

 

 

Currently not in care

39,000

 

 

Uninsured

 

 

Currently in care

56,048

 

 

 

Currently not in care

7,500

297,128

In care, once enrolled in the program

 

 

Public

 

 

Currently in care

194,580

 

 

 

Currently not in care

29,250

 

 

Uninsured

 

 

Currently in care

56,048

 

 

 

Currently not in care

5,625

285,503

Need HAART in the program

 

 

Public

 

 

Currently in care

158,303

 

 

 

Currently not in care

23,797

 

 

Uninsured

 

 

Currently in care

36,880

 

 

 

Currently not in care

3,701

222,681

Receiving HAART in the program

 

 

Public

 

 

Currently in care

129,275

 

 

 

Currently not in care

19,433

 

 

Uninsured

 

 

Currently in care

30,118

 

 

 

Currently not in care

3,023

181,848

Receiving HAART outside of the program (private and other public programs)

 

 

Private (in care)

62,350

 

 

Public (in care)

21,160

 

 

Uninsured (in care)

23,339

106,849

Gain in HAART use

 

 

Public

 

 

Currently in care

27,411

 

 

 

Currently not in care

19,433

 

 

Uninsured

 

 

Currently in care

8,831

 

 

 

Currently not in care

3,023

58,697

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-4 Increase in HAART Use Anticipated Given Implementation of Enhanced Medicaid

Population

Estimate by Subpopulation

Estimate Total

Eligible

 

 

Public

 

 

Currently in care

216,200

 

 

 

Currently not in care

97,500

 

 

Uninsured

 

 

Currently in care

62,275

 

 

 

Currently not in care

25,000

400,975

Enroll, if eligible

 

 

Public

 

 

Currently in care

129,721

 

 

 

Currently not in care

26,000

 

 

Uninsured

 

 

Currently in care

37,365

 

 

 

Currently not in care

5,000

198,086

In care, once enrolled in Enhanced Medicaid program

 

 

Public

 

 

Currently in care

129,721

 

 

 

Currently not in care

19,500

 

 

Uninsured

 

 

Currently in care

37,365

 

 

 

Currently not in care

3,750

190,336

Need HAART in Enhanced Medicaid program

 

 

Public

 

 

Currently in care

105,536

 

 

 

Currently not in care

15,864

 

 

Uninsured

 

 

Currently in care

24,587

 

 

 

Currently not in care

2,468

148,455

Receiving HAART in Enhanced Medicaid program

 

 

Public

 

 

Currently in care

67,910

 

 

 

Currently not in care

10,208

 

 

Uninsured

 

 

Currently in care

15,821

 

 

 

Currently not in care

1,588

95,527

Receiving HAART outside of the Enhanced Medicaid program (private and other public programs)

 

 

Private (in care)

62,350

 

 

Public (in care)

55,114

 

 

Uninsured (in care)

30,435

147,899

Gain in HAART use

 

 

Public

 

 

Currently in care

0

 

 

 

Currently not in care

10,208

 

 

Uninsured

 

 

Currently in care

1,630

 

 

 

Currently not in care

1,588

13,426

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-5 Derivation of Increase in HAART Use for 58,697 Individuals Estimated to Begin HAART Use as a Result of the HIV-CCP

Mechanism for Increase in HAART Use

Individuals Brought onto HAART

Moving from uninsured to insured (assumes publicly insured)

17,449

Enhanced reimbursement resulting in HAART use at private insurance levels

15,717

Enabling effects of ancillary services

25,531

Total

58,697

1987 definition, 49 percent have AIDS only by the 1993 definition (CD4 < 200), and 15 percent have symptomatic disease but not AIDS. This heavy contribution of individuals with more severe disease reflects several factors characterizing these individuals: higher awareness of infection, high levels of uninsurance and public insurance, low observed HAART use among individuals who are uninsured or publicly insured, greater likelihood of enrolling in HIV-CCP than less sick individuals, and clearer need for HAART. By way of comparison, the Committee estimates that implementation of the Enhanced Medicaid option would result in an increase of 13,426 individuals newly on HAART (Table A-5).

In the absence of HIV-CCP, some of the of the 58,697 individuals who start HAART because of this program would start HAART later in time, due to worsening of clinical condition. Specifically, the model estimates that 6 percent of survivors at 2 years would be on HAART, 15 percent at 5 years, and 30 percent at 10 years. These numbers should be considered in the context of estimates made by the Committee that currently only 45 percent of individuals with AIDS by the 1993 definition are on HAART, and only 64 percent of those with AIDS by the 1987 definition are on HAART. The model indicates that individuals who would go on HAART due to HIV-CCP are those, by definition, with no current HAART use due to not being in care, uninsurance and public insurance, and other factors. Thus, they are at high risk of not moving quickly to HAART without a change in the financing system.

Health Effects

Without implementation of the HIV-CCP program, the disease state-transition model predicts 35,489 deaths in a 10-year period among the 58,697 individuals likely to receive HAART given implementation of the program. With the program, the number of deaths is predicted to fall by

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-6 Premature Deaths Prevented Through HIV-CCP During a 10-Year Period (among those newly on HAART) (undiscounted)

 

Deaths in a Period of 10 Years

Without access to HAART

35,489

With access to HAART

15,664

Premature deaths prevented

19,825

TABLE A-7 Life Expectancy and Quality-Adjusted Life Expectancy Gain Through the HIV-CCP During a 10-Year Period (among those newly on HAART) (undiscounted)

 

Life Years

QALYs

Without access to HAART

385,180

299,516

With access to HAART

507,050

425,276

Gain

121,870

125,760

55.9 percent to 15,664 deaths, with 19,825 premature deaths prevented among the individuals who are enrolled in the program in its first year (Table A-6). In terms of life expectancy, the model predicts a gain of 121,870 life years and 125,760 QALYs in the same 10-year period (Table A-7). The quality of life adjustment assumes that in addition to extending life, there are benefits to antiretroviral therapy (e.g., reduced morbidity due to fewer opportunistic infections and slower progression of HIV disease) that outweigh the negative impacts associated with HAART (e.g., the side effects of treatment). By comparison, the Enhanced Medicaid option is predicted to prevent 4,537 premature deaths, resulting in a gain of 24,110 QALYs in the HIV-infected population.

Cost per QALY Gained

Discounting at an annual rate of 3 percent over a 10-year period to present value, implementation of the HIV-CCP would result in a quality-adjusted gain in life expectancy of 105,403 QALYs for the 58,697 individuals who would be newly on HAART (Table A-8). We conservatively estimate that the provision of substance abuse treatment, mental health services, and case management would result in an additional gain of 23,982 QALYs over the same time period, also discounted to present value, resulting in a total gain of 129,385 QALYs among those individuals likely to enroll in the

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-8 Expected Health and Economic Outcomes for the 58,697 Individuals Who Would Receive HAART as a Result of HIV-CCP, over 10 years*

 

QALYs

Deaths

Cost (millions)

Current system

264,371

35,489

$6,889

HIV-CCP

369,773

15,664

$9,538

Difference

105,403

–19,825

$2,649

*QALYs and costs are discounted to present value at a rate of 3 percent per year. Costs reflect only the effects of increased use of HAART for these individuals. It excludes costs due to changes in Medicaid outpatient reimbursement; case management, mental health, and substance abuse care; and bringing individuals into care. These additional costs are reflected in the next table.

TABLE A-9 Estimated Cost per QALY Gained Associated with the HIV-CCP Program over a 10-Year Period for 297,128 Individuals Enrolled in the First Year (among those newly on HAART)*

Program Element

QALY Gain

Cost ($)

Cost/QALY Gained

HAART

105,403

2.648 billion

 

Substance abuse treatment, mental health treatment, case management

23,982

1.750 billion

 

Other services (additional costs associated with bringing people into care)

Assumed zero

775 million

 

Outpatient reimbursement = Medicare or Medicare + 5%

Undetermined

387 million

 

Total

129,385

5.560 billion

$42,972

*QALYs and costs are discounted to present value at a rate of 3 percent per year. No QALY gains are attributed specifically to changes in Medicaid reimbursement, being brought into care, or case management. These actions are portrayed as having health benefits only by increasing access to HAART. The QALY gains for mental health are 0.05 per year with mental services, and for substance abuse care 0.1 per year in substance abuse treatment (see text for discussion).

program in the first year. The estimate, from a societal perspective, of the 10-year incremental program as it applies to those initially enrolled is $5.56 billion, resulting in an estimated cost per QALY gained of $42,972. This is well within what is considered a “good buy” in terms of health care investment (Hirth et al., 2000) (Table A-9) (see Chapter 6).

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Budget Impact

We estimate that public spending on care for people with HIV disease, including the cost of care for the uninsured, was $7.161 billion in 2002 (fiscal year 2001) and that an additional $574 million in public spending would be needed to fund the HIV-CCP program in the first year the program is operational (Table A-10). The estimate is a summary figure that collapses the budgetary impact on all public payers. It assumes no “crowd-out” of private insurance and does not take into account any cost savings such as discounted drug costs or reductions in disability payments that might be found to offset the cost of an expansion of publicly financed HIV care. The estimate assumes that all outpatient care will be delivered through a Center of Excellence and billed at Medicare rates plus 5 percent. Though it is highly unlikely that all care will be delivered through a Center of Excellence, the Committee attempted to model the optimal and most expensive scenario.

The incremental cost to the federal government is measured by expenditures for the new program, plus residual spending for Medicaid and Medicare recipients who are not enrolled in the new program. The new program is estimated to cost $4.408 billion. Overall federal Centers for

TABLE A-10 Comparison of Estimated Year One Expenditures, Current and Anticipated, by Payer Associated with the HIV-CCP (in millions)

 

Current

Year 1 of HIV-CCP

Incremental Costs/(Savings)

Federal share of Medicaid/Medicare

$3,003

$5,610a

$2,607

State share of Medicaid

$2,138

$984b

($1,154)

Subtotal CMS-administered (federal/state Medicaid/Medicare)c

$5,141

$6,594

$1,453

Care for the uninsuredd

$2,020

$1,140

($880)

Total public (includes Medicare and federal/state Medicaid and the uninsured)

$7,161

$7,734

$574

a The cost of the HIV-CCP ($4,408) is included in the federal share of Medicaid/Medicare.

b This reflects state spending on individuals with HIV who remain in the Medicaid program as well as incomplete adjustment for dual Medicaid and Medicare eligibility.

c This excludes the cost of care provided by the Ryan White CARE Act, which is included under care for the uninsured. See text for discussion of potential CARE Act savings.

d The estimate of the cost of care for the uninsured includes care provided to veterans with HIV/AIDS by the Veterans Administration (VA) health care system. Though the VA is the largest single provider of HIV/AIDS care in the country, the amount of money it spends on HIV/AIDS care is small compared with other public programs, totaling less that $400 million in FY 2002. The VA does not cover care for veterans with private insurance, so in a sense it is a program for the uninsured.

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-11 Comparison of Estimated Expenditures, Current and Anticipated, by Payer Associated with Enhanced Medicaid Expansion (in millions of dollars)

 

Current

Year 1 of Enhanced Medicaid Program

Incremental Costs (Savings)

Federal share of Medicaid/Medicare

$3,003

$3,635a

$632

State share of Medicaid

$2,138

$2,225

$87

Subtotal public (Medicaid/Medicare)

$5,141

$5,859

$719

Care for the uninsured

$2,020

$1,433

($587)

Total public (includes Medicaid, Medicare, and the uninsured)

$7,161

$7,292

$132

aThe cost of the Enhanced Medicaid program ($2,748) is included in federal share of Medicaid/Medicare.

Medicare & Medicaid Services (CMS) spending, when compared to existing federal Medicaid and Medicare spending on HIV, is estimated to rise by $2.607 billion. The states, which would shift much of the cost of their Medicaid expenditures for individuals with HIV to the federal government if the HIV-CCP were established, would collectively realize a first-year savings of $1.154 billion. The Committee predicts that care for the uninsured, currently estimated at $2.02 billion, would fall to $1.140 billion, resulting in a net savings of $880 million shared by the federal government, states, counties, providers of uncompensated care, and other payers.

Enhanced Medicaid

Implementation of the Enhanced Medicaid option would be less costly overall, requiring an estimated increase in public expenditures of $132 million in the first year of operation (Table A-11). The Enhanced Medicaid option would also require less of a financial commitment by the federal government. However, while the cost to the federal government would be considerably less ($632 million in additional spending by CMS versus $2.57 billion in the first year), collectively, the states would have to spend more ($87 million versus a savings of $1.16 billion).

Sensitivity Analyses

We performed univariate sensitivity analyses for 36 model input variables to the model (Table A-12), including HIV population estimates, cost

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

TABLE A-12 Univariate Sensitivity Analysis

 

Values

Outcomes: QALYs Gained; Societal Cost; Cost/QALY

 

Variable

Base Case (low, high)

Low Valuea

High Value

Base case

NA

129,385

$5.56 billion

$42,972

HIV Population Characteristics

Aware

670,000

(536,000; 804,000)b

103,508

$4.45 billion

c

155,262

$6.67 billion

By clinical stage among aware

Base case

(CD4>500/CD4 499–350/CD4 349–200/AIDS 93/AIDS 87)

0.07/0.15/0.24/0.31/0.22

 

 

CD4 349–200 portion

(0.07/0.18/0.19/0.33/0.22, 0.07/0.12/0.29/0.29/0.22)

129,582

$5.60 billion

$43,207

129,114

$5.51 billion

$42,669

AIDS 93 portion

(0.07/0.15/0.27/0.25/0.25, 0.07/0.15/0.21/0.37/0.19)

131,256

$5.53 billion

$42,122

127,514

$5.59 billion

$43,808

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

 

Values

Outcomes: QALYs Gained; Societal Cost; Cost/QALY

 

Variable

Base Case (low, high)

Low Valuea

High Value

By insurance status, among aware

Base case (public/uninsured/private)

0.50/0.25/0.25

 

 

Low private

0.53/0.27/0.20

130,928

127,843

High private

0.47/0.23/0.30

$5.72 billion

$43,742

$5.39 billion

$42,161

HAART Use

Individuals currently on HAART—total

230,000

(184,000; 276,000)

108,141

$5.41 billion

$50,031

150,627

$5.21 billion

$34,601

Individuals currently on HAART—public and uninsured

167,650

(134,120; 201,180)

152,367

$6.72 billion

$38,097

82,419

$4.40 billion

$53,391

Relative risk of receiving HAART if family income <$25,000

0.60

(0.5; 0.7)

153,326

$5.94 billion

$38,715

112,283

$5.26 billion

$46,825

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Relative risk of receiving HAART in program versus private insurance

1.0

(0.92, NAd)

100,965

$5.05 billion

$49,973

NA

Relative risk of getting HAART if receiving case management

1.5

(1.2, 1.8)

116,291

$5.33 billion

$45,837

142,675

$5.78 billion

$40,490

Relative risk of getting HAART if receiving mental health treatment

1.4

(1.2, 1.6)

124,108

$5.47 billion

$44,607

134,662

$5.65 billion

$41,944

Relative risk of getting HAART if receiving substance abuse treatment

1.7

(1.3, 3.0)

120,590

$5.41 billion

$44,840

158,114

$6.00 billion

$37,967

HIV Clinical Costs

Clinical care, individuals not on HAARTe (per person-year)

$18,705

($16,834; $20,576)

$5.51 billion

$42,582

$5.61 billion

$43,361

HAART, in the program

$9,222

($8,300; $10,144)

$5.15 billion

$39,830

$5.97 billion

$46,113

Non-HAART clinical care, individuals on HAART

$12,373

($11,136; $13,611)

$5.09 billion

$39,340

$6.03 billion

$46,603

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

 

Values

Outcomes: QALYs Gained; Societal Cost; Cost/QALY

 

Variable

Base Case (low, high)

Low Valuea

High Value

Case management

$826

($661; $991)

$5.50 billion

$42,452

$5.62 billion

$43,401

Mental health treatment

$1,380

($1,104; $1,656)

$5.50 billion

$42,541

$5.62 billion

$43,402

Substance abuse treatment

$6,193

($5,574; $6,812)f

$5.46 billion

$42,167

$5.66 billion

$43,777

Increase in Service Utilization

Substance abuse treatment

0.075

(0.06; 0.09)

126,387

$5.35 billion

$42,343

132,383

$5.77 billion

$43,572

Mental health treatment

0.09

(0.07; 0.11)

127,387

$5.50 billion

$43,160

131,384

$5.62 billion

$42,789

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Case management

0.15

(0.12; 0.18)

$5.50 billion

$42,542

$5.62 billion

$43,401

Eligibility and Enrollment

Proportion Eligible

By insurance status

In care

Public

0.92

(0.87; 0.97)g

121,393

$5.24 billion

137,378

$5.88 billion

Uninsured

0.53

(0.42; 0.64)

$43,176

$42,784

Not in care

Public

0.975

(0.93; 1.0)h

126,756

$5.42 billion

131,308

$5.66 billion

Uninsured

0.50

(0.4; 0.6)

$42,760

$43,139

Enrollment Ratesi

In care

Publicly insured

0.90 (0.45; 0.99)

84,518

138,358

Uninsured

0.90 (0.45; 0.99)

$3.77 billion

$44,649

$5.92 billion

$42,773

Not in care

Publicly insured

0.40 (0.20; 0.60)

109,559

149,211

Uninsured

0.30 (0.15; 0.45)

$4.57 billion

$41,680

$6.55 billion

$43,927

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

 

Values

Outcomes: QALYs Gained; Societal Cost; Cost/QALY

 

Variable

Base Case (low, high)

Low Valuea

High Value

If enrolled, in care

Not in care (previously)

Publicly insured

0.75 (0.6; 0.9)

121,454

137,315

Uninsured

0.75 (0.6; 0.9)

$5.16 billion

$42,503

$5.96 billion

$43,386

Health Effects

Utility deficit due to advanced disease

0.12–0.24

(–10%, +10%)

127,128

$43,735

131,642

$42,235

Utility change (drop) for being on HAART (side effects, inconvenience)

–0.03

(0.0; –0.06)j

141,340

$39,337

117,430

$47,347

Utility gain for being on HAART

(symptom reduction)

0.06–0.13

(–10%, +10%)

125,665

$44,244

133,105

$41,771

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

Utility adjustment for receiving substance abuse treatment

0.1

(0.08; 0.12)

126,387

$43,991

132,383

$41,999

Utility adjustment for receiving mental health treatment

0.05

(0.04; 0.06)

127,587

$43,578

131,184

$42,383

aLow value/high value indicates the value of the input variable.

bUnless otherwise indicated sensitivity analyses were done using a range of ± 20%.

cA dash (—) indicates same value as base case.

dFor HAART use in program, no upper bound is specified because use at the level of private insurance (base case) is considered a maximum.

eCost of care not on HAART is for those individuals who would be on HAART with the program, to facilitate comparison with subsequent rows.

fA range of ± 10% was used for this variable.

gA range of ± 5% was used for this variable.

hA range of ± 5% was used for this variable.

iA range of ± 50% (with a maximum of 0.99) was used for all of the variables in this section.

jA range of ± 100% was used for this variable.

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

of care data, and estimated health utility gains from treatment. Generally, we used ranges of ±10 percent for the high/low values when the original input was from a well-done and directly relevant study or source, up to ±20 percent to determine the high/low values when the original input was from a published but less definitive source or sources, and ±50 percent or more when published data were scarce and we relied on expert judgment to estimate the input.

Each sensitivity analysis estimated three outputs (QALY gain, societal cost, and cost per QALY gained, all discounted) for the low and high input values. We found that no single variable had an unexpected impact on the results of the model and, in general, the variations in outputs resulting from the analyses were modest, especially for cost effectiveness. Predictably, total population with HIV along with HAART use and cost produced the widest range of results. Varying the total HIV population aware affected total program cost proportionately (i.e., ±20 percent) but did not affect cost per QALY gained. If, however, all newly aware were asymptomatic and not candidates for HAART over the five years, a 20 percent gain in awareness would generate much smaller gains in QALYs (to 134,181) and costs ($6.2 billion) and a small rise in cost per QALY gained (to $46,076) (not in table). Different disease distributions among the aware had little effect. Different insurance status distributions affected cost and QALYs gained a little, and cost per QALY gained almost not at all.

Varying current HAART use among those publicly insured or uninsured by ±20 percent produced relatively substantial changes in terms of both total cost and QALYs gained, and moderate variation in cost effectiveness ($34,000 to $54,000 per QALY gained). Variations in the relative risk of getting HAART due to use of ancillary services had only small effects.

HIV clinical costs had only modest effects on cost per QALY gained. The inputs with the greatest impact were cost of HAART per person-year and of non-HAART clinical costs for those on HAART. These sensitivity analyses by ±20 percent produced no change in QALYs and some variation in total cost. It produced one of the widest variations in cost effectiveness, however, from $39,000 to $46,000. Only non-HAART clinical cost for those on HAART had a greater variation in terms of cost effectiveness, from $39,340 to $46,603. Changes in utilization of ancillary services had very small effects.

For eligibility and enrollment, the largest variation in outputs resulted from inputs where the value was based on expert judgment. For example, uncertainty in enrollment led to variation in costs of $3.8 to $5.9 billion, though very little change in cost effectiveness due to similar changes in QALYs gained. This is essentially a program scaling effect.

Changes in health inputs had small effects due to fairly narrow uncertainty (e.g., for utility decrement due to disease status) or only limited

Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×

impact on results (e.g., utility gain for one ancillary service). The largest effect was for the utility decrement associated with HAART use, due to complete lack of data, with variation in QALYs gained from 117,000 to 141,000, and for cost effectiveness from $39,000 to $47,000 per QALY gained.

Additional and more nuanced sensitivity analysis would be useful to explore the implications of variations of other assumptions, for example, differing distributions of HAART use by disease stage, particularly late AIDS. Time and resource constraints, however, dictated that we focus on those analyses where the outcomes could materially affect the findings of the model.

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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
×
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Suggested Citation:"Appendix A: Technical Appendix Estimating the Impact and Cost of Expanded HIV Care Programs." Institute of Medicine. 2005. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: The National Academies Press. doi: 10.17226/10995.
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Each year it is estimated that approximately 40,000 people in the U.S. are newly infected with HIV. In the late 1990s, the number of deaths from AIDS dropped 43% as a result of highly active antiretroviral therapy. Unfortunately, the complex system currently in place for financing and delivering publicly financed HIV care undermines the significant advances that have been made in the development of new technologies to treat it. Many HIV patients experience delays in access to other services that would support adhering to treatment. As a result, each year opportunities are missed that could reduce the mortality, morbidity, and disability suffered by individuals with HIV infections.

Public Financing and Delivery of HIV/AIDS Care examines the current standard of care for HIV patients and assesses the extent the system currently used for financing and delivering care allows individuals with HIV to actually receive it. The book recommends an expanded federal program for the treatment of individuals with HIV, administered at the state level. This program would provide timely access and consistent benefits with a strong focus on comprehensive and continuous care and access to antiretroviral therapy. It could help improve the quality of life of HIV/AIDS patients, as well as reduce the number of deaths among those infected.

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