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Economic and public health consequences of delayed access to medical care for migrants living with HIV in France

The European Journal of Health Economics volume 19, pages 327–340 (2018)Cite this article

Abstract

In 2013, migrants accounted for 46% of newly diagnosed cases of HIV (human immunodeficiency virus) infection in France. These populations meet with specific obstacles leading to late diagnosis and access to medical care. Delayed access to care (ATC) for HIV-infected migrants reduces their life expectancy and quality of life. Given the reduction of infectivity under antiretroviral (ARV) treatment, delayed ATC for HIV-infected migrants may also hinder the control of the HIV epidemic. The objective of this study is to measure the public health and economic consequences of delayed ATC for migrants living with HIV in France. Using a healthcare payer perspective, our model compares the lifetime averted infections and costs of early vs. late ATC for migrants living with HIV in France. Early and late ATC are defined by an entry into care with a CD4 cell count of 350 and 100/mm3, respectively. Our results show that an early ATC is dominant, even in the worst-case scenario. In the most favorable scenario, early ATC generates an average net saving of €198,000 per patient, and prevents 0.542 secondary infection. In the worst-case scenario, early ATC generates an average net saving of €32,000 per patient, and prevents 0.299 secondary infection. These results are robust to various adverse changes in key parameters and to a definition of late ATC as an access to care at a CD4 level of 200/mm3. In addition to individual health benefits, improving ATC for migrants living with HIV proves efficient in terms of public health and economics. These results stress the benefit of ensuring early ATC for all individuals living with HIV in France.

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Fig. 1

Notes

  1. CD4 cells are a type of white blood cell that fights infection. CD4 count helps tell how strong the immune system is, indicates the stage of the HIV disease, guides treatment, and predicts how the disease may progress. Keeping the CD4 count high reduces complications of HIV disease and extend life expectancy of patients.

  2. Antiretroviral treatments are used to delay progression of the disease and death for HIV-positive patients.

References

  1. Supervie, V., Brouard, C.: Cascades et parcours de soins, analyse comparative VIH/VHC.: presented at the XVème congrès de la SFLS. http://invs.santepubliquefrance.fr/content/download/109012/388078/version/1/file/2014_Cascade_VIHVHC_SFLS.pdf (2014)

  2. Lert, F., Annequin, M., Tron, L., Aubriere, C., Spire, B.: Situation socioéconomique des personnes vivant avec le VIH suivies a l’hôpital en France métropolitaine en 2011. Premiers résultats de l’enquête ANRS-Vespa2. Bull. Epidemiol. Hebd. 26–27, 293–299 (2013)

    Google Scholar 

  3. Cazein, F., Pillonel, J., Le Strat, Y., Pinget, R., Le Vu, S., Brunet, S.: Découvertes de séropositivité VIH et de sida, France, 2003-2013. Bull Epidemiol Hebd. 9–10, 152–161 (2015)

    Google Scholar 

  4. Jusot, F., Silva, J., Dourgnon, P., Sermet, C.: Inégalités de sante liées à l’immigration en France: effet des conditions de vie ou sélection à la migration? Revue économique 60(2), 385 (2009)

    Article  Google Scholar 

  5. Massari, V., Lapostolle, A., Cadot, E., Parizot, I., Dray-Spira, R., Chauvin, P.: Gender, socio-economic status, migration origin and neighbourhood of residence are barriers to HIV testing in the Paris metropolitan area. AIDS Care 23(12), 1609–1618 (2011)

    Article  PubMed  Google Scholar 

  6. Lydie, N., Beltzer, N., Fenies, K., Halfen, S., Lert, F., and Le Vu, S.: Les populations africaines d’Ile-de-France face au VIH/sida. Connaissances, attitudes, croyances et comportements. Institut National de Prévention et d’Education à la Sante, Saint-Denis. http://inpes.santepubliquefrance.fr/Barometres/Etude_sida_migrants/pdf/synthese.pdf (2007)

  7. Fakoya, I., Reynolds, R., Caswell, G., Shiripinda, I.: Barriers to HIV testing for migrant black Africans in Western Europe. HIV Med 9(s2), 23–25 (2008)

    Article  PubMed  Google Scholar 

  8. Alvarez-del Arco, D., Monge, S., Azcoaga, A., Rio, I., Hernando, V., Gonzalez, C., Bolumar, F.: HIV testing and counselling for migrant populations living in high-income countries: a systematic review. Eur J Public Health 23, 1039–1045 (2013)

    Article  PubMed  Google Scholar 

  9. Conseil National du Sida.: Avis sur la protection sociale des étrangers vivant avec le VIH en France et l’intérêt de son évolution vers le droit commun. http://cns.sante.fr/wpcontent/uploads/2015/2013-09-19_avi_fr_politique_publique.pdf (2013)

  10. Carrera, S., & Merlino, M.: Undocumented immigrants and rights in the EU. Addressing the gap between social science research and policy-making in the Stockholm Programme? CEPS, Brussels. http://aei.pitt.edu/15103/1/Undocumented_Migrants__Zennstrom_Rpt__by_Carrera__Merlino_eversion.pdf (2009)

  11. Keygnaert, I., Guieu, A., Ooms, G., Vettenburg, N., Temmerman, M., Roelens, K.: Sexual and reproductive health of migrants: does the EU care? Health Policy 114(2), 215–225 (2014)

    Article  PubMed  Google Scholar 

  12. Pérez-Molina, J.A., Ortega, F.P., Comité de expertos del Grupo para el Estudio del Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC): Evaluación del impacto del nuevo marco legal sanitario sobre los inmigrantes en situación irregular en España: el caso de la infección por el virus de la inmunodeficiencia humana. Enfermedades Infecciosas y Microbiología Clínica 30(8), 472–478 (2012)

    Article  PubMed  Google Scholar 

  13. Cohen, M.S., McCauley, M., Gamble, T.R.: HIV treatment as prevention and HPTN 052. Curr Opin HIV AIDS 7(2), 99–105 (2012)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. Cohen, M.S., Chen, Y.Q., McCauley, M., Gamble, T., Hosseinipour, M.C., Kumarasamy, N., Godbole, S.V.: Antiretroviral therapy for the prevention of HIV-1 transmission. N. Engl. J. Med. 375(9), 830–839 (2016)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. Hayes, R., Ayles, H., Beyers, N., Sabapathy, K., Floyd, S., Shanaube, K., Fraser, C.: HPTN 071 (PopART): rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment–a study protocol for a cluster randomised trial. Trials 15(1), 57 (2014)

    Article  PubMed  PubMed Central  Google Scholar 

  16. Kahn, G.J., Marseille, A.E., Williams, G.B., Granich, R.: Cost-effectiveness of antiretroviral therapy for prevention. Curr. HIV Res. 9(6), 405–415 (2011)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. Sloan, C.E., Champenois, K., Choisy, P., Losina, E., Walensky, R.P., Schackman, B.R., Ajana, F., Melliez, H., Paltiel, A.D., Freedberg, K.A., Yazdanpanah, Y., Cost-Effectiveness of Preventing AIDS Complications (CEPAC) investigators : Newer drugs and earlier treatment: impact on lifetime cost of care for HIV-infected adults. AIDS (London, England) 26(1), 45–56 (2012)

    Article  Google Scholar 

  18. Antiretroviral Therapy Cohort Collaboration: Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet 372(9635), 293–299 (2008)

    Article  Google Scholar 

  19. Lodi, S., Phillips, A., Touloumi, G., Geskus, R., Meyer, L., Thiebaut, R., Pantazis, N., Amo, J.D., Johnson, A.M., Babiker, A., Porter, K., CASCADE Collaboration in Euro Coord: Time from human immunodeficiency virus seroconversion to reaching cd4 + cell count thresholds 200, 350, and 500 cells/mm3: assessment of need following changes in treatment guidelines. Clin. Infect. Dis. Off. Publ. Infect. Dise. Soc. Am. 53(8), 817–825 (2011)

    CAS  Article  Google Scholar 

  20. Cohen, M.S., McCauley, M., Gamble, T.R.: HIV treatment as prevention and HPTN 052. Curr Opin HIV AIDS 7(2), 99 (2012)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  21. Attia, S., Egger, M., Müller, M., Zwahlen, M., Low, N.: Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS (London, England) 23(11), 1397–1404 (2009)

    Article  Google Scholar 

  22. Baggaley, R.F., White, R.G., Hollingsworth, T.D., Boily, M.-C.: Heterosexual HIV-1 infectiousness and antiretroviral use: systematic review of prospective studies of discordant couples. Epidemiology (Cambridge, Mass.) 24(1), 110–121 (2013)

    Article  Google Scholar 

  23. Anglemyer, A., Rutherford, G.W., Horvath, T., Baggaley, R.C., Egger, M., Siegfried, N.: Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev 4, CD009153 (2013)

    PubMed Central  Google Scholar 

  24. Jia, Z., Mao, Y., Zhang, F., Ruan, Y., Ma, Y., Li, J., Guo, W., Liu, E., Dou, Z., Zhao, Y., Wang, L., Li, Q., Xie, P., Tang, H., Han, J., Jin, X., Xu, J., Xiong, R., Zhao, D., Li, P., Wang, X., Wang, L., Qing, Q., Ding, Z., Chen, R.Y., Liu, Z., Shao, Y.: Antiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003–11): a national observational cohort study. Lancet 382(9899), 1195–1203 (2013)

    Article  PubMed  Google Scholar 

  25. Birungi, J., Wang, H., Ngolobe, M.H.and Muldoon, K., Khanakwa, S., King, R., Kaleebu, P., Shannon, K., Ocha, R., Montaner, J., Mills, E., Laurenco, L., Abdallar, N., and Moore, D.: Lack of effectiveness of art as an hiv prevention tool for sero-discordant couples in a rural art program in Uganda. Oral abstract session: 19th International AIDS Conference (2012)

  26. Sullivan, P., Kayitenkore, K., Chomba, E., Mwananyanda, L., Vwalika, C., Conkling, M., Luisi, N., Tichacek, A., and Allen, S.: Is the reduction of HIV transmission risk while prescribed antiretroviral therapy (arvt) different for men and women? Results from discordant couples in Rwanda and Zambia. 5th International AIDS Society Conference on HIV Pathogenesis and Treatment and Prevention. Abstract Number 2009 WEAC101. Cape Town. (2009)

  27. Marks, G., Crepaz, N., Sentertt, J.W., Janssen, R.S.: Meta-analysis of high risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J. Acquir. Immune Defic. Syndr. 39(4), 446–453 (2005)

    Article  PubMed  Google Scholar 

  28. Ndawinz, J.D.A., Costagliola, D., Supervie, V.: New method for estimating HIV incidence and time from infection to diagnosis using HIV surveillance data: results for France. AIDS (London, England) 25(15), 1905–1913 (2011)

    Article  Google Scholar 

  29. Desgree du Lou, A., Pannetier, J., Ravalihas, A., Gosselin, A., Supervie, V., Panjo, H., Bajos, N., Lert, F., Lydie, N., Dray-Spira, R., and the PARCOURS study group (2015).: HIV acquisition after arrival in France among sub-Saharan African migrants living with HIV in Paris area. Estimations from the ANRS PARCOURS study. Presented at IAS 2015-Vancouver, Canada

  30. Rice, B.D., Elford, J., Yin, Z., Delpech, V.C.: A new method to assign country of HIV infection among heterosexuals born abroad and diagnosed with HIV. AIDS (London, England) 26(15), 1961–1966 (2012)

    Article  Google Scholar 

  31. Marks, G., Crepaz, N., Janssen, R.S.: Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS (London, England) 20(10), 1447–1450 (2006)

    Article  Google Scholar 

  32. Supervie, V.: L’épidémie cachée. Communication orale lors des soirées ASLP/COREVIH—Les rencontres VIH en Paca Ouest Corse. http://fr.aphm.fr/sites/default/files/files/Corevih/corevih_vsupervie_epidemiecachee.pdf (2014)

  33. McCabe, C., Claxton, K., Culyer, A.J.: The NICE cost-effectiveness threshold. Pharmacoeconomics 26(9), 733–744 (2008)

    Article  PubMed  Google Scholar 

  34. Belza, M.J., Hoyos, J., Fernández-Balbuena, S., Diaz, A., Bravo, M.J., de la Fuente, L., the Madrid HIV rapid testing group: Assessment of an outreach street-based HIV rapid testing programme as a strategy to promote early diagnosis: a comparison with two surveillance systems in Spain, 2008–2011. Eur. Surveill. 20(14), 23–33 (2015). (pii = 21089)

    Article  Google Scholar 

  35. European Centre for Disease Prevention and Control. Migrant health: epidemiology of HIV and AIDS in migrant communities and ethnic minorities in EU/EEA countries. ECDC, Stockholm. http://ecdc.europa.eu/en/publications/publications/0907_ter_migrant_health_hiv_access_to_treatment.pdf (2009)

  36. Miners, A., Phillips, A., Kreif, N., Rodger, A., Speakman, A., Fisher, M., Lampe, F.C.: Health-related quality-of-life of people with HIV in the era of combination antiretroviral treatment: a cross-sectional comparison with the general population. Lancet HIV 1(1), e32–e40 (2014)

    Article  PubMed  Google Scholar 

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Acknowledgements

We are very grateful to Virginie Supervie, Stéphane Le Vu, and France Lert for the comments and suggestions. We also thank the members of CESP, especially Kayigan d’Almeida and France Lert, for allowing us to access the VESPA 2 data.

Author information

Affiliations

  1. Université Clermont Auvergne, CNRS, CERDI and Paris School of Economics, 63-65 Boulevard François Mitterrand, 63000, Clermont-Ferrand, France

    Marlène Guillon

  2. Conseil National du Sida-French National AIDS Council, 39-43 Quai André Citroën, 75902, Paris Cedex 15, France

    Michel Celse

  3. Paris School of Economics, 48 Boulevard Jourdan, 75014, Paris, France

    Pierre-Yves Geoffard

Authors
  1. Marlène Guillon
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  2. Michel Celse
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  3. Pierre-Yves Geoffard
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Corresponding author

Correspondence to Marlène Guillon.

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Declaration of interests

MG reports a grant of the Ile-de-France Region for the funding of her PhD. MG also reports a grant from the French National AIDS Council for this study. This work was supported by the Agence Nationale de la Recherche of the French government through the program “Investissements d’avenir ’’ ANR-10-LABX-14-01’’. MC and PYG declare no competing interests. MC is an expert advisor to the French National AIDS Council. PYG is a professor at Paris School of Economics and a member of the French National AIDS Council.

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The funding source had no involvement in study design, analysis and interpretation of data; in the writing of the article and the decision to submit it for publication.

Appendices

Appendix A: share of undiagnosed time spent in France for migrants infected abroad

The calculation of the share of the total undiagnosed time spent in France and in the countries of origin for migrants infected abroad was realized on data extracted from the VESPA2 survey. This survey was conducted in 2011 by researchers from INSERM (Unités 912, SESSTIM, Marseille et 1018, CESP Villejuif) with the financial support of Agence Nationle de Recherche sur le Sida et les hépatites virales (ANRS). The access to VESPA2 data necessary to this estimation was possible thanks to the help of the Centre de Recherche en Epidémiologie et Santé des Populations (CESP). We are grateful to members of CESP ant to her head of department, France Lert, for allowing us to access these data.

The share of total time undiagnosed spent in France and in the country of origin for migrants infected abroad is calculated to be used as a proxy to determine the share of infected migrants infected abroad but already in France. For this calculation, the following data are used for migrants declaring contamination in their country of origin: date of arrival in France, date of diagnosis, date of first available medical examination related to HIV and CD4 level at this first examination. Several computational steps were performed to obtain the share of total time undiagnosed spent in France for migrants infected abroad from the VESPA2 data.

  1. 1

    Calculation of the duration of infection at the time of initial medical examination.

    Data from Lodi et al. [19] on time from seroconversion to different levels of CD4 cell count are used to estimate the duration of infection at first medical examination. Based on these data, the estimated duration of infection at first medical examination is assumed to be, less than or equal to 4 years if the CD4 cell count is above 350/mm3 between 4 and 8 years if the number of CD4 is between 200 and 350/mm3 and greater than or equal to 8 years if the CD4 cell count at examination is less than 200/mm3. Regarding the latter, an upper bound for the duration of infection is set to twelve years. Indeed, after 12 years of untreated infection patients are assumed to be diagnosed because of symptoms related to the entry into the AIDS stage.

  2. 2

    Calculation of the year of infection.

    The probable year of infection is calculated as the difference between the year of the first medical examination and the probable duration of the infection since the first examination. If the estimated year of infection exceeds the year of arrival in France it is then considered that the year of infection is the same as the year of arrival in France.

  3. 3

    Calculation of the total time spent undiagnosed, the time spent undiagnosed in France and the share of the total time undiagnosed spent in France.

    The total time spent undiagnosed is calculated as the difference between the year of diagnosis and the estimated year of infection. The total time spent undiagnosed in France is calculated using the date of arrival in France and the estimate of the total time spent undiagnosed. It is assumed that, if the year of arrival in France is the same as the year of diagnosis and the year of infection, total time spent undiagnosed is equal to 1 year divided equally between the country of origin and France.

  4. 4

    Calculation of the share of undiagnosed time spent in France.

    The share of the total time spent undiagnosed in France is calculated by dividing the estimated time spent undiagnosed in France by the total time spent undiagnosed.

Appendix B: cost per QALY of early ATC

Compared to late ATC, QALYs saved thanks to early ATC can be divided in two categories, those saved for early treated patients compared to late-treated patients and those saved due to averted HIV infections.

  1. 1.

    QALYs saved for early treated patients compared to late treated patients.

    In the main analysis, early and late patients have respective life expectancies of 24 and 34 after ATC. Moreover, early and late-treated patients start treatment 4 and 9 years after infection, respectively. Therefore, life expectancy from infection to death is 38 for early presenters and 33 years for late presenters. At the individual level, 5 years of life after HIV diagnosis are thus saved thanks to early ATC. In the UK, a recent study highlighted a 11% decrease in health-related quality of life (HRQoL) of HIV-infected patients under ARV treatment compared to that of the general population [36]. Thus, if we normalize to 1 the HRQoL of uninfected individuals, each year spent while being HIV-infected is worth 0.89 QALY. As a result, 4.5 (5 × 0.89) QALYs are saved thanks to prolonged life expectancy for early presenters.

    When we consider that the life expectancy of early presenters after treatment initiation increases to 36 years or that the life expectancy of late presenters after treatment initiation decreases to 22 years, early presenters benefit from 7 extra years of life compared to late presenters and the number of QALYs saved for early treated patients compared to late treated patients increases to 6.2 (7 × 0.89).

  2. 2.

    QALYs saved for averted HIV infections.

    In our model, early treated patients initiate treatment at age 38 (given cost data of Sloan al. [17] used) and have a residual life expectancy of 34 years after treatment initiation. Among the general population in France, residual life expectancy is 45 among people aged 38 (data from the Institut National d’Etudes Démographiques). Then, 11 years of life expectancy are won thanks to the avoidance of one secondary infection. If we normalize to 1 the HRQoL of uninfected individuals, 11 QALYs are lost due to shortened life expectancy in case of HIV infection. Besides reduced life expectancy, HIV-infected individuals also suffer from reduced HRQoL compared to non-infected individuals. During their residual life expectancy of 34, early treated patient experience an 11% decrease in HRQoL compared to non-infected individuals. Thus, around 3.7 QALYs (0.11 × 34) are lost due to decreased HRQoL in case of HIV infection. In total, the loss of 14.7 (11 + 3.7) QALYs is thus saved for one averted infection.

  3. 3.

    QALYs saved in early ATC compared to late ATC.

    To obtain the total number of QALY saved thanks to early HIV treatment compared to late treatment we need to add QALYs saved for early treated patients compared to late treated patients and QALYs saved for one averted infection weighted by the number of averted infections in each scenario. Table 6 presents the results of sensitivity analyses as cost per QALY in the cases where early ATC is not dominant:

    Table 6 Cost per QALY of early ATC
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Guillon, M., Celse, M. & Geoffard, PY. Economic and public health consequences of delayed access to medical care for migrants living with HIV in France. Eur J Health Econ 19, 327–340 (2018). https://doi.org/10.1007/s10198-017-0886-6

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Keywords

  • HIV/AIDS
  • Migrant populations
  • France
  • Access to care
  • Public policy

JEL Classification

  • I180
  • I13