According to the US Centers for Disease Control and Prevention (CDC), Americans pay 14% of their prescription drug costs out of pocket each year, and the United States spends more per capita on prescription drugs than any other high-income country in the world. High costs contribute to a certain degree of nonadherence among patients generally
, but little information exists about the impact of financial barriers on adherence for people living with HIV specifically.
An analysis presented in the CDC’s Morbidity and Mortality Weekly Report
shows that from 2016-17, 14% of people living with HIV have used a drug-cost saving strategy and 7% have had cost saving-related nonadherence.
The CDC’s Medical Monitoring Project analyzed nationally representative surveillance data on medical care, behaviors, and clinical outcomes among adults with HIV infection. Data were collected through medical record abstraction as well as face to face and telephone interviews between June 2016-May 2017. Investigators weighted data for unequal selection probabilities and nonresponse.
Using data from 3948 people taking prescription drugs, the prevalence of prescription drug cost-saving strategies among those living with HIV was estimated overall and by sociodemographic characteristics. Investigators also assessed differences in clinical outcomes between those who did and did not have cost-saving related nonadherence.
Questions pertained to 6 different types of cost-saving strategy. Patients reported whether they had asked a clinician for a lower-cost medication, used alternative therapies, bought prescription drugs from another country, skipped doses, taken less medication, or delayed filling a prescription because of cost. Those interviewed were asked about all prescription drugs, not solely antiretrovirals.
Cost-saving nonadherence was qualified by having used the cost saving strategies of skipping doses, taking less medication, or delaying a prescription due to cost.
Care engagement and viral suppression were abstracted from medical records. Individuals interviewed were also asked if they needed but had not received medication from the Ryan White AIDS Drug Assistance Program (ADAP) to investigate unmet need.
Of the approximately 14% of Americans with HIV who had used a medication cost-saving strategy, 4% had skipped doses, 4% took less medicine, and 6% had delayed a prescription. In the categories which were not considered directly nonadherent, 9% had asked clinicians for lower-cost medicine, 1% had bought medication from another country, and 2% used alternative medicine.
Household income above the poverty line was associated with nonadherence due to prescription drug costs, with 8.3% reporting nonadherence above the poverty line, ($12,490 as of 2019
) compared to 5.3% below the poverty line.
“Persons with incomes above the poverty level might not be eligible for the Ryan White HIV/AIDS Program or other assistance programs that can reduce medication costs,” the authors of the report wrote.
Those who reported unmet need for medication through ADAP were around 5 times more likely to be nonadherent due to cost than those who received ADAP.
People living with HIV who reported cost-saving related nonadherence were less likely to be virally suppressed at their most recent viral load test (64%) than those who did not report cost-saving related nonadherence (76%). Nonadherence related to drug cost was also associated with lower HIV care engagement rates and more emergency department visits.
The greater occurrence of costly hospitalizations and lower viral suppression rates (increasing likelihood of HIV transmission) among those who were nonadherent due to prescription drug costs demonstrate that cost-related nonadherence presents a broad social need with many stakeholders.
In a recent interview
concerning upcoming long-acting antiretroviral therapies, Carlos del Rio, MD, FIDSA, Co-director for the Emory Center for AIDS research, claimed that clinicians must take cost seriously when treating HIV.
“I think that as clinicians it's something that we just have to begin to understand, we can no longer ignore the cost of health care and ignore the cost of what happens,” del Rio said.
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