Medicare Ineligible PLHIV: Lessons from the ATRAS Study
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This presentation on findings from a trial of providing HIV medication to people not eligible for Medicare was given by Tony Maynard from the National Association of People With HIV Australia (NAPWHA) at AFAO'S HIV and Mobility Forum on 30 May 2016.
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Medicare Ineligible PLHIV: Lessons from the ATRAS Study
- 1. Medicare Ineligible PLHIV Lessons from the ATRAS Study Mobility Conference Tony Maynard May 30th, 2016
- 2. ‘Medicare Ineligible’ • In Australia legally • No Access to PBS subsidised ARVs • Existing provisions for this group vary significantly across jurisdictions • Only 60% of HIV+ people who need treatment are getting it • 31% are on sub-optimal combinations
- 3. A AHOD T Temporary R Residents A Access S Study
- 4. Aims • To describe the population of HIV+ temporary residents • To describe the HIV disease status of this group • To model HIV transmission rates • To provide compassionate ARV access for up to 4 years (ended in Nov 2015)
- 5. The Sample • Recruited 180 people from 21 sites • 74% male, 26% female • 46% SE Asia, 19% SS Africa, 11% S America, 11% S Pacific, 9% Europe, 6% N America • 31% Student visa, 33% Working visa, 14% Bridging visa, 13% Spousal Visa, 13% other visa • Route of transmission; 49% MSM, 39% Heterosexual contact, 12% Other
- 6. HIV transmission 53% detectable VL at baseline After 12months (12% detectable) • 77.4% reduction in detectable viral load and who have a substantial risk of onward transmission After 24 months (6% detectable) • 93% reduction in the risk of onwards transmission
- 7. Transition to Medicare Eligibility • At July 2013 – 39 patients had left ATRAS • At July 2014 – 79 patients had left ATRAS • At November 2015 – 90 patients had left ATRAS Thus leaving 80 ATRAS patients and a further 450 Medicare Ineligible PLHIV without an alternative scheme to access their ARV.
- 8. Modelling • Estimated 450 - 480 Medicare Ineligible people in Australia at any time. • Total Treatment cost over 5 years estimated at $29,642,230. or $320,000 per infection averted. • Potential to avert a median 81 new infections over 5 years. • Equivalent to a cost saving of $69,412,098 over their lifetime Broadly cost-neutral
- 9. Why do we Care? • It’s not just about Human Rights, it’s also about Public Health • We care a lot in Australia about Public Health; $ 2.3 billion dollars annually • So why is one particular group of people being excluded from this herculean effort to secure public health?
- 10. It doesn’t make sense • Comparisons with other diseases • National Strategy Commitments • Enormous amounts of wasted time trying to access medications impact negatively on the Health Service and Community Organisations • Financial considerations are misleading
- 11. The time before ATRAS…. • Series of Band-Aid solutions… Band-Aids on Band-Aids • Compassionate access schemes • ‘Under the radar’ arrangements through clinics • Trials • Benevolent pharmaceutical companies
- 12. Since ATRAS • We know where they are and how many • The time it takes to transition to Medicare eligibility is short: median 4 years • We have made the issue visible • We have achieved some sort of jurisdictional standardisation.
- 13. Jurisdictional Arrangements Jurisdiction Arrangements for managing Medicare Ineligible HIV +ve patients NSW Patients are advised if the cost of starting or staying on HIV medications is getting in the way of their being on treatment to please talk to their doctor/prescriber for advice, support and referral services. ASHM also targets the s100 prescribers and advises where a patient is experiencing financial barriers to treatment access, clinicians should telephone their local HIV/Sexual Health Service to discuss options for support with HIV medications. The rationale for directing people and/or their clinicians to the sexual health clinics is that some of the Clinic Directors have the discretion to approve the purchase of treatments for patients in need. The sexual health clinic will also be able to link people to other options such as charities (like the Bobby Goldsmith Foundation). The HIV Support Program provides a safety mechanism. The program follows up each new diagnosis and in particular enables/challenges to treatment uptake.
- 14. TAS As yet there have not been cases requiring ARV treatment for Medicare ineligible HIV people but are considering options currently. SA All treatment and medication costs for Medicare ineligible HIV+ve people are met by SA Health WA An Operational Directive is in place whereby funds must be recouped from health insurance companies. If this is not possible, then approval must be provided by the director of an area health service for treatment costs in excessive of $10,000. http://www.health.wa.gov.au/CircularsNew/circular.cfm?Circ_ID=12895 QLD Different arrangements across services and regions; a decentralised health system that results in a local decision. Ranges from full support to applying for welfare grants. The process is unwieldy and time consuming for staff. ACT 17 HIV+ve patients who are ineligible for Medicare, of which 16 are receiving ART through ‘compassionate access’. NT ARVs are obtained from companies under “compassionate access” arrangements on an individual basis. Less than a handful involved per annum. VIC Victoria does not have a formal system-wide approach; Medicare ineligible patients are referred to the Melbourne Sexual Health Centre, where HIV drugs are provided at no cost to the patient.
- 15. Gaps in the response • Medicare Ineligible people are not recognised as a priority population by the National Strategy • ‘Measured progress’ is not ‘actual progress’ • Politically unpopular subject and there is no permanent solution on the horizon • Federation ‘dance’
- 16. Possible Solutions • Agreement of the Federal Government to reimburse State and Territory Governments for Medicare Ineligible PLHIV on the basis of “Public Health Protection” • Currently, Reciprocal Health Care Agreements exist between Australia and New Zealand, the United Kingdom, the Republic of Ireland, Sweden, the Netherlands, Finland, Italy, Belgium, Malta, Slovenia and Norway. Hospitals and Sexual Health Clinics have special Medicare numbers to use in these cases and get reimbursed.
- 17. Possible Solutions • Other, more complicated arrangements have been suggested, but politically they would be unpopular in that allowing Medicare for all Visa holders would ‘open the flood gates’ to all conditions. • Using the “Public Health Protection” rationale would be politically palatable and the case for it strengthened by using the economic modelling which shows it would be cost-saving in terms of new HIV infections averted
Hinweis der Redaktion
- Today I have been asked to talk about the ATRAS study and what lessons have come out of it. ATRAS is a joint project of NAPWHA and The Kirby Institute and is supported by the seven pharmaceutical companies who provide HIV antiretroviral drugs in Australia and the Australian HIV Observational Database (AHOD) clinical sites. It’s designed to help us get a better understanding of ARV treatment and access for people who are HIV positive but Ineligible for Medicare in Australia. Before we get started;
- Medicare Ineligible people are those people that are in Australia, perfectly legally, on various temporary student, business or employer sponsored visas that do not allow access to Australia’s Medicare scheme. This means no access to subsidised drugs through the PBS. So for HIV positive people who are Medicare ineligible that means; Delaying treatment commencement or stopping treatment Accessing medication through studies or compassionate access schemes where possible Accessing treatments from their country of origin OR paying the full unsubsidised price in Australia This has a number of problems. Obtaining ARVs from overseas can be problematic in terms of availability, supply reliability and drug quality. Cost estimates put the unsubsidised cost of a first line regimen like Atripla at $12,438 per year so it is prohibitive for most. There is SOME provision for this group at the State and Territory level but it varies significantly. Some states have formal state-wide arrangements, some don’t. In some states it comes down to the individual clinic or health area. This is problematic because it wastes time and costs money for health professionals to spend hours trying to arrange uncertain compassionate access on a case by case basis. The result is a patchwork system of access that falls short of the standard of care and treatment given to Australian citizens and permanent residents. Only an estimated 60% of Medicare Ineligible people who needed treatment were getting in 2007. Around 31% them were receiving sub-optimal treatment because that is what was available.
- ATRAS stands for the AHOD Temporary Resident Access Study and And AHOD, in case anyone doesn’t know, is the Australian HIV Observational Database.
- The ATRAS study was established to describe this population of HIV positive temporary residents To understand the disease status of that group To model transmission rates. And it was also a mechanism by which we could supply appropriate ARV access for up to four years - to a population that is being denied access
- Between November 2011 and June 2012 we recruited 180 people from 21 AHOD sites – most came from Sexual Health Clinics (46%), then General Practices (27%), then Tertiary Referral Centres (27%). 74% were male, 26% Female Most came from SE Asia (46%), then Sub-Saharan Africa (19%), then South America and the Pacific (11%), Europe (9%) and North America (6%). The most common visas were student visas (31%) and working visas (33%), then Bridging visas (14%), Spousal Visas (13%) and other visas (13%). The most common mode of transmission was sex between men, then heterosexual sex then other. Less than 2% reported Injecting Drug Use as a mode of transmission.
- So, just to emphasise that point; From 53% detectable at baseline there was a 77.4% reduction in detectable viral load after 12 months and a 93% reduction in detectable viral load after 24 months. With a corresponding reduction in the risk of onward transmission.
- Also important to note is that a substantial percentage of people who are Medicare ineligible either return to their country of origin or they transition to a Visa which allows Medicare access… and this happens relatively quickly. At July 2013 39 patients were no longer receiving ART from ATRAS. 4 of those had left the country and 2 were lost to follow up so 33 of those had transitioned to Medicare Eligibility. By July 2014 79 patients were no longer receiving treatment And by November 2015 we predict that there will only be about 70 people left on the study. That means nearly two thirds of people either transition to Medicare Eligibility or return to their country of origin within four years. That has a couple of implications that I think are worth mentioning; First it means that supplying cost free drug to this group is not a lifelong financial burden that Medicare must shoulder – rather, it is capped to a relatively small group of people for a limited time. AND secondly it means that complications caused by delays in treatment commencement, treatment cessation or sub-optimal treatment combinations will, in the most part, end up having to be resolved by the Medicare system in the end. Early treatment of this group therefore holds the potential for cost savings in the long run.
- As part of the most recent report there was also a number of pieces of modelling undertaken. We undertook two surveys one in July 2013 and again in October 2014 and we established that at any one time there are about 450 Medicare ineligible people living in Australia. It was calculated that providing treatment for that group would cost about $29 million over 5 years with the potential to avert 81 new infections over that same period. Avoiding these new infections 81 would mean a cost saving of about $26 million over five years, with further savings after that. So, what ATRAS has established is that providing free access to ARV’s for Medicare Ineligible HIV positive people is broadly cost neural over five years AND there are additional cost savings over that period.
- Medicare Ineligible people are those people that are in Australia, perfectly legally, on various temporary student, business or employer sponsored visas that do not allow access to Australia’s Medicare scheme. This means no access to subsidised drugs through the PBS. So for HIV positive people who are Medicare ineligible that means; Delaying treatment commencement or stopping treatment Accessing medication through studies or compassionate access schemes where possible Accessing treatments from their country of origin OR paying the full unsubsidised price in Australia This has a number of problems. Obtaining ARVs from overseas can be problematic in terms of availability, supply reliability and drug quality. Cost estimates put the unsubsidised cost of a first line regimen like Atripla at $12,438 per year so it is prohibitive for most. There is SOME provision for this group at the State and Territory level but it varies significantly. Some states have formal state-wide arrangements, some don’t. In some states it comes down to the individual clinic or health area. This is problematic because it wastes time and costs money for health professionals to spend hours trying to arrange uncertain compassionate access on a case by case basis. The result is a patchwork system of access that falls short of the standard of care and treatment given to Australian citizens and permanent residents. Only an estimated 60% of Medicare Ineligible people who needed treatment were getting in 2007. Around 31% them were receiving sub-optimal treatment because that is what was available.
- The ATRAS study was established to describe this population of HIV positive temporary residents To understand the disease status of that group To model transmission rates. And it was also a mechanism by which we could supply appropriate ARV access for up to four years - to a population that is being denied access
- Between November 2011 and June 2012 we recruited 180 people from 21 AHOD sites – most came from Sexual Health Clinics (46%), then General Practices (27%), then Tertiary Referral Centres (27%). 74% were male, 26% Female Most came from SE Asia (46%), then Sub-Saharan Africa (19%), then South America and the Pacific (11%), Europe (9%) and North America (6%). The most common visas were student visas (31%) and working visas (33%), then Bridging visas (14%), Spousal Visas (13%) and other visas (13%). The most common mode of transmission was sex between men, then heterosexual sex then other. Less than 2% reported Injecting Drug Use as a mode of transmission.
- The median CD4 cell count at enrolment was 376 cells per microliter of blood. There were discrepancies for lower CD cell counts related to country of origin, with people from lower income countries having generally lower CD4 counts. 63% of recruits were on treatment with most accessing their treatment from overseas (47%), Australian compassionate access programs (22%), Australian clinical trials (11%), 18% not reported. Only 47% had an UDVL 46% changed their regimen once they enrolled because they were not on regimens consistent with those recommended under Australian ARV treatment guidelines.
- The median CD4 cell count at enrolment was 376 cells per microliter of blood. There were discrepancies for lower CD cell counts related to country of origin, with people from lower income countries having generally lower CD4 counts. 63% of recruits were on treatment with most accessing their treatment from overseas (47%), Australian compassionate access programs (22%), Australian clinical trials (11%), 18% not reported. Only 47% had an UDVL 46% changed their regimen once they enrolled because they were not on regimens consistent with those recommended under Australian ARV treatment guidelines.
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