The Lifetime Cost of HIV

Balancing the Relationship Between Cost and Quality Care

A number of studies have not only looked into the lifetime cost of HIV therapy but its cost-effectiveness during different states of infection.

One such study from the Journal of Acquired Immune Deficiency Syndromes aimed to estimate the average lifetime cost of HIV—both for individuals starting antiretroviral therapy (ART) early (CD4 count of 500 cells/mL or less) and those starting late (200 cells/mL or less).

The results confirmed what many smaller studies have long suggested: that early initiation of ART correlates to far lower lifetime costs.

According to the research, for those starting treatment at higher CD4 counts, the estimated average lifetime cost is roughly $250,000. By contrast, those starting at 200 cells/mL or less were likely to spend twice that amount—from anywhere between $400,000 and $600,000.

HIV blood test blood vials
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Among the reasons cited for the higher costs are the increased risk of both HIV-related and non-HIV-related illnesses in those with compromised immune systems. Moreover, the likelihood that a person will be able to restore immune function to near-normal levels (i.e., CD4 counts of 500-800 cells/mL) becomes less likely the later one starts treatment.

Retrospective analyses from Weill Cornell Medical College further supported the conclusions. tracking individuals with HIV from the age of 35 until death. While the cost of treatment for those who started treatment on diagnosis ($435,200) was significantly higher than those who delayed therapy ($326,500), the saving in terms of disease and hospitalization avoidance was considered substantial.

The investigators were further able to conclude that the lifetime cost savings of avoiding HIV infection in a single person was between $229,800 to $338,400.

Putting Lifetime Cost of HIV Into Perspective

While the lifetime cost of treatment may, on the surface, appear exorbitant—suggesting inflated HIV drug prices or American healthcare costs—it's important to look at the costs in relation to other attributable health concerns.

Consider, for example, that the average lifetime cost of smoking for a 24-year-old male is $183,000, while a 24-year-old female can expect to spend an average of $86,000. Beyond the cost of the cigarettes themselves, the social costs to Medicare, Medicaid, Social Security, and health insurance are seen to be far seen to be far greater—whether due to smoking cessation, emphysema, lung cancer, etc.

(These figures are exacerbated by the fact that smoking, as an independent factor, is known to reduce life expectancy by as much as 12.3 years in people with HIV.)

Meanwhile, the lifetime cost of drinking three alcoholic beverages a day comes to a startling $263,000 over a lifetime, which correlates to a 41% increased risk of cancer in men, whether HIV-positive or HIV-negative.

Cost Containment Strategies

None of this, of course, is meant to diminish the financial impact of HIV, both on the individual and the healthcare system as a whole.

From an individual perspective, the cost of HIV care directly relates to how well a patient is retained in care and how effectively that person can adhere to a prescribed therapy. In their May 2014 revision of the U.S. HIV treatment guidelines, the Department of Health and Human Services (DHHS) addressed these concerns by recommending that clinicians "minimize patients' out-of-pocket drug-related expenses whenever possible."

This includes the use of generic drug alternatives whenever possible or reasonable. However, the decision should be accompanied by a careful assessment as to whether the reduced costs might increase the pill burden for the patient. In such cases, the use of generics may reduce overall costs but at the expense of patient adherence. Furthermore, the generic components of a multi-drug regimen could lead to higher insurance co-pay, increasing rather than decreasing out-of-pocket expenses.

In a similar vein, the DHHS has recommended a reduction in the frequency of CD4 monitoring for patients who have been on ART for at least two years and have had consistent, undetectable viral loads. While this is seen to be less impactful in terms of actual cost containment, associated tests such as CD8 and CD19 are, in fact, costly; have virtually no clinical value; and are not recommended as a course of managed HIV care.

For those who have exhibited long-term viral suppression on ART, the DHHS currently recommends that:

  • CD4 monitoring be performed every 12 months for those with CD4 counts between 300 and 500 cells/mL, and;
  • CD4 monitoring is considered optional for those with CD4 counts over 500 cells/mL.

According to the guidelines, CD4 counts direct when to start or stop prophylactic therapy designed to prevent opportunistic infections, or to assess whether the patient's immunological response to ART is adequate. (An "adequate" response is defined as an increase in the CD4 count by 50 to 150 cells during the first year of therapy, with similar increases every year until a steady state is achieved.)

By contrast, viral load testing should be considered the key barometer for treatment success. As such, the DHHS recommends viral load monitoring every 3-4 months for patients with consistent, stable viral suppression.

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  1. Farnham PG, Gopalappa C, Sansom SL, et al. Updates of lifetime costs of care and quality-of-life estimates for HIV-infected persons in the United States: late versus early diagnosis and entry into care. J Acquir Immune Defic Syndr. 2013;64(2):183-9. doi:0b013e3182973966

  2. Schackman BR, Fleishman JA, Su AE, et al. The lifetime medical cost savings from preventing HIV in the United States. Med Care. 2015;53(4):293-301. doi:10.1097/MLR.0000000000000308

  3. Sloan FA, Ostermann, J, Conover c, Taylor, Jr.  DH, Picone G. The Price of Smoking. Cambridge, MA: MIT Press; 2006.

  4. U.S. Department of Health and Human Services (DHHS). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.

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