How much does HIV treatment cost? What factors affect the costs? Discover the ins and outs of HIV treatment expenses, from private insurance to government programs that can help ease the financial burden.

The Staggering Costs of HIV Treatment

Living with HIV is no longer the death sentence it once was, thanks to advancements in medical treatment. People with HIV can now live longer, healthier lives than ever before, thanks to the availability of antiretroviral therapy (ART) and other therapies. However, the cost of this life-saving care can be staggering, with estimates ranging from $1,800 to $4,500 per month during a person’s lifetime.

Factors That Influence HIV Treatment Costs

The price of HIV treatment can vary significantly based on several factors. The type of medication prescribed, whether it’s a brand-name or generic drug, and the need for additional treatments for co-occurring conditions all play a role in determining the overall cost.

Medication Costs

The cost of HIV medications can range widely, from around $400 per month for the drug lamivudine (Epivir) to nearly $1,700 for a 30-day supply of emtricitabine/tenofovir disoproxil fumarate (Truvada). Newer, more specialized medications, such as ibalizumab-uiyk (Trogarzo), which is administered through an injection, can cost as much as $9,000 per month.

Co-occurring Conditions

If an individual with HIV also has another condition, such as hepatitis C, the costs of treatment can escalate significantly. They will need to continue taking their HIV antiretroviral therapy in addition to the medications for the secondary condition, resulting in higher overall expenses.

Laboratory Tests

The cost of laboratory tests required for managing HIV can also contribute to the overall treatment expenses. Studies have shown that nearly half of the lab tests ordered for people with HIV may not be necessary, highlighting the importance of open communication with healthcare providers to ensure only essential tests are conducted.

Navigating Insurance and Financial Assistance

Given the high costs of HIV treatment, it’s crucial for individuals to explore various insurance and financial assistance options to ease the financial burden.

Private Insurance

Many people with HIV obtain private health insurance through their employer or a family member’s job. The Affordable Care Act (ACA) also allows individuals to purchase their own private insurance plans, which must cover essential benefits, including HIV-related care, without denying coverage or imposing lifetime limits due to the condition.

Government Programs: Medicare and Medicaid

For those who do not have adequate private insurance coverage or struggle with deductibles and co-pays, government-funded programs like Medicare and Medicaid can provide crucial support. Medicare covers individuals over 65, those under 65 with certain disabilities, and people of all ages with advanced kidney disease. Medicaid, on the other hand, is designed to assist low-income individuals, older adults, and those with disabilities, with coverage varying by state.

Financial Aid Programs for HIV Treatment

In addition to insurance options, there are specialized financial aid programs available to help people with HIV cover the costs of their treatment.

The Ryan White HIV/AIDS Program

The Ryan White HIV/AIDS Program is a federal government initiative that provides support to individuals with HIV or AIDS who are struggling to pay for their care. The program helps fill gaps in coverage not addressed by private insurance or other federal funding sources, including assisting with the costs of prescription drugs through state-operated AIDS Drug Assistance Programs (ADAPs).

Manufacturer Assistance Programs

Many drug manufacturers also offer patient assistance programs to help individuals with HIV afford their medications. These programs can provide discounts or even free access to essential drugs for those who qualify based on factors such as income and insurance status.

Conclusion

The cost of HIV treatment can be a significant financial burden, but with a thorough understanding of the various factors that influence these expenses and the available resources for assistance, individuals with HIV can navigate the healthcare system and access the life-saving care they need. By exploring private insurance, government programs, and specialized financial aid initiatives, people with HIV can focus on their health and well-being, rather than worrying about the high cost of treatment.

How Much Does HIV Treatment Cost?

People with HIV can live longer, healthier lives than ever before thanks to HIV medicines and other therapies. These include once-a-day pills that treat the infection.

But HIV treatments can be expensive. HIV care involves a type of medication called antiretroviral therapy (ART) and regular visits with your doctor. One study estimated that costs of this care could run anywhere between $1,800 to $4,500 each month during a person’s lifetime. Most of this, about 60%, comes from the high cost of ART medications.

The cost is more than most people can afford on their own. But there are options available to ease the financial strain so you can get the medication you need.

What Affects Costs?

The price of HIV treatment varies based on a few things. For example, some name-brand medications cost more than others. The average wholesale price for the drug emtricitabine/tenofovir disoproxil fumarate (Truvada) is nearly $1,700 for a 30-day supply of tablets in the U. S., while the drug lamivudine (Epivir) costs around $400.

If there’s a generic version of your medication, that can lower your costs. For example, while the drug tenofovir disoproxil fumarate (Viread) costs about $1,400 per month, the generic version may cost anywhere between $110 and $1,200. But not all drugs have a generic available, especially if they are newer. Still, it’s always worth asking your doctor or pharmacist if there’s a less expensive version of your medication.

Sometimes HIV can become resistant to more common drugs, so they don’t work as well in controlling your condition. That means your doctor will need to prescribe something much stronger but more costly. The drug ibalizumab-uiyk (Trogarzo), for example, which you take through a shot instead of in a pill, can cost about $9,000 a month.

If you’re getting treatment for both HIV and another condition, this will also make your costs go up. For example, up to nearly one-third of people with HIV also have hepatitis C. Treatments for both conditions work well, but they are expensive because you will still need to keep taking your HIV antiretroviral therapy along with your hepatitis C medications.

Lab tests can also raise costs, and some studies have shown that nearly half of lab tests that doctors order for people with HIV weren’t necessary. Talk to your doctor to make sure you understand why you are getting each type of test.

Private Insurance

Many people get private health insurance through their employers or through a family member’s job, but you can buy a plan for yourself as an individual, although it’s usually more expensive. Depending on your plan, your insurance may cover some or all of your HIV treatments.

If you purchase a plan through a government marketplace under the Affordable Care Act (ACA), it covers many benefits that people with HIV need, including:

Wherever you get your insurance, the Affordable Care Act guarantees that you won’t be denied coverage because you have HIV and that there won’t be lifetime limits on your benefits. You can visit HealthCare.gov to explore your options.

Medicare and Medicaid

If your insurance plan does not pay for the HIV care you need, or it covers some of the cost but you are still struggling to handle deductibles and co-pays, you may qualify for federal resources like Medicare or Medicaid. These are important sources of health care for people with HIV — about a quarter of people with HIV get their health insurance coverage through Medicare.

Medicare is for people more than 65 years old, people under 65 with certain disabilities, and people of all ages with advanced kidney disease. Medicaid provides help for people with low incomes, older people, those with disabilities, and some families and kids, depending on where you live. Medicaid is a federal program, but your state decides how much coverage you actually get. If you’re eligible, you can enroll in Medicaid at any time.

Contact a local HIV/AIDS service organization who can help you figure out what programs or services you’re eligible for. The Health Resources and Services Administration, part of the U.S. Department of Health and Human Services, also has phone numbers for state HIV/AIDS services on its website.

Financial Aid Programs

The Ryan White HIV/AIDS Program is a federal government program for people with HIV or AIDS who have trouble paying for care. The program fills gaps in care that aren’t covered by private health insurance or other federal funding. It also helps states operate AIDS Drug Assistance Programs (ADAPs) so they can offer financial support for prescription drugs. Talk to your local service organization about help you might be able to receive through your state’s ADAP. You can use the HIV.gov HIV Testing and Care Services Locator to find a Ryan White clinic in your area.

Many drug manufacturers also offer patient assistance programs for people who are eligible. Some pharmacies offer discounts on certain drugs, perhaps by negotiating discount prices by buying medications in bulk. Other organizations, such as the Department of Veterans Affairs, have drug assistance programs of their own. Ask your treatment clinic or pharmacy about support options in your community that could apply to you.

You may also be able to take part in a clinical trial for a new HIV/AIDS treatment that isn’t yet available to the general public. Often, the medicines being tested in these trials will be free of charge. Clinical trials are safe, but they are still experimental, so there may be a higher risk of side effects. Talk to your doctor about whether this might be a good option for you.

HIV Cost-effectiveness | Guidance | Program Resources | HIV/AIDS

What is cost-effectiveness analysis?
Cost-effectiveness analysis (CEA) is a type of economic analysis where both the cost and the outcome (impact, result, effect, benefit, health gain …) of an intervention are evaluated and then expressed in the form of a cost-effectiveness ratio. The numerator of the cost-effectiveness (CE) ratio represents the cost of the intervention associated with one unit of “outcome”. The denominator is the unit of outcome. It can be expressed using many types of measures including: years of life gained, quality-adjusted life years gained (QALYs), new diagnoses, infections averted, and deaths averted. CEA is usually conducted on interventions that are known to be effective.

The CE ratio is a fraction used to compare the relative costs and outcomes of two or more interventions. In Example 1, the outcome measure chosen is “new HIV diagnoses” and the CE ratio of the programs evaluated is expressed in terms of “cost per new HIV diagnosis”. The CE ratio of Program A is $41,667 per new HIV diagnosis. This ratio does not reveal the cost of implementing the program nor the number of new HIV diagnoses detected by the program. However, when comparing the CE ratio of Program A to that of Program B, we can say that Program B is more cost-effective than Program A when CE is measured in terms of “cost per new HIV diagnosis,” because at $7,400 per new HIV diagnosis, Program B is less costly for the same outcome.

Cost per new HIV diagnosis
HIV interventions, such as screening and partner services, are intended to identify HIV-positive persons who are unaware of their infection. When evaluating several such programs in CE analysis, the outcome “new HIV diagnoses” is often used to enable a comparison across these programs; so the CE ratio is expressed in terms of cost per new HIV diagnosis.

Cost per infection averted (IA)
HIV prevention interventions such as syringe exchange programs, counseling for at-risk youth or post-exposure prophylaxis are intended to prevent (avert) infection in HIV-negative persons. Such programs can be evaluated to determine the number of infections prevented that would have otherwise occurred had the intervention not been provided. When evaluating several such programs in CE analysis, the outcome “HIV infections averted” is often used to enable a comparison across these programs; so the CE ratio can be expressed in terms of cost per infection averted.

The lifetime treatment cost of an HIV infection can be used as a conservative threshold value for the cost of averting one infection. Currently, the lifetime treatment cost of an HIV infection is estimated at $379,668 (in 2010 dollars), therefore a prevention intervention is deemed cost-saving if its CE ratio is less than $379,668 per infection averted.

As an outcome, the number of HIV infections averted due to a program can be evaluated using different mathematical techniques that vary in complexity and the amount of data or number of assumptions required. Attention should be paid to the timeframe of the intervention effect considered in the evaluation. For example, if the timeframe is one year, then the cost may have to be incurred annually in order to continue to avert the HIV infections.

Cost per life year (LY) gained
HIV treatment interventions, including retention in care and treatment adherence, are in part intended to extend the lives of HIV-positive persons. Such programs can be evaluated to determine the number of additional life years gained (or saved) that otherwise would have been lost to premature death. When evaluating these types of  programs in CE analysis, the outcome “life years” often is used to compare them; so the CE ratio can be expressed in terms of cost per life year gained.

Cost per quality-adjusted life year (QALY) gained
As an outcome, life years do not reflect any of the positive or negative effects on the quality of life of the patients receiving an intervention. For example, drug treatment A may provide an additional 2 years of life dominated by hospitalization while drug treatment B may provide an additional 1 year of life without any significant ill effects.

A quality-adjusted life year (QALY) is an outcome measure that considers both the quality and the quantity of life lived. The QALY is based on the number of years of life added by the intervention. Each year in perfect health is assigned the value of 1. 0.  Each year of less-than-perfect health is assigned a value less than 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, be blind or suffer from worse mental health, then the extra life-years may be given a value of less than 1 to account for this.

HIV interventions intended to improve and/or extend the lives of HIV positive persons can be evaluated to determine the number of additional QALYs gained (or saved) that would have otherwise been lost. When evaluating several such programs in CE analysis, the CE ratio can be expressed in terms of cost per QALY gained.

Most outcome measures, including infections averted, life years gained and new HIV diagnoses, can be translated into QALYs, thereby providing a consistent measure of comparison across many different types of intervention programs.

Cost-effectiveness thresholds

A cost-effectiveness ratio of $50,000 to $100,000 per QALY gained has been long cited in the literature as a conservative threshold for a cost-effective intervention. Traditionally, if an intervention was estimated to cost less than $50,000 to $100,000 per QALY gained, it would be considered cost-effective. However, recent studies have argued that this benchmark is likely too low since the threshold has not been reassessed over time.¹ To reflect the advances of modern health care, Braithwaite et al reevaluated the threshold and estimated the plausible range for a cost-effectiveness decision rule to be between $109,000 and $297,000 per QALY saved (in 2003 dollars; $143,000-$388,000 in 2010 dollars).²

What does “cost-saving” mean?

When two or more programs are being compared (intervention vs. comparator), the intervention is labeled as “cost-saving” when both the net outcome of the intervention is greater than or equal to that of the comparator and the cost of the intervention is less than the cost of the comparator. A program can only be deemed cost-saving when it is compared to an alternative. The alternative is typically the status quo or the current standard of care.

In Example 2, Program A is both cheaper and more beneficial than the current standard of care and is therefore a cost-saving alternative. CE ratios cannot be negative.

If the costs of Program A and the Standard of care are borne by the same institution, then the savings will be reaped by that institution. Often, however, the costs of HIV interventions are borne by many distinct entities, including government, health care systems and individuals, and the savings are not realized by any single entity. In addition, the savings may occur over many years.

How to interpret a CE ratio?

At $100,000 per QALY (or at higher thresholds), a program may be considered cost-effective. However, this ratio contains a numerator and a denominator and thus no interpretation can be made as to the annual cost of this program.

In Example 3, both programs A and B have the same measure of cost-effectiveness in terms of cost per QALY gained, however, Program B is more costly to implement than A. Investment in Program B may nonetheless be justified depending on budgetary constraints and the ability to implement for the program in the population and setting considered.

If A and B are complementary rather than alternative programs, then they can both be implemented. Implementing Program A and/or B in a particular population and setting requires an evaluation of the number of persons that potentially could be served by the intervention and the resulting overall costs.

Estimated Lifetime HIV-Related Medical Costs in the United States

Background:

Lifetime cost estimates are a useful tool in measuring the economic burden of HIV in the United States. Previous estimation methods need to be updated, given improving antiretroviral therapy regimens and updated costs.

Methods:

We used an updated version of the agent-based model progression and transmission of HIV (PATH) 3. 0 to reflect current regimens and costs. We simulated a cohort of those infected in 2015 until the last person had died to track the lifetime costs for treatment of HIV, including HIV health care utilization costs (inpatient, outpatient, opportunistic infection prophylaxis, non-HIV medication, and emergency department), opportunistic infection treatment costs, and testing costs. We assumed a median per-person diagnosis delay of 3 years and a 3% base monthly probability of dropout from care for a base-case scenario. Additionally, we modeled a most favorable scenario (median diagnosis delay of 1 year and 1% base dropout rate) and a least favorable scenario (median diagnosis delay of 5 years and 5% base dropout rate).

Results:

We estimated an average lifetime HIV-related medical cost for a person with HIV of $420,285 (2019 US$) discounted (3%) and $1,079,999 undiscounted for a median 3-year diagnosis delay and 3% base dropout rate. Our discounted cost estimate was $490,045 in our most favorable scenario and $326,411 in our least favorable scenario.

Conclusions:

Lifetime per-person HIV-related medical costs depend on the time from infection to diagnosis and the likelihood of dropping out of care. Our results, which are similar to previous studies, reflect updated antiretroviral therapy regimens and costs for HIV treatment.

Cost Of Treatment Still A Challenge For HIV Patients In U.S. : Shots

Ruben Bermudez stands in front of a sign that says in Spanish, “To love yourself is to protect yourself.” He has struggled to remain eligible for AIDS drug assistance programs since he went on treatment four years ago.

Jessica Camille Aguirre/NPR

hide caption

toggle caption

Jessica Camille Aguirre/NPR

Ruben Bermudez stands in front of a sign that says in Spanish, “To love yourself is to protect yourself. ” He has struggled to remain eligible for AIDS drug assistance programs since he went on treatment four years ago.

Jessica Camille Aguirre/NPR

When Ruben Bermudez, 31, found out that he had HIV more than a decade ago, he didn’t want to take his medicine. He went on treatment for a few weeks, but said the intensive pill regimen made him feel dizzy.

He stopped treatment and tried to ignore the diagnosis, moving to Florida from Washington in pursuit of sunshine. In 2008, he learned that one of his best friends died of a brain tumor that couldn’t be treated because his immune system has been debilitated by AIDS. Bermudez realized that his only chance at a relatively healthy life would depend on taking pills daily.

“With his passing I decided to wake up and take control of my health and my life,” Bermudez says. “Because at that point my HIV was spiraling way downhill. I should have been dead.”

But the pills for HIV that he’s taken daily since then have come with a hefty price tag. Monthly HIV treatment regimens range from $2,000 to $5,000 — much of it for drugs. With the life expectancy for HIV patients increasing, the lifetime cost of treatment in today’s terms is estimated at more than half-million dollars. And while many people qualify for public assistance programs, staying eligible for support is a constant balancing act.

“Individuals that are receiving their drugs for free through a program like ADAP or through Medicaid are really concerned about earning more than what would then be eligible for that program.”

Murray Penner, Deputy Executive Director of NASTAD

According to the Centers for Disease Control and Prevention, around half the people diagnosed with HIV in the U.S. don’t receive regular health care. Of those who do, 42 percent receive Medicaid and 24 percent are uninsured.

People who are uninsured can still qualify for health services through the federally funded and state-run Ryan White Care act, which pays for medication through the AIDS Drug Assistance Program, or ADAP.

While the Obama administration released $79 million in funding for ADAP last week — eliminating waiting lists in 10 states — the program’s support has fluctuated with each annual congressional appropriations process.

Each state has an eligibility process to receive ADAP support, and Murray Penner, with the National Alliance of State and Territorial AIDS Directors, explains that in many places the income cut-off limit for aid is $22,000 annually.

“Individuals that are receiving their drugs for free through a program like ADAP or through Medicaid,” he says, “are really concerned about earning more than what would then be eligible for that program.”

For Bermudez, making sure he remains eligible for assistance with his HIV care has meant refusing offers of full-time employment and raises.

Still, he’s grateful to have the support. “I’m really lucky to have those programs available to me, because without them I probably wouldn’t — I would not — take medication,” he says. “Because I would not be working just to pay for my medication. I probably couldn’t even afford it.”

Medicaid’s recent expansion under the Affordable Care Act may also make it easier for people living with HIV to pay for care, and many hope that with patents expiring on vital drugs in the coming years, cheaper generics may bring down the price.

Expanding access to care has implications beyond treating the virus in the person – public health experts say it’s also critical to stopping the disease from spreading. People taking AIDS drugs are much less likely to transmit the virus to someone else, which ameliorates the long-term burden to public assistance programs.

“When we can avert HIV infections,” says David Holtgrave, a professor at the Johns Hopkins Bloomberg School of Public Health. “We’re not only saving lives. We’re also saving dollars as well.”

Bermudez, whose health has stabilized since he started taking medications four years ago, hopes to eventually be able to buy private insurance and pay for his drugs himself.

“Hopefully in the future it would available at a reasonable cost for everyone that is working, so that they won’t have to do the things that I had to do — to quit jobs or to lie about income or just cover it up or anything like that,” Bermudez says. “Because it has to be a way of life that’s comfortable for everybody.”

Analysis of the treatment cost of HIV/AIDS in Turkey | Kockaya

Farmeco 2016;17(1)13-17.html

Farmeconomia. Health economics and therapeutic pathways 2016; 17(1): 13-17

http://dx.doi.org/10.7175/fe.v17i1.1219

Original research

Analysis of the treatment costs of HIV/AIDS in Turkey

Guvenc Kockaya 1, Tuba Elbir Zengin 1, Fatma Betul Yenilmez 2, Canan Dalgic 1, Simten Malhan 3, Pamir Cerci 2, Ergun Oksuz 3, Serhat Unal 2

1 Gilead Sciences Turkey, Istanbul, Turkey

2 Hacettepe University, Ankara, Turkey

3 Baskent University, Ankara, Turkey

Abstract

OBJECTIVE: Infection with the human immunodeficiency virus (HIV), the causative agent of acquired immune deficiency syndrome (AIDS), is a major global health problem. Patients with HIV can live normal lives with today’s new treatment options. As the treatment is generally successful, the life expectancy of patients infected with HIV is rising. As a result, the economic burden of HIV treatment on health systems is set to increase. According to the Ministry of Health, there were more than 6000 HIV-positive patients in Turkey in 2013. The aim of this study was to determine the direct costs of HIV treatment in Turkey.

METHOD: A retrospective data analysis was performed from the reimbursement agency perspective. Data for 252 patients at a university hospital in Ankara from 2001 to 2012 were used for the analysis. The average costs of treatment per HIV patient and the average costs per HIV patient, depending on the state of the patient’s health, were calculated. The latter was determined according to the number of CD4 cells/ml, as defined by the CDC’s classification system for HIV infection. The cost of treatment was calculated based on published reimbursement prices in 2013, per patient per year.

RESULTS: The CD4 values of 25.3%, 29%, and 45.7% of the 252 patients were <100 cells/mm3, 100–300 cells/mm3, and >300 cells/mm3, respectively. The treatment costs per patient per year for 2013 for those with CD4 values of <100 cells/mm3, 100–300 cells/mm3, and >300+ cells/mm3 were $ 5,637.04, $ 2,211.54, and $ 2,182.35, respectively. The weighted average of the treatment cost per patient was $ 3,344.64 for 2013.

CONCLUSION: This analysis is unique to Turkey and calculates the cost only of HIV treatment in Turkey. Lower CD4 values are associated with higher treatment costs. Appropriate HIV treatment is crucial for controlling CD4 values and lowering the treatment costs of HIV patients. These findings need to be considered by policy makers who may need to focus on HIV.

Keywords

HIV/AIDS; Cost of treatment; Turkey

Corresponding author

Guvenc Kockaya

[email protected]

Disclosure

This study was supported by Gilead Science Turkey

Introduction

According to a 2014 report by the World Health Organization (WHO), 35 million people are infected worldwide with the human immunodeficiency virus (HIV) [1]. In 2013, 2.1 million people were newly infected, with the number of deaths related to acquired immune deficiency syndrome (AIDS) about 1.5 million [1]. In Turkey, according to Ministry of Health data published in 2013, more than 6000 people were infected with HIV [2]. The numbers of new cases in 2010, 2010, and 2013 (the first 6 months) in the same report were 589, 1,068, and 587, respectively [2].

HIV transmission includes heterosexual intercourse, homosexual/bisexual intercourse, intravenous drug use, nosocomial transmission, vertical transmission, and unknown reasons [3]. The HIV-1 RNA concentration (viral load) is an important predictor of the HIV transmission level through sexual intercourse, needle sharing, or from mother to infant [3]. The CD4 cell count is the most important predictor of patient survival when starting antiretroviral (ART) HIV therapy. In patients with lower CD4 cell counts, the immune deficiency may be irreversible and early treatment shows more benefits when compared to delayed treatment [4].

In 2009, the WHO recommended new regimens for ART treatments and recommended ART treatment for adults and adolescents with early stage disease [5,6]. These revised ART treatment guidelines also recommended ART treatment for all adults and adolescents, including HIV-infected pregnant women, with a CD4 count of < 350 cells/mm3, regardless of clinical symptoms [5]. While the WHO’s 2009 guidelines were outdated, the newly published guidelines recommend treatment as soon as possible [6].

According to data from a cost-effectiveness study in sub-Saharan Africa, HIV prevention was 28 times more cost-effective than highly active ART treatment (HAART) [7]. According to that study, each 1 year of life acquired by HAART equaled to 28 years of life acquired by prevention. In the meta-analysis of Creese et al. [8], there were gross differences between interventions in terms of cost-effectiveness. Furthermore aiming at condom dispensation in treatment of sexually-transmitted diseases and selective blood safety measurements led to $ 11 cost for each prevented HIV patient, and 1 DALY (lost life year) was gained for each 1 $ [8].

Today in Turkey diagnostic methods and ART treatment are provided free of charge to HIV patients as part of a national insurance system [9]. However, no previous studies have reported the disease- and treatment-related costs of HIV in Turkey. The main goal of the present study was to determine the treatment costs of HIV patients in Turkey.

Materials and methods

Data collection

To obtain data for the cost analysis, patient files of a university hospital in Ankara were retrospectively evaluated. The university hospital in Ankara was one of the first HIV clinics in Turkey and is a reference center for the entire country. Within a 12-year follow-up period (2001-2012) in the university hospital, 252 patients allocated, and data included polyclinic, clinic, intervention, laboratory and imaging tests, medications, side effects, comorbidities, treatments, and complications.

Table I. Classification of the patients according to their CD4 cell counts and their distribution

Classification of the patient groups

The HIV patients were classified according to their CD4 cell counts (cell/mm3). Group 1 consisted of patients with CD4 cell counts of <100 cells/mm3, Group 2 consisted of those with cell counts of 100–300 cells/mm3, and Group 3 consisted of those with cell counts of >300 cells/mm3. Patient distribution of the university hospital was used as the generalization of estimation of expert opinions (Table I).

Health service-related cost calculations

In the analysis, the total cost of hospital outpatient clinics was calculated by using gynecology, infectious disease, psychiatry, neurology, dermatology, physical therapy and rehabilitation, emergency medicine, internal diseases/endocrinology visits, percent of patients in visits, number of visits per patient, and cost of visit. Cost of tests were calculated by using percent patients requiring test, number of tests per patient, and cost of each test. The cost of infection was calculated by using data on the number of hospitalizations per year, percentage of patients requiring hospitalization, mean number of days of hospitalization, daily costs of hospitalization, and total costs of hospitalization. The total costs of complications were calculated based on the percentage of patients with side effects and treatment duration of the complications.

Clinical and intensive care hospitalization costs were included in the cost calculations. The clinical and intensive care hospitalization costs were calculated by using the number of annual hospitalizations, percentage of patients requiring hospitalization, mean duration of the hospital stay, and daily cost of hospitalization. The annual number of interventions, percentage of patients requiring interventions, number of interventions, and costs of interventions were used to calculate the total cost of intensive care interventions.

In the cost calculation, the cost of health services was based on the 2013 prices of the Health Administration Notification of Social Security Institution. The costs obtained in Turkish lira were converted into U.S. dollars based on the mid-year exchange ratio in 2013 of $ 1.90.

Estimation of the cost per patient

The disease costs were calculated for each CD4 patient group. The weighted mean method and patient distribution were used to calculate the annual cost of HIV per capita. The costs of ART drugs were excluded from the analysis.

Results

The costs of the treatment in the three groups and the weighted mean cost of HIV patients are reported in Table II. The healthcare costs of Group 1, 2, and 3 were $ 5,637.04, $ 2,211.54, and $ 2,182.34, respectively. When these data were used to calculate the annual HIV weighted cost per patient, the cost was $ 3,344.64.

Table II. Total healthcare costs of HIV patients

*The costs of ART pharmaceuticals were excluded

Figure 1. Annual cost ($) per patient in the CD4 cell count classification groups

Discussion

In Turkey, the treatment cost of HIV/AIDS is not evaluated in terms of the disease burden. This may be due to the lower numbers of HIV patients compared with those in developed countries. However, considering reports of increases in the numbers of new patients in Turkey [2], it may be necessary to determine the cost of HIV to understand the burden of the diseases in the country.

The cost of HIV infections in the U.S. was estimated to be $ 36.4 billion (direct and indirect costs) in 2002. Of this, $ 6.7 billion comprised direct treatment costs, and $ 29.7 billion comprised indirect costs. According to a sensitivity analysis of the cost analysis in the United States, universal ART utilization and more effective ART regimes would reduce the disease cost [10]. In the U.S the direct and indirect costs of HIV increased from $ 36.4 billion in 2002 to $ 51.2 billion in 2009, and HIV was among the top 20 diseases in terms of disease cost [11]. Another analysis based on Medicaid claims in the state of California reported that the medical cost per patient was $ 36,469 [12].

The cost of HIV treatment per patient was estimated to be € 11,638, € 32,110, € 14,821, € 6,399, and € 25,340 in Spain, Germany, France, Italy, and the U.K. respectively [13]. According to that report, there was great disparity in the total medical costs for patients with CD4 lymphocyte counts of 200-500 cells/mm3 [13]. For example, in Italy the total healthcare cost of HIV treatment per patient was reported to be € 19,252, € 12,227, and € 6,399 for CD4 counts of < 200, > 200 but < 500, and > 500, respectively [13].

According to a study conducted in the U.S. in 2006, adult HIV patients with a CD4 count higher than 350/ml who were receiving ART treatment had a predicted expected life expectancy of 24.2 years [14]. In that study, the reduced and unreduced life cost of these patients were $ 385,200 and $ 618,900, respectively. Of these costs, ART drugs accounted for 73%, hospitalization accounted for 13%, outpatient treatment accounted for 9%, and HIV-related drugs and laboratory tests accounted for 5%s. In patients with a CD4 count higher than 200/µl, ART treatment led to 22.5 years of expected life. The reduced and unreduced life cost of these patients were calculated to be $ 354,100 and $ 567,000, respectively.

According to a 2011 study conducted in 22,315 patients, starting earlier ART treatment of patients led to significantly increased survival [15]. The primary goal of ART treatment is to prevent mortality and morbidity related to chronic HIV infection. According to previous research, patients with a CD4 cell count of < 200 cell/mm3 had higher cumulative direct HIV treatment costs in cases of delayed treatment when compared to patients who had early treatment [16]. According to another study, decreased HIV transmission due to ART treatment might reduce the growth of the HIV epidemic and related costs [17].

The results of the analysis highlight the cost of HIV healthcare in Turkey. According to the analysis, the weighted mean healthcare cost of treating each HIV patient in Turkey was $ 3,344. 64. In addition, the treatment cost of patients with a CD4 level of <100 cell/mm3 was two-fold higher than that of patients with a CD4 level of 100-300 cell/mm3 or >300 cell/mm3. These findings are similar to those reported in the international literature [10-17].

A limitation of the present study is the study sample, which consisted of patients who attended a university hospital. These might not be representative of the greater population in Turkey.

Conclusion

This study is the first economic analysis of HIV in Turkey. Given the continued rise in the number of new patients diagnosed with HIV/AIDS annually in Turkey, its social and economic impacts on the Turkish population need to be determined to understand the burden of the disease. Future studies should include a greater number of hospitals and centers to reflect the national context.

The present analysis demonstrated that the cost of treatment rose in accordance with a decrease in CD4 levels, possibly pointing to a direct relationship between CD4 levels and treatment costs. Start treatment at an early stage prior to a fall in CD4 cell counts may reduce healthcare costs. These findings may be useful to clinicians treating HIV patients and decision makers charged with shaping future of HIV/AIDS health care policies.

References

1. World Health Organization. Fast Track Ending The AIDS Epidemic by 2030. Available at: http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf (last accessed January 2015)

2. AIDS Cases and its Carriers in Turkey Distribution by years. Available at http://www.hatam.hacettepe.edu.tr/veriler_Haziran_2013.pdf (last accessed January 2015)

3. Montaner JS, Lima VD, Harrigan PR, et al. Expansion of HAART Coverage Is Associated with Sustained Decreases in HIV/AIDS Morbidity, Mortality and HIV Transmission: The “HIV Treatment as Prevention” Experience in a Canadian Setting. PLoS ONE 2014; 9: e87872; http://dx.doi.org/10.1371/journal.pone.0087872

4. Edward J, Millsa EJ, Bakandab C, et al. Mortality by baseline CD4 cell count among HIV patients initiating antiretroviral therapy: evidence from a large cohort in Uganda. AIDS 2011; 25: 851-5; http://dx.doi.org/10.1097/QAD.0b013e32834564e9

5. World Health Organization. Towards Universal Access Scaling up priority HIV/AIDS interventions in the health sector Progress Report, 2010. Available at: https://vpn.ku.edu.tr/iris/bitstream/10665/44443/1/,DanaInfo=apps.who.int+9789241500395_eng.pdf (last accessed January 2015)

6. British HIV Association. British HIV Association guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012. HIV Medicine 2014; 15 (Suppl. 1): 1-85

7. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet 2002; 359: 1851-56; http://dx.doi.org/10.1016/S0140-6736(02)08705-6

8. Creese A, Floyd K, Alban A, et al. Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet 2002; 359: 1635-42; http://dx. doi.org/10.1016/S0140-6736(02)08595-1

9. Erdem H ve Akova M. Leading infectious diseases problems in Turkey. Clin Microbiol Infect 2012; 18: 1056-67; http://dx.doi.org/10.1111/1469-0691.12000

10. Hutchinson AB, Farnham PG, Dean HD, et al. The Economic Burden of HIV in the United States in the Era of Highly Active Antiretroviral Therapy Evidence of Continuing Racial and Ethnic Differences. J Acquir Immune Defic Syndr 2006; 43: 451-7

11. Kockaya G, Wertheimer A. What are the top most costly diseases for USA? The alignment of burden of illness with prevention and screening expenditures. Journal of Health 2010; 2: 1174-8; http://dx.doi.org/10.4236/health.2010.210172

12. Leibowitz AA, Desmond K. Identifying a Sample of HIV-Positive Beneficiaries From Medicaid Claims Data and Estimating Their Treatment Costs. Am J Public Health 2015; 105: 567-74; http://dx.doi.org/10.2105/AJPH.2014.302263

13. Trapero-Bertran M, Oliva-Moreno J. Economic impact of HIV/AIDS: a systematic review in five European countries. Health Economics Review 2014; 4: 15; http://dx.doi.org/10.1186/s13561-014-0015-5

14. Schackman BR, Gebo KA, Walensky, RP, et al. The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. Med Care 2006; 44: 990-7; http://dx.doi.org/10.1097/01.mlr.0000228021.89490.2a

15. Edward J, Millsa EJ, Bakandab C, et al. Mortality by baseline CD4 cell count among HIV patients initiating antiretroviral therapy: evidence from a large cohort in Uganda. AIDS 2011; 25: 851-5; http://dx.doi.org/10.1097/QAD.0b013e32834564e9

16. Fleishman JA, Yehia BR, Moore RD, et al.; HIV Research Network. The Economic Burden of Late Entry Into Medical Care for Patients With HIV Infection. Med Care 2010; 48): 1071-9; http://dx.doi.org/10.1097/MLR.0b013e3181f81c4a

17. Lima VD, Johnston K, Hogg RS, et al. Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. J Infect Dis 2008; 198: 59-67; http://dx. doi.org/10.1086/588673

Refbacks

• There are currently no refbacks.

© SEEd srl

Department of Health | 4.6 HIV treatment costs

The annual costs of treatment of HIV by stage of disease (Table 4.4.2) were converted to Year 2000 prices, where required, by application of the relevant CPI ratio. These were then applied to the number of survivors in each stage. Detailed figures of the results are provided in Table 4.4.3 (See Appendix D).

Figure 4.6 illustrates the annual costs of treatment for the diagnosed cases of HIV avoided as a result of the ten year investment in NSPs. Annual treatment costs rise progressively to the year 2008 as patients progress to later stages of the disease, at which time they peak at approximately $269 million. Thereafter, annual costs decline, brought about mainly by the declining number of patients in the second and third stages of HIV.

Cumulative HIV treatment costs avoided over the lifetime of consumers are illustrated in Figure 4. 7. Costs accumulate throughout the lifetime of survivors, but at a slower rate after about 2008.

4.6.1 HCV treatment costs

Figure 4.6 Annual costs of treatment of diagnosed cases of HIV avoided by NSPs (Not discounted)

Top of page

Text version of Figure 4.6

Figures in this description are approximate as they have been read from the graph.

Figure 4.6 consists of four graphs:

• Total HIV costs avoided: this increases sharply from close to 0 in 1991 to $270,000,000 in 2009, before decreasing rapidly to less than $10,000,000 by 2060 and remains stable to 2069.
• CDV4 greater than 500: increases gradually from less than $10,000,000 in 1991 to $15,000,000 in 1997, before spiking to $80,000,000. The cost of treatment then decreases sharply to less than $10,000,000 by 2012 and remains less than $10,000,000 for all years to 2069.
• CDV4 less than 500: remains at less than $10,000,000 from 1991 to 1998, before increasing sharply to $130,000,000 in 2008 and decreasing gradually less than $10,000,000 by 2051, remaining stable to 2069.
• AIDS: increases gradually from less than $10,000,000 in 1991 to $145,000,000 in 2012 and decreasing gradually less than $10,000,000 by 2057, remaining stable to 2069.

Figure 4.7 Cumulative costs of treatment of diagnosed cases of HIV avoided by NSPs (Not discounted)

Top of page

Text version of Figure 4.7

Figures in this description are approximate as they have been read from the graph.

Figure 4.7 consists of two graphs

• Cumulative NSP expend: this slowly increases from about $0 in 1991 to about $1 million in 2002.
• Cumulative HIV costs avoided: this slowly increases from about $0 in 1991 to about $2 million in 2002, and then increases more steadily to about $6 billion in 2030. The costs avoided then increases more slowly to about $7 billion in 2054, before remaining steady at about $7 billion for subsequent years.

4.6.1 HCV treatment costs

The annual costs of treatment of HCV by stage of disease (Table 4. 5.1) were converted to Year 2000 prices, where required, by application of the relevant CPI ratio. These were then applied to the number of diagnosed survivors in each stage of the disease. Detailed figures of the results are provided in Table 4.4.3 (See Appendix D).

Figure 4.8 illustrates the annual costs of treatment for the diagnosed cases of HCV avoided as a result of the ten year investment in NSPs. Annual treatment costs rise progressively to the year 2040, at which time they peak at approximately $18.8 million and decline thereafter. The major factor influencing this cost profile is the number of patients with liver failure who, while relatively small in number, have extremely high costs of treatment.

Cumulative costs of treatment of HCV are presented in Figure 4.9. Costs accumulate throughout the period as patients progress through stages of HCV, reaching a plateau in the late 2050s. The shapes of the curves for both annual and cumulative costs of HIV and HCV treatment are indicative of the different rates of progression through each disease, with progression in HCV occurring at a much slower rate than for HIV, and hence treatment for later stages of the disease peaking much later for HCV than for HIV. This deferral has implications for the determination of the Net Present Values of this expenditure, as discussed below.

Overall, total treatment costs avoided over the life of the cases of HIV and HCV avoided by NSPs are approximately $7,808 million (before discounting). The costs of HIV treatment avoided are approximately ten times those for HCV, which reflects a combination of the number of cases avoided in the first instance (25,000 for HIV compared to 21,000 for HCV), a higher diagnosis rate for HIV than HCV, and higher average annual treatment costs for HIV than for HCV.
Top of page

Figure 4.8 Annual costs of treatment of diagnosed cases of HCV avoided by NSPs (Not discounted)

Text version of Figure 4.8

Figures in this description are approximate as they have been read from the graph.

Figure 4.8 consists of 6 graphs:

• Stage 0/1: increases gradually from $800,000 in 1991 to $1,900,000 in 2001, before decreasing very gradually to $100,000 in 2066, remaining stable to 2075.
• Stage 2/3: increases very gradually from $100,000 in 1991 to $800,000 in 2036, before decreasing very gradually to $100,000 in 2060, remaining stable to 2075.
• Cirrhosis: increases very gradually from $100,000 in 1991 to $800,000 in 2036, before decreasing very gradually to $100,000 in 2063, remaining stable to 2075.
• Liver failure: increases dramatically from $100,000 in 1991 to $14,000,000 in 2042, before decreasing dramatically to $100,000 in 2072.
• Total costs avoided: increases dramatically from $100,000 in 1991 to $18,500,000 in 2040, before decreasing dramatically to $100,000 in 2072.

Top of page

Figure 4.9 Cumulative costs of treatment of diagnosed cases of HCV avoided by NSPs (Not discounted)

Text version of Figure 4.9

Figures in this description are approximate as they have been read from the graph.

The graph in Figure 4. 9 shows a gradual increase from $0 in 1991 to about $780 million in 2064, and remains at about that level for subsequent years until 2070.
Top of page

Analysis of hospitalization expenses of 610 HIV/AIDS patients in Nantong, China | BMC Health Services Research

In our study, we described the HIV/AIDS-associated expenses of 610 inpatients in Nantong City. Though free antiretroviral therapy for HIV/AIDS patients was implemented in China at the end of 2004 [8], patients still accrued associated care costs. The average expenses per HIV patient was 5454 RMB (about $808 USD) for one hospital stay and 23,555 RMB (about $3489 USD) per AIDS patient for one hospital stay. Though Nantong is considered an economically developed area, HIV/AIDS can lead to detrimental impacts on resources, particularly if a positive person is unable to work due to his or her illness. Further research to estimate these indirect costs, as well as to understand how patients and their families are impacted by these healthcare costs, are needed.

A handful of factors were found to be associated with the increased hospitalizations costs amongst people living with HIV and AIDS in Nantong. For people living with HIV, gender directly affected hospitalization expenses. Females’ hospitalization expenses was 761 RMB (about $113 USD) more than that of males. The gender difference in hospitalization expenses may not be due to factors of gender itself, but perhaps to adherence to ART. Previous research has shown that females are more sensitive to symptoms, such as allergies or gastrointestinal reactions during ART, resulting in poorer adherence compared to males [14]. In turn, this can lead to more serious illness and higher hospitalization expenses for females. A follow-up assessment determining such factors associated with this higher cost could help inform gender-specific guidelines when assessing HIV-budgetary needs. This study also showed that for those living with HIV, the cost of laboratory tests accounted for the largest portion (37.46%) of associated in-patient costs, as those living with HIV may require semi-regular biochemical tests in order to track their disease progression while infected. Additional changes to current insurance policies, which promote reimbursement for laboratory tests could help lower patients’ financial burden and promote compliance [15].

In our study, the average hospitalization expenses of AIDS patients was 23,555 RMB (about $3489 USD), which is higher than a study in a hospital in Lanzhou, China reported of 15,714 RMB (about $2470 USD) [16]. The higher hospitalization expenses of AIDS in Nantong was related to the regional economic level and hospital grade [11, 12]. Nantong is located in an economically developed region in eastern China, which meant that local patients had greater health needs and stronger personal payment ability. Nantong Infectious Disease Hospital is a third-grade hospital, while the Infectious Hospital of Gansu Province, where the study in Lanzhou took place, is a second-grade hospital. Therefore, the higher grade the hospital, the larger expenditure patients will have to pay. Thus, not only should prevalence be considered when determining how best to allocate resources, but so should the economic viability of those infected. For AIDS patients, the cost of treatment for AIDS complications accrued a large economic burden [17], accounting for the largest portion of their expenses. This was consistent with other findings from Guangxi, China, which showed that the cost of medications constituted 65.33% of total expenses of AIDS infected patients [18]. Additionally, the number of complications not only directly affected hospitalization expenses, but also indirectly affected expenses through the length of hospital stay, indicating that the more complications or the more serious the condition an AIDS patient had, the more difficult to treat, leading to rising costs. In September 2015, the World Health Organization released updated treatment guidelines which recommended that ART be provided to all patients diagnosed with HIV, regardless of CD4+ T cell count [19]. Early detection and treatment to control viral load levels and improve CD4 + T cell counts are integral steps to reducing the risk of AIDS complications, and are thus, an ideal way to reduce the economic burden on patients and their families.

According to the findings from this study, the strongest predictor of higher hospital expenses was length of hospital stay (total path coefficient = 0.563 and 0.649, respectively for people living with HIV and AIDS patients). In our study the average length of hospital stay was 19.0 days, much higher than a study in South Africa, which reported an average length of stay of 9.3 days for HIV-positive admissions [7]. The average length of hospital stay is an important indicator, which can reflect the efficiency of hospitals in China. Without affecting the patient’s treatment, the hospital should take certain measures to reduce the length of hospital stay, which not only reduces the patient’s hospitalization expenses, but also improves the utilization rate of hospital medical resources. Expanded medical training of staff, as well as efforts to promote ART adherence may be preventive factors, which could help reduce medical expenditure in the long-term.

These findings should be considered in light of the study limitations. The cost in our study was lack of the fee of ART for its paid by the government. Participants in this study were limited to one infectious disease hospital in a low prevalence area in eastern China and as such, findings may not be generalizable to the other patients across the country. Additionally, in this study, we did not distinguish between the amounts paid by the patient and the amounts paid by their insurance companies. As such, further analysis addressing the true direct costs, supplemented with the potential impact on indirect costs, is needed. Further follow-up, which captures total hospitalizations costs of the patient, particularly out-of-pocket expenses and other associated costs of care not captured in this initial assessment, would help inform the true cost of HIV/AIDS care in Nantong City.

90,000 The cost of HIV treatment in Russia has halved in a year

The cost of HIV drugs has more than halved in a year. This was announced by the Minister of Health of Russia Veronika Skvortsova, speaking at the high-level session of the UN General Assembly on the fight against HIV / AIDS. “The use of standardized treatment regimens recommended by the World Health Organization, the centralization of government procurement, the widespread use of generic drugs and, most importantly, the import substitution policy made it possible to reduce prices in one year by more than two times, and for some drugs, more significantly, by several times”, – quotes the minister’s words by the press service of the department.

According to Ms. Skvortsova, adherence to drug therapy in Russia has increased to 70%. “The coverage of antiretroviral therapy among HIV-infected citizens in recent years has grown fivefold – up to 37% of all those under observation, and in a number of regions with the most difficult situation, for example, in Crimea, where in 2014 there was a peak incidence of HIV against the background of increased drug use – significantly more, which made it possible to reduce HIV mortality in Crimea by 26% in 2015 alone, ”she said, noting that in order to increase coverage to the target (90%), the country is implementing a set of measures to increase adherence to treatment.

Let us remind you that the HIV epidemic in a number of regions of Russia has reached the highest, generalized stage, according to the criteria of the WHO and the United Nations Joint Program on HIV / AIDS. This means that HIV infection is firmly rooted in the population and its spread is almost independent of risk groups. International experts assessed the situation with the spread of HIV in Eastern Europe and Central Asia as “special, requiring special measures” and “political will”.

Read more about the epidemic in the article “Kommersant” “HIV has left the risk group.”

90,000 Prevention and treatment of HIV / AIDS and drug addiction

Antiviral therapy for HIV infection – an opportunity to live a long and healthy life.

Therapy is provided free of charge.

HIV / AIDS hotline in St. Petersburg 955-27-00 (Mon-Fri from 9.30 to 17.00) , except weekends and holidays.

St. Petersburg Center for the Prevention and Control of AIDS and Infectious Diseases

Address: St. Petersburg, nab.Obvodny Canal 179 (polyclinic), st. Paper house 12 (hospital)

Website: www.hiv-spb.ru

955-27-00 AIDS Center hotline
246-70-98 anonymous HIV testing room

246-70-91 registry

246-70-81 information on the cost of analyzes and paid services

SPb GBUZ “Center for the Prevention and Control of AIDS and Infectious Diseases” is a complex medical structure, fully integrated into the city’s health care system.

The structure of the outpatient complex of the Center includes:

• Infection department
• Clinical diagnostic department
• Maternity and Childhood Department
• Department of Chronic Hepatitis
• Somatic department
• Dental department
• Department of functional diagnostics (ultrasound, fibroelastography, ECG, echocardiography, daily monitoring, densitometry)
• Department of Radiation Diagnostics
• Clinical diagnostic laboratory
• Department of Epidemiology and Medical Statistics
• Department of Medical and Social Psychology
• Department of Prevention and Medical and Social Work
• Reception
• Pharmacy (dispensing drugs)

In the polyclinic of the AIDS Center, at the address: nab.Obvodny Canal, 179 on the 1st floor is Anonymous office , where a qualified specialist of the AIDS Center will provide reliable information free of charge and anonymously and answer questions of interest regarding HIV infection, ways of its transmission and ways of protecting against HIV infection.

Opening hours of Anonymous Office No. 109 (first floor): Mon – Fri: from 9:00 to 20:00. Anonymous HIV testing is carried out free of charge, without documents and an appointment.Before the examination, it is necessary to fill out a questionnaire (without specifying personal data), receive obligatory consultation on HIV / AIDS issues and donate blood for research in the Procedure Room No. 107.

Working hours of Treatment Room No. 107 (ground floor): Mon – Thu: 9:00 am to 7:00 pm, Fri from 9:00 am to 1:00 pm.

HIV prevention point . Address: nab. Obvodny Canal, 179, polyclinic courtyard, to the right of the porch. Any visitor to the site will be able to talk about HIV infection with experienced counselors, undergo free HIV testing in the Center’s anonymous office, receive condoms, and exchange used syringes.

Opening hours: Mon-Fri from 12:00 to 18:00 hours.

The AIDS Center hosts weekly classes on Wednesdays at Patient School , where people affected by HIV infection (patients, their spouses, relatives, friends) can listen to lectures by the Center’s specialists, get answers to questions related to HIV infection, chat.

Annually on the basis of the Center cycles of educational seminars-trainings for employees of NGOs, social workers, peer consultants, volunteers are held.

Departments of prevention and clinical examination of patients with chronic viral infections were organized in St. Petersburg .

In the departments, patients can receive the following services:

• Consultation with an infectious disease doctor regarding HIV infection
• Laboratory examination for the level of immunity and HIV viral load
• Prescribing antiretroviral therapy (ART) if indicated

City Narcological Hospital

Today, the hospital has 6 departments with 381 beds, including 2 emergency drug treatment departments with 80 beds and a medical rehabilitation department with 100 beds.

In 2004, a 6-bed resuscitation and intensive care unit was commissioned, an X-ray room and an ultrasound diagnostics room were equipped.

About 8,500 patients are treated annually in the “City Narcological Hospital”, of which a third are drug addicts. The clinic employs highly qualified medical personnel, provides assistance to people with alcohol and drug addiction, with intoxication, and also carries out the first stage of inpatient rehabilitation.

The hospital has a fully equipped physiotherapy department, which uses a unique device for abdominal decompression.

The clinical diagnostic laboratory is capable of performing a wide range of studies.

The institution also includes 18 district drug treatment rooms in St. Petersburg. 3 outpatient medical rehabilitation departments. Department of medical examination for intoxication and chemical and toxicological laboratory.

Treatment for patients, in hospital, medical rehabilitation departments and dispensary observation in drug treatment rooms is carried out at the expense of the city budget.

Address: St. Petersburg, Vasilievsky Island, 4th line, house 23-25, (departments No. 3, 4, 6, 7, emergency department, intensive care unit) and 5th line, house 56-58 (administration, departments No. 1, 2, 10).

Tel / fax 323-43-08

e-mail: [email protected]

Helpline: 7144210 (around the clock).

90,000 HIV infection

The first medical center in Tel Aviv named after Sourasky applies innovative diagnostic methods and develops individualized HIV treatment. The infection, getting into the body, does not show activity for a long time. HIV treatment in Israel is aimed at early diagnosis after infection, reducing the amount of human immunodeficiency virus in the body and increasing immunity.

Find out the exact cost of treatment

Symptoms

Early symptoms appear in 70% of cases 3-6 weeks after infection.The incubation period lasts from 4 months to 4 years or more – the period depends on the patient’s immunity, the stage of detection of the infection and the treatment regimen. The period between the appearance of antibodies in the blood and the manifestation of signs of AIDS is 7-10 years.

Stages

Primary infection: (asymptomatic carriage, incubation period). Lasts 3 to 12 weeks. There are no signs, the infection is spreading. Clinically asymptomatic: Stage of primary manifestations (in 30% of patients, the stage is asymptomatic).Period from 3 to 52 weeks (1 year). Antibodies are produced, headaches appear, temperature up to 39-40 degrees C (fever for 30 days), sore throat, inflammation of the pharynx and liver, swollen lymph nodes (armpits, groin and neck) and spleen, muscle and joint pain, sweating during sleep, oropharyngeal candidiasis, herpes. Symptoms are mild, short-lived, and treatable. The stage of primary manifestations goes into subclinical or immediately into the stage of secondary symptoms. Symptomatic subclinical: Period from 2 to 20 years (the average is 7 years).Lymph nodes in adults increase in diameter by more than 1 cm, in children – from 0.5 cm. The nodes are painless and elastic. A maculopapular rash appears on the skin (seborrheic dermatitis), swelling of the extremities. Progression to AIDS The multiplication of the human immunodeficiency virus provokes the development of oncological and / or infectious diseases, T-lymphocytes are not restored. Treatment removes secondary manifestations. In stage IV, the phases of progression are distinguished: 4A (6-10 years) – fungal and bacterial skin lesions, repeated sinusitis and pharyngitis, inflammatory diseases of the upper respiratory tract.4B (7-10 years old) – skin lesions deepen. Weight decreases (for 6 months by 10% or more), lipodystrophy is observed, ulcers on the genitals and on the oral mucosa, chronic diarrhea. 4B (10-12 years old) – Pneumocystis pneumonia, atypical mycobacteriosis, CNS damage, depletion of the body. Terminal period (AIDS) Secondary symptoms are irreversible. The therapy is not effective. The final stage is fatal.

Diagnostics in Israel

Diagnostics of the human immunodeficiency virus in Israel is carried out in several stages: consultation, diagnosis, treatment, observation, prevention.Laboratory and instrumental research at the Sourasky Israel Hospital corresponds to the world class, the disease is diagnosed in the early and late stages of development. For diagnostics, the following is carried out:

• laboratory blood test to determine the level of CD4 + populations (a surrogate marker of the depth of the infectious process), a blood test for HIV, a detailed blood test and biochemical, urinalysis.
• method of enzyme-linked immunosorbent assay (screening test for the determination of antibodies to HIV), immune blotting (laboratory diagnostics of blood from a vein).
• Resistance and Antigenation – A four-step study determines the stage and susceptibility of human immunodeficiency virus to drugs.
• The PCR method (polymer chain reaction) determines the human immunodeficiency virus within 10 days after infection, determines the RNA of the pathogen (specific strain). An additional method, detects diseases in newborns and adults, determines the concentration of infection, is carried out in case of doubtful IB or for the study of donated blood.
• CT (computed tomography), MRI (magnetic resonance imaging), ultrasound (ultrasound) are prescribed in the presence of accompanying diseases caused by the human immunodeficiency virus.

The results indicate the fact of infection, stage and secondary clinical manifestations; prognosis of HIV progression.

Cost of diagnostics

Find out the exact cost of diagnostics

Guaranteed response within 30 minutes

Effective treatment methods

1. suppressing drug reproduction infections.
2. Antiretroviral drugs. They are divided into three types: protease inhibitors, nuocleside and non-nuoclizide inhibitors of human immunodeficiency virus reverse transcriptase.
3. Prevention of opportunistic infections.
4. Vaccination of a patient with human immunodeficiency virus in order to prevent the development of concomitant diseases.

What innovative treatment methods are used in a clinic in Israel?

Treatment at the First Medical Center of Tel Aviv named after Sourasky is developed individually, treatment protocols (combination anti-HIV therapy) are adjusted in the process of regular testing.Treatment of the human immunodeficiency virus in Israel is aimed at:

• suppression of HIV multiplication and prevention of degeneration into AIDS;
• restoration of the concentration of T-lymphocytes in the blood;
• fight against opportunistic diseases.

A polytherapy complex of 4-5 preparations is used for treatment. Israeli doctors prescribe one of the HAART (high-intensity antiretroviral drug therapy) treatment regimens to reduce the infection in the blood.After the elimination of viral particles, immunotherapy is prescribed. HIV treatment is carried out with therapy and / or prevention of concomitant diseases.

Which doctor of the clinic should I contact?

Experienced doctors, laboratory assistants, nurses work in the First Medical Center of Israel. For a full-fledged complex treatment of the human immunodeficiency virus, medical and consulting activities are carried out with social workers, psychologists, immunologists, nutritionists, infectious disease specialists and venereologists.

Get help in selecting a specialist

Guaranteed response within 30 minutes

Get tested for HIV, the price of an AIDS test in Moscow at Invitro

Method of determination
Enzyme-linked immunosorbent assay (ELISA).

Study material
Blood serum

Home visit available

Attention. In case of positive and questionable reactions, the term for issuing the result can be increased up to 10 working days.

Synonyms: Blood test for antibodies to HIV1 and 2 and HIV1 and 2 antigen; HIV-1 p24; HIV-1 antigen, p24 antigen; HIV 1 and 2 antibodies and p24 / 25 antigen, 4th generation HIV test systems; Simultaneous qualitative determination of HIV p24 antigen and antibodies to HIV antigens of types 1 and 2. Anti-HIV, HIV antibodies, human immunodeficiency virus antibodies; HIV-1 p24, HIV-1 Ag, p24-antigen; HIV-1 and HIV-2 Antibody and Antigen Evaluation; HIV Screening Tests; AIDS Test; AIDS Screen; HIV Serology.

Brief description of the study for Antibodies to HIV1 & 2 and HIV1 & 2 antigen

Antibodies to HIV may appear as early as the second week after infection; their content increases within 2-4 weeks and persists for many years. In 90-95% of infected people, they appear in the first three months after infection, in 5-9% – in the period from three to six months, in 0.5-1% – at a later date. After HIV infection, even before antibodies appear (seroconversion), HIV antigens can be detected in serum or plasma samples.The structural nuclear protein of HIV p24, which appears in the blood two weeks after infection, disappears only after two months. The 4th generation test system, using which this test is performed, allows, in addition to detecting antibodies to HIV-1 and 2, to detect the HIV p24 antigen. Thus, the study can be informative even before seroconversion. A similar approach in laboratory diagnosis of HIV allows for the earliest determination of infection. The special characteristics of the test used in the INVITRO laboratory for detecting HIV infection include the high specificity of the study:> 99.5%; 100% sensitivity of the assay to antibodies characteristic of the seroconversion period, and the sensitivity of the assay to p24 antigen is about 18 pg / ml.

Most people with HIV antibodies may not show clinical signs of illness (AIDS) for two to ten years or more. The procedure for conducting laboratory tests for the presence of HIV antigens and antibodies to HIV is strictly regulated by orders of the Ministry of Health of the Russian Federation and includes the stage of screening (screening) studies using enzyme-linked immunosorbent assay (ELISA) methods that are approved for use, and the stage of verification (confirming) studies by immunoblot in the laboratory of the city center AIDS.

It should be noted that even the best diagnostic ELISA systems do not have 100% specificity, that is, there is a certain probability of obtaining non-specific, false-positive results associated with the characteristics of the patient’s blood serum. Therefore, a positive ELISA screening test result may not be confirmed in a confirmatory test, after which the patient will be given a negative result. If uncertain results are obtained in a confirmatory study, testing is repeated over time.It is recommended to carry out repeated examinations in 2-3 weeks.

Laboratory diagnostics of HIV infection in children born to HIV-infected mothers has its own characteristics. Maternal antibodies to HIV (IgG class) can circulate in their blood up to 18 months from birth. The absence of antibodies to HIV in newborns does not mean that the virus has not penetrated the placental barrier. Children of HIV-infected mothers are subject to laboratory diagnostic examination within 36 months after birth.

What is the purpose of testing for Antibodies to HIV1 and 2 and HIV1 and 2 antigen

The study is used to detect HIV, including at the preclinical stage of the disease. The combined determination of specific antibodies to HIV types 1 and 2 and the HIV p24 antigen in the blood is used as an analysis for the presence of infection with the human immunodeficiency virus. Timely diagnosis of the infectious process can prevent the spread of the virus in the population and will allow starting specific therapy as soon as possible.

What can affect the test result for Antibodies to HIV1 and 2 and HIV1 and 2 antigen

In rare cases, a false positive result is possible if the subject’s blood contains antibodies to the Epstein-Barr virus, rheumatoid factor, major histocompatibility complex HLA, or antibodies after the administration of the HIV vaccine.

90,000 UNAIDS Representative: timely HIV treatment enables you to live a full and long life

The head of the UNAIDS regional office in Moscow Vinay Saldana told Anton Uspensky about what can and should be done to stop the spread of HIV in the countries of the region, as in the world in general …

BC: The trend in our region is not only an increase in new infections, but also a very high mortality rate due to HIV infection. This indicates that not all people who have been diagnosed receive life-saving treatment. The treatment regimen should now be optimal: one tablet per day, fixed-combination dose. This enables the patient to comply with the so-called “adherence” to treatment. But, unfortunately, such optimal regimens are not available for many people living with HIV.We see that in the Eastern Europe and Central Asia region, the level of coverage and quality of treatment is poor.

OU: Why is this treatment not available? No drugs? Or are they too expensive?

BC: Today, the cost of these drugs, which 10-15 years ago cost $ 10,000 per patient per year, is $ 100-300 per year, despite the fact that the treatment itself has become more optimal than then. Nevertheless, the healthcare system was not particularly prepared for such a huge wave of people diagnosed with HIV.The estimated number of people living with HIV in Eastern Europe and Central Asia is 1.5 million. This is a huge amount of need for treatment. And the health care system in our region was not ready to immediately provide all these people with access to treatment: neither from a financial point of view, nor in terms of infrastructure, nor in terms of the number of medical staff who must diagnose the disease and take care of patients – hundreds of thousands of patients.

It is not easy for us to use the term “HIV epidemic” in Eastern Europe and Central Asia, but what we see today is a full-fledged HIV epidemic.We hope to see some stabilization in the epidemic, but so far we do not see any sharp reduction, or those trends that are observed in almost all other regions of the world. There is the so-called “Target 90-90-90”. This is when 90 percent of the estimated number of people living with HIV are diagnosed and aware of their status; 90 percent of those who are aware of their status are on treatment; and 90 percent of those on treatment have achieved so-called undetectable viral loads.Why are these three “90s” so important? Because in people who are being treated for HIV infection, there is a sharp decrease in the concentration of the HIV virus to such a low level that they cease to be a source of possible spread of infection. And thus there is a “magic” effect of treatment as prevention.

UNAIDS PHOTOS

Vinay Saldana (right) with famous singer Vera Brezhneva. She, as a UNAIDS Goodwill Ambassador, helps fight HIV in Russia.

But it is equally important that these people, who feel good and have the opportunity to live a full, long life with HIV infection, are also freed from feelings of awkwardness, stop thinking: “God forbid, I endanger my sexual partner’s infection …” …A person on treatment who has reached an undetectable viral load cannot infect his sexual partner with HIV. Treatment is not only important for the health of those infected, it is becoming an important factor in preventing the spread of new HIV infections.

OO: What are the top priority measures needed to combat what you call the HIV / AIDS epidemic in Eastern Europe and Central Asia?

VS: First, the time for testing HIV infection must be reduced to a minimum.In the modern world, a few hours are enough to get a full diagnosis. Second, once a person is diagnosed, they should be provided with continuous quality treatment. There are two more points that I would like to add. It is necessary to strengthen all programs for the prevention of HIV infection, first of all – new methods of prevention, “pre-exposure prophylaxis”. Not for the entire population, but only for those people who are at high risk of infection. They should be offered regular access to medications that, when taken daily, reduce their risk of contracting HIV to virtually zero.And I would also like to draw your attention to the topic of our report: “Power to the People” (Power to the people!). This report shows that if we do not strengthen our cooperation with civil society, if we do not give leadership roles to people affected by HIV infection, those living with HIV infection, public organizations that do critical work, we will not put an end to the AIDS epidemic. In general, in countries, in communities around the world, where we are seeing excellent success in the fight against AIDS, public and civil organizations play key roles.

OU: Do you meet with support and understanding? Are your efforts, UNAIDS efforts actively supportive?

BC: I and all UNAIDS staff throughout the Eastern Europe and Central Asia region are in contact every day with governments, ministries of health, and decision-makers to not only continue to fight HIV / AIDS, but also so that they set very tough and very ambitious goals to defeat the epidemic once and for all.I am more than confident that this is possible, but it will take a change in mentality and understanding of the urgency of these measures.

90,000 Network Partner ANTIAIDS Foundation will purchase ART for more than 6,500,000 hryvnia

For the first time in Eastern Europe, HIV-positive patients will be treated with private funds

BO “All-Ukrainian Network of People Living with HIV” applied to the Elena Pinchuk ANTIAIDS Foundation with a proposal to support a treatment project in Kiev in 2017-2018.We are pleased to announce that the Foundation has announced the launch of a new project, within the framework of which more than a thousand HIV-positive patients will be taken for treatment in Kiev. The project budget is over 6.5 million hryvnia. The procurement operator will be the PLHIV Network. The goal of this project is to accelerate the access of HIV-positive people to life-saving therapy and to present the newest drug for ARV therapy in Ukraine as soon as possible. Treatment will be carried out at the Kiev City AIDS Center.

In Eastern Europe, this is the first precedent for a private foundation to participate in a treatment program.Until now, the antiretroviral therapy program in Ukraine has been financed exclusively from the state budget and international organizations. Thanks to the emergence of a private partner, treatment with the latest sixth generation drug will begin in our country for the first time (now the treatment is carried out with fourth generation drugs), and the cost of treatment will be halved. Following this practice, already in 2018 Ukraine will be able to double the number of patients who will receive life-saving treatment without additional costs.

“The task of my foundation has always been to stop the AIDS epidemic,” says Elena Pinchuk, founder of the ANTIAIDS Foundation. – According to the latest trends in the fight against AIDS, taking antiretroviral therapy is not only a treatment, but also a prevention. The person who is on therapy does not transmit the virus. The Joint UN Agency on HIV / AIDS recommends that 90 percent of people who know their diagnosis have access to treatment. The sooner Ukraine can get closer to these standards, the fewer new HIV cases, the more lives we can save, the faster we can stop the epidemic.That is why we responded to the request of the Network of People Living with HIV to provide a grant of 6.5 million hryvnia for the purchase of the newest drug for 1,200 people in Kiev who are in dire need of treatment. ”

Today, the PLHIV Network is one of the main operators of treatment and procurement, which will be able to provide the most favorable conditions for the supply of drugs. The selection of patients for this program and their treatment will be carried out on the basis of the Kiev City AIDS Center under the public supervision of patient organizations.These will be the first patients in Ukraine who will begin treatment with a new generation drug – dolutegravir. It is more effective and less toxic than the drugs used today. Taking the drug once a day simplifies the treatment process and reduces the number of people who can refuse it.

Also, for the first time in its history, Ukraine will be able to treat patients at such a sensationally low price – $ 170 per year. Now an annual course of treatment in Ukraine costs an average of $ 360.Thanks to the new approach, pioneered by the fund, our country will have an opportunity, without spending additional resources, to double the coverage of ARV therapy for HIV-positive people. This will be one of the most important results of an initiative that will completely change the situation in the fight against the epidemic.

Dmitry Sherembey, Head of the Coordinating Council of the All-Ukrainian Network of People Living with HIV: “Today we are talking about a small revolution in the fight against AIDS. We are starting a partnership with a private foundation, expanding the treatment program in Kiev, purchasing the latest generation of drugs and reducing the cost of treating patients by almost half.The participation of a private foundation in treatment programs is a precedent not only for Ukraine. We do not know of a single example when private foundations paid for the treatment of patients with HIV / AIDS. In two years, all clients of this program will come under our care and will be provided with further treatment, and thanks to the participation of the ANTIAIDS Foundation, we will be able to expand the practice of using the sixth generation drug. ”

Alexander Yurchenko, chief physician of the Kiev City AIDS Center: “According to expert estimates, today there are about 24 thousand HIV-positive people living in Kiev.But only every second person is registered at the dispensary. Only 12 thousand HIV-positive people of Kiev know about their status, and only 6 thousand of them receive therapy. Thanks to the initiative of the Network of PLHIV and a new partnership with the ANTIAIDS Foundation, we will be able to start recruiting people who are waiting for the start of therapy for treatment next year. This will reduce AIDS deaths and reduce the number of new HIV cases. ”

In November 2015, the WHO European Office released a new Global Guidelines on HIV Infection to improve the effectiveness of prevention and treatment.The revolutionary change announced in this document is that ART should be given to all people living with HIV, regardless of CD4 cell count. From that moment on, treatment began to be interpreted not just as a factor that positively affects prevention, but as an effective tool for mass response to the epidemic. According to expert data, one person living with HIV and not taking therapy can infect up to two people a year. A patient taking antiretroviral therapy becomes completely safe for others.He cannot infect his partners, as the concentration of the virus in his blood drops sharply. With regular medication, the blood of an HIV-positive person becomes literally pure.

HIV / AIDS in Ukraine

For ten months of 2016, in Ukraine, according to the Ukrainian Center for Control over Socially Dangerous Diseases of the Ministry of Health of Ukraine, 13,381 new cases of HIV infection were registered (of which 2,349 were children under 14 years of age). In total, since 1987, 293 739 new cases of HIV infection have been officially registered in Ukraine, during this time 40 816 people have died from AIDS.The regions most affected by HIV infection are Dnepropetrovsk, Donetsk, Kiev, Nikolaev and Odessa regions, as well as Kiev.

Ukraine remains the leader in Europe in terms of the spread of HIV infection. According to UNAIDS experts, up to 250 thousand people live with HIV in Ukraine. And only every second person knows about their diagnosis – as of April 1, 2016, 132,714 HIV-positive patients are registered in Ukraine.

ARV therapy in Ukraine

As of September 1, 2016, 43 344 patients were receiving treatment from the state budget.Another 24,969 patients received treatment at the expense of international donors, drugs for these patients are purchased by the PLHIV Network. In accordance with the state program to combat AIDS in 2016, 105,748 people should receive treatment. Currently, only 68,313 people receive ARV therapy.

A record 5.9 billion hryvnia has been set aside in the 2017 draft budget for the purchase of drugs. The increase in state funding will allow for treatment of an additional 34 thousand HIV-positive Ukrainians.In 2017, a total of 101 thousand patients will be able to receive ARV therapy.

For detailed information, please contact Pavel Piminov, Communications Director of the Elena Pinchuk ANTIAIDS Foundation: +380 44 490 4805, [email protected].

90,000 Unique Hepatitis C Treatment Program

EMC offers a new, unique for Russia program of hepatitis C treatment, which allows, with a 95-100% probability, to completely get rid of the disease.

Proven program effectiveness 95-100%!

The program is based on the use of an innovative antiviral drug, the appearance of which in 2014 was a real breakthrough in medicine.

Advantages of the new program:

• Treatment efficiency – 95-100%

• Possibility of using in patients with liver cirrhosis and concomitant pathology.

• High tolerance: in clinical trials, more than 98% of patients were able to complete the course completely.

The new program, developed by specialists-hepatologists of the European Medical Center, is based on the innovative drug Vikeira Pak and approved for the treatment of patients with hepatitis C (1st genotype subtypes a and b), co-infection of chronic hepatitis C and human immunodeficiency virus 1- type th (HIV-1), as well as patients after liver transplantation. The effectiveness of treatment does not depend on whether the patient has previously received interferon therapy or not.

EMC’s unique hepatitis C treatment program is available in 3 variants, in which Vieira Pak is used alone or in combination with ribavirin.

Attention! The drugs are already included in the cost of treatment!

Program options:

• Optima – for patients without cirrhosis and comorbidities

• Optima Plus – for patients without cirrhosis, with comorbidities

• Ultra – for patients with cirrhosis

Before each program an in-depth examination is performed – screening.

Leading specialists of the program:

1. Bakulin I.G. – gastroenterologist-hepatologist, chief gastroenterologist of Moscow, doctor of medical sciences, professor. Author of over 200 scientific publications, co-author of 6 monographs, member of the European Association for Liver Diseases (EASL), American Association for the Study of the Liver (AASLD), Russian Society for the Study of Liver Diseases (ROPIP).

2. Blokhina N.P. – infectious disease hepatologist, doctor of medical sciences, professor, specialization – treatment of viral hepatitis, author of more than 70 publications, including 7 teaching aids and 56 scientific works.Member of the International Society for Infectious Diseases (ISID).

3. Nurmukhametova U.A. – infectious disease hepatologist, Ph.D. Author of over 40 publications, member of the International Society for Infectious Diseases (ISID).

4. Polunina T.E. – Gastroenterologist-hepatologist, Doctor of Medical Sciences, Professor of Moscow State Medical University, Head of the EMC Hepatology Center. Author of over 100 scientific publications, member of the European Association for the Study of Liver Diseases (EASL), the American Association for the Study of the Liver (AASLD), the Russian Society for the Study of Liver Diseases (ROPIP).

The treatment program is 12 weeks long.

Stages of the program for a patient with hepatitis C:

1. Sign up for a consultation with an EMC clinic hepatologist or a leading program specialist for pre-program screening.

2. Screening – in-depth instrumental and laboratory examination – to identify the type of virus, stage of the disease, the presence of concomitant pathology.

3. Consultation of a leading specialist, determination of the treatment program: Optima, Optima Plus or Ultra.

4. Passage of the program: taking medications, interim tests and consultations with the attending physician.

5. Completing the examination program.

What is Vieira Pak

Vieira Pak was registered in the United States at the end of 2014, appeared in the European Union in early 2015, and is now available in Russia, due to the high demand for drugs that are really effective against the hepatitis C virus : in Russia alone, the number of patients with hepatitis C is, according to various sources, from 3.5 to 4.7 million people.The emergence of a new drug that effectively suppresses the multiplication of the hepatitis C virus has become a real breakthrough in medicine.

Vieira Pak is used in combination with or without ribavirin, depending on the stage of the disease, the severity of liver cirrhosis, and the presence of concomitant pathology. Clinical studies conducted with the participation of over 2300 patients from more than 25 countries have shown that this therapy regimen demonstrates 95-100% effectiveness. Less than 2% experienced virologic failure.The drugs are highly tolerated: more than 98% of patients were able to complete the course.

Enrollment for Hepatitis C Treatment

Patient enrollment for the new unique hepatitis C treatment program at EMC has already begun. The program is also available for nonresident patients: the presence of the patient is required at the stage of the first examination and consultation with a leading specialist, at intermediate consultations and examinations with the attending physician (their number depends on the program: Optima, Optima Plus or Ultra), as well as at the end of treatment consultations.