Dr
Mike Youle MB ChB Director of HIV Clinical Research, Royal Free Hospital,
The HIV epidemic, which is well into its second decade, has left a lasting
impression on healthcare in the
From 1986, when zidovudine (AZT) became the first available antiretroviral
agent, the costs of drug therapy and the continuing care of patients who need to
be hospitalised have produced an increasing burden on most health authorities.
Due to the epidemiology of the epidemic, this has been concentrated largely in
urban centres - and specifically in
In the early part of the epidemic, physicians'
energies were largely taken up with concentrating on the expanding range of
presentations and unusual conditions seen in HIV, learning how to treat them
effectively and conducting studies of putative anti-HIV agents. However, things
have now changed.
There has been a dramatic decrease in morbidity and mortality since the
introduction in late 1995 of protease inhibitors and combination antiretroviral
therapies. Death rates have plummeted and numbers of patients willing to test
for the presence of HIV have increased, thereby swelling the numbers being cared
for. The increasing complexity of care has led to longer patient visits and the
need for constant monitoring has increased outpatient load. Meanwhile inpatient
numbers have declined.
Whether this situation will continue shall be determined, to a degree, by the
quality of care delivered to patients and by the ongoing effects of drugs in
suppressing HIV replication. Further agents are in the pipeline, and the
possibility of immune stimulation with agents such as interleukin-2 are future
options that may bring benefits and will certainly incur costs.
Clearly, the time has come not only for clinical
and epidemiological assessment of the benefits of therapy but also of their
costs to the NHS. Within a socialised system, which requires allocation of
monies to a problem in a measured manner, it is vital to have appropriate tools
to measure economic outcomes.
To date there has been a paucity of investigation and research into issues
surrounding health economics in
Modelling approaches have been utilised until now, since there has been a
shortage of prospective survival data with new therapies. All modelling studies
have limitations, but they are likely to be required for the foreseeable future,
since most clinical trials are stopped as soon as differences in surrogate
markers are observed. Moreover, the size of studies available are likely to
remain too small to yield useful resource-utilisation data for economic
analysis.
Another difficulty in assessing the issue is the lack of cost data for
procedures and other resource-utilisation in both hospital and community.
Additionally, since many of the benefits of therapy are indirect (such as
improvements in quality of life and economic capacity), problems arise when
purely health-related benefits are evaluated. Certainly patients' reduced need
for community care and increased willingness to re-enter the job market has an
economic impact that is rarely assessed when considering the benefits of new
therapy.
Several studies have assessed the cost effectiveness of HIV
monotherapy treatment . Cost per life-year saved has varied from
£30-40,000, depending on the assumptions made and the country in which the
research was conducted. Meanwhile, for combination
therapy , the incremental cost-effectiveness ratio has been
assessed at between £6-10,000. This compares very favourably with the other
interventions, with almost all assessed interventions costing more than £15,000
per life-year saved (other than counselling for smoking cessation).
Health economics are currently being built into
most clinical studies, along with assessment of quality of life. Outside the
Health economics is a growth area within the health service and is a vital
component for the planning and provision of quality care. Clearly, the next
century will see a revolution in the methods by which we assess the costs of
healthcare and the way improvements can be delivered at best price for both the
system and the individual patient.