Once-a-day HIV Treatment: Pricey But Perhaps Worth It

An Express Scripts analysis backs up industry claims that high-priced HIV medications may save money in the long run because they improve adherence.

Ed Silverman

Sometimes, that pricey pill isn’t as expensive as you may think. That’s the takeaway from a recent analysis that found using expensive, single-tablet regimens to treat HIV is less costly than multi-tablet regimens. One reason is simply that some combination treatments cost more because of the mix of pills. But another is that the greater patient adherence that comes with using once-a-day pills should lead to better health outcomes that can save health care dollars.

The annual pharmacy costs for single-tablet regimens were $6,100 less compared with regimens involving multiple pills, at least among HIV patients who were taking the medicines as intended, according to an Express Scripts analysis. On average, the company found that health plans could save about $4,160 per patient per year if they switched patients to clinically equivalent single-tablet regimens. Patient adherence is the main reason for the difference. Express Scripts found that 74.5% of patients taking a once-a-day pill took the medication as prescribed compared with 64.9% of those using multitablet regimens.

The PBM’s researchers arrived at those and other figures by sifting through a data­base of more than 41 million pharmacy claims from commercial and government-sponsored plans that Express Scripts administered between 2014 and 2017.

To be clear, the single-tablet regimens do not come cheap.

Two years ago, the annual health plan and member costs for these once-a-day pills ranged from a low of around $18,800 for Trizivir (abacavir, lamivudine, zido­vudine), which is sold by ViiV Healthcare, to more than $34,600 a year for Stribild (elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate), one of several Gilead Sciences medicines for HIV. Most of the once-a-day pills are priced so they cost about $30,000 once rebates are applied, according to Express Scripts.

Claims data reveal that the average plan and patient out-of-pocket costs for multitablet regimens per patient in 2017 totaled nearly $32,900, while the once-a-day pills were about $29,200, or roughly $3,700 less. The difference can be explained, in part, because some combination treatments cost more than others.

Moreover, Glenn Stettin, MD, senior vice president for clinical, research, and new solutions at Express Scripts, points out that the convenience of a once-a-day pill and increased adherence should lower hospitalization and overall cost of care later.

The number of combination pills for HIV treatment has mushroomed. A website maintained by HHS, aidsinfo.gov, listed 21 different combination drugs as of early March (see “FDA-approved combination HIV medications,” below).

FDA-approved combination HIV medications
Brand name Generic ingredients of the combination medication Date of FDA approval
Atripla efavirenz, emtricitabine, tenofovir disoproxil fumarate July 12, 2006
Biktarvy bictegravir, emtricitabine, tenofovir alafenamide February 7, 2018
Cimduo lamivudine, tenofovir disoproxil fumarate February 28, 2018
Combivir lamivudine, zidovudine September 27, 1997
Complera emtricitabine, rilpivirine, tenofovir disoproxil fumarate August 10, 2011
Delstrigo doravirine, lamivudine, tenofovir disoproxil fumarate August 30, 2018
Descovy emtricitabine, tenofovir alafenamide April 4, 2016
Epzicom abacavir, lamivudine August 2, 2004
Evotaz atazanavir, cobicistat January 29, 2015
Genvoya elvitegravir, cobicistat, emtricitabine, tenofovir alafenamide November 5, 2015
Juluca dolutegravir, rilpivirine November 21, 2017
Kaletra lopinavir, ritonavir September 15, 2000
Odefsey emtricitabine, rilpivirine, tenofovir alafenamide March 1, 2016
Prezcobix darunavir, cobicistat January 29, 2015
Stribild elvitegravir, cobicistat, emtricitabine, tenofovir disoproxil fumarate August 27, 2012
Symfi efavirenz, lamivudine, tenofovir disoproxil fumarate March 22, 2018
Symfi Lo efavirenz, lamivudine, tenofovir disoproxil fumarate February 5, 2018
Symtuza darunavir, cobicistat, emtricitabine, tenofovir alafenamide July 17, 2018
Triumeq abacavir, dolutegravir, lamivudine August 22, 2014
Trizivir abacavir, lamivudine, zidovudine November 14, 2000
Truvada emtricitabine, tenofovir disoproxil fumarate August 2, 2004
Source: HHS, Aidsinfo website , FDA-approved HIV medicines, March 2019

Adherence is “incredibly important” for keeping HIV infection under control, says James Krellenstein, a founding member of the Prevention of HIV Action Group at ACT UP/New York, a prominent AIDS advocacy organization. He notes the Express Scripts findings appear to support industry arguments that packaging multiple HIV medications into a single combination pill increases adherence and, therefore, saves money in the long run. But, he adds, other factors could account for the differences in adherence as well.

The Express Scripts report is a good first step, but there’s a need for more rigorous analysis, Krellenstein says. “This is really a post-hoc analysis, not a randomized, case-controlled study,” he says. “And it’s not like they compared the exact same regimens to determine adherence…. We would also want to know why some people are getting an inferior regimen. Is it because a doctor isn’t up to speed?”

Meanwhile, though, single-tablet regimens appear to be gaining traction. Among patients who were covered by commercial insurance and who were new to HIV therapy, 66% started treatment by taking a once-a-day pill and, over the next two years, less than 7% later switched to a multitablet regimen, says the Express Scripts report. Meanwhile, among the 34% of new patients who started with a multiple-tablet regimen, 38% later switched to a single-tablet regimen within two years.

For his part, Stettin acknowledged the limitations of the company’s analysis.

“You wouldn’t use this to prove that treating people one way is better than another, but at the same time, it does look like people treated with single-tablet regimens are doing better than people who were treated with multiple-tablet regimens,” he says. “It’s a description of what’s going on in the real world, as it compares the use of medicines and cost of care.”

Of course, as Express Scripts points out, the choice of regimen depends on numerous factors, such as known viral resistance to specific drugs, patient comorbidities, side effects, convenience, and out-of-pocket costs. As it so happens, once-a-day regimens are easier to take and typically have lower out-of-pocket costs, but also cost more per prescription.

The bottom line, Stettin contends, is that the data reveal “important news for those treating and providing coverage for HIV patients, since misperceptions about the costs may be preventing the prescribing” of single-tablet regimens.

Ed Silverman founded the Pharmalot blog and has covered the pharmaceutical industry for 20 years.

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