Fewer AIDS Deaths and Illnesses: New Information

Two issues ago we reported that AIDS death rates have fallen to about half of what they were previously, in three very different patient populations who have access to modern treatment (see "1997 Outlook," AIDS TREATMENT NEWS #263, January 17, 1997). The patient groups were people with AIDS in British Columbia (2/3 drop in death rate in two and a half years), inmates at California's medical prison in Vacaville (exact figures not available but probably more than a 50% drop in death rate in one year), and San Francisco residents whose obituaries were published in the BAY AREA REPORTER gay newspaper (at least 50% drop in number of deaths per week, compared to the year before). This article summarizes new information on survival and hospitalization rates presented at the recent Retroviruses conference and elsewhere. All of it shows a large drop in deaths, or in hospitalizations and other evidence of major illnesses, during the last year.

New York City Deaths Decline Almost 50%

Total AIDS deaths in New York City declined from 19.5 per day in January 1996 to 10.1 per day in November 1996, a decline of 48%. Note: Because this decline occurred within 1996, it did not apply to the full calendar year. Therefore, a comparison of total deaths in 1996 vs. 1995 gives a smaller 30% decline when comparing one calendar year with another -- the figure reported in THE NEW YORK TIMES on January 25 ("Deaths from AIDS Decline Sharply in New York City," page 1). The fall in deaths per day (from January to November, the latest month for which figures were available) is more relevant for showing the effect of improvements in medical care which occurred during 1996.

Exactly what caused the drop in deaths is not clear. The new antiviral combinations with protease inhibitors probably could not by themselves have caused such a large drop, because they were not widely enough available. Other factors widely believed to have contributed have been (1) the campaigns to get people to be tested and get medical care if HIV positive (especially to prevent pneumocystis if their T-helper count is low), and (2) good Federal and state funding for both care and prevention in New York.

Efforts to find the exact causes of this decline (which had never been seen before in the New York statistics and was entirely unexpected) are continuing. Almost certainly there are many improvements -- in HIV treatments, opportunistic infection treatments, prevention of transmission, opportunistic infection prophylaxis, and other advances in medical care and its delivery, which have contributed.

Los Angeles: HIV Specialist Practice Reports Dramatic Reduction in Need for Healthcare Services

A Los Angeles medical center which specializes in infectious diseases and cares for about 480 HIV patients (through contracts with other managed-care organizations) reported a large drop in deaths, opportunistic infections, need for hospitalization, home care, specialist referrals, and other indications of illness, after starting combination therapy including protease inhibitors.(1) The death rate dropped several fold in the last half of 1996 (although this was not emphasized in the presentation) -- and the reduced expenses for medical services more than paid for the cost of the drugs. Peter Ruane, M.D., of Tower I.D. Medical Associates, presented these results on January 23, at the 4th Conference on Retroviruses and Opportunistic Infections in Washington, D.C.

In this fairly advanced patient population (half had a CD4 count lower than 200, and 25% had a CD4 count under 50), only 9% were receiving protease inhibitor treatment in 1995, but about 62% had been prescribed a protease inhibitor by October 1966. In the time between late 1994 and late 1996, the number of hospital days required fell by 57%, and the number of skilled nursing or hospice days fell by 65%.

"These new therapies have completely transformed home care as well," added Dr. Ruane. "In the last six months of 1994 we had 65 people on home care. Now we have five. These drugs clearly reduce the incidence of opportunistic infections. In fact, among compliant patients we have not seen a new case of CMV disease in a year." In two years, home-care use of G-CSF fell 70%, erythropoietin use was down 74%, and CMV treatments fell 90%.

Referrals to specialists also dropped greatly. Radiation treatment was down 80%, total parenteral nutrition (TPN) down 70%, dermatology down 53%, and gastroenterology was down 53%.

Total medication costs increased by 116% in 1996 vs. 1994 (and by 301% for those patients with CD4 counts under 50). But for every $1 increase in medication cost, $2 was saved on other costs (and the savings were higher for patients with CD4 count under 50).

Comment: The Tower I.D. data may be the most complete so far in relating the increased cost of drugs to reduced medical costs elsewhere -- information which is important in advocating for access to care. This is because the total HIV care was delivered under a "capitated " system, meaning that the practice was paid a fixed amount per patient, and provided what care was considered necessary; therefore, all the HIV-related costs were accounted for in the same budget. In many other settings, the drug costs are charged to one institution, but the overall savings to the medical system are scattered among other unrelated institutions, making it difficult or impossible to assemble comprehensive information on the economics of care.

St. Vincents Hospital, New York: Hospitalization Down Despite More Patients Seeking Treatment

Ramon Torres, M.D., reported a major reduction in hospitalization at St. Vincents Hospital in New York -- including a 24% drop in inpatient census from 1995 to 1996, despite an increase in persons seeking HIV care.(2) Cost of antiretrovirals increased 6.7 fold (from $28,471 to $219,446) between 1995 and 1996. (Use of protease inhibitors at the inpatient pharmacy started in 1996, and nucleoside analog use also increased in that year, due to combination treatments.) Dr. Torres noted that it is unclear how the cost of the drugs was offset by reduced hospitalization and other services required.

French Study Finds Triple Combination Therapies Reduce Hospitalization, Save More Than Drug Costs

Changes in antiretroviral use, AIDS-defining events, and hospitalizations were studied at nine medical centers in France, which together care for over 7,000 patients.(3) The three centers which started early in prescribing triple combination therapies with protease inhibitors saved $250,000 (U.S.) per month (by avoided hospitalization costs, minus the cost of the additional drugs). But the three centers which started latest in prescribing the new treatments have not yet reduced hospitalizations enough to pay for the drug costs. (A different breakdown was used in the published abstract.)

AIDS Survival: San Francisco Update

In reporting the decline of deaths in New York, THE NEW YORK TIMES (January 25 article referred to above) quoted an official from the San Francisco Health Department, that deaths reported in San Francisco rose slightly between 1995 and 1996. Since this goes against other findings, we called the Health Department for more information.

The Surveillance office there told us that statistics are kept both as DEATHS REPORTED and DEATHS OCCURRED -- and the latter is more reliable. In March 1996, for example, a
periodic reconciliation with the National Death Index was completed, and 300 deaths were added to the 1996 "reported" total -- even though these people actually died in 1993 or 1994. The "deaths occurred" figure shows a steady decrease -- 734 in the first half of 1995, 678 in the second half, and 573 in the first half of 1996. The total for the second half of 1996 has not been released because it is not yet complete. The Health Department noted, however, that "the relative impact that changes in treatment and access to care may have on survival cannot be determined from these data."

Turning to the reduction in the number of obituaries submitted to the gay press in San Francisco -- a less comprehensive but more rapid source of information on changes in the epidemic -- the information we previously reported, that these deaths were running about half or slightly less than half of those last year, currently remains true. The actual improvement is probably better than this, since some of these deaths are not HIV related -- meaning that the HIV deaths would have to decline by more than half to bring the total drop to half.

In San Francisco there is now much interest in returning to work and planning for a future which had not been expected -- dealing with issues such as obtaining medical care when one no longer qualifies for disability. A February 8 forum on "returning to work, protecting benefits, and ideas on how to maximize assets and increase cash flow" had 300 people call to reserve one of the 50 spaces available.

But there are still many deaths -- three per day in San Francisco, and ten in New York City -- from HIV disease. Many of these occur despite the best possible treatment and care. The epidemic is not over.

References

1. Ruane PJ, Ida J, Zakowski PC, Sokolov RJ, Uman SJ and Daly R. Impact of newer antiretroviral (ARV) therapies on inpatient and outpatient utilization of healthcare resources in patients with HIV. 4th Conference on Retroviruses and Opportunistic Infections, Washington, January 22-26 [abstract #262].

2. Torres R and Barr M. Impact of potent new antiretroviral therapies on in-patient and out-patient hospital utilization by HIV-infected persons. 4th Conference on Retroviruses and Opportunistic Infections, Washington, January 22-26 [abstract #264].

3. Mouton Y, Cartier F, Dellamonica P, and others. Dramatic cut in AIDS defining events and hospitalization for patients under protease inhibitors (P.I.) and tritherapies (TTT) in 9 AIDS reference centers (ARC) and 7,391 patients. 4th Conference on Retroviruses and Opportunistic Infections, Washington, January 22-26 [abstract #LB12].