The cost of hospital care for HIV patients in Colombia: an insurer’s perspective

Abstract

The aim of this study was to evaluate the cost derived from the hospitalization of people living with HIV (PLHIV) in Colombia between 2011 and 2015. This is an analysis of the direct cost of PLHIV hospitalization from the perspective of an insurer of the Colombian General Social Security System. The costs were calculated in Colombian pesos and corrected for inflation on the basis of the 2017 Consumer Price Index of the Bank of the Republic of Colombia. It was converted to US dollars at the Market Representative Exchange Rate of the same year. We analyzed 1129 hospitalizations in 612 PLHIV, of which 12% started with a diagnosis of HIV during the same hospitalization, with the majority in the AIDS stage (63%). The median overall cost of hospitalizations was US$1509 (25th and 75th percentiles: US$711–US$3254), being even higher in patients with AIDS and as the CD4 T lymphocyte count decreased. The cost derived from the medical care of PLHIV increases as the clinical control of the disease worsens, and it is a key indicator of the impact of the strategies implemented for the timely identification of the infection and subsequent management of the disease.

Keywords

HIV infections acquired immunodeficiency syndrome AIDS-related opportunistic infections costs and cost analysis

Introduction

It has been estimated that, since the year 2000, the incidence of the human immunodeficiency virus (HIV) infection has decreased by 35% worldwide, with a 42% decrease in AIDS-related deaths since 2004. This is mainly due to improvements in the access to antiretroviral therapy (ART). However, the global coverage of people receiving this type of treatment only accounted for 40% in 2015, and it is estimated that at least 22 million patients with the infection did not receive ART.¹ In Colombia, the prevalence of HIV infection was 0.5% in the population between 15 and 49 years of age in 2017; that is around 150,500 people living with HIV (PLHIV).² Of these, only 71,076 people had been identified by the General System of Social Security in Health (SGSSS, for its Spanish acronym), with 91.5% use of ART and a virological success of 63%.³

The Colombian SGSSS is a public service that provides health protection to all the inhabitants of the national territory based on the principles of efficiency, universality, and solidarity, among other services. Individuals and their families who contribute to the SGSSS directly or together with their employer belong to the contributory regime. When such association is made through the payment of a subsidized contribution with fiscal or solidarity resources, membership is to the subsidized regime.⁴

The regulatory framework of the Colombian SGSSS guarantees the care of patients with HIV infection. Law 972 of 2005 stands out within this framework, which declared the State’s comprehensive attention to the fight against HIV to be of national interest and priority, making explicit the duty of the SGSSS to supply medicines, reagents, and devices for the diagnosis and treatment of the infection.⁵

Despite the regulatory and health-related efforts made in Colombia, the 90–90–90 goals for the year 2020 are still far from being fulfilled, which is reflected in the HIV-associated morbidity and mortality, especially due to preventable causes, which remains high.^3,6 The HIV mortality rate in the country has remained between 5.0 and 5.7 per 100,000 inhabitants in the last ten years. Although there has been a decrease in mortality in recent years (4.1 cases per 100,000 inhabitants in 2016 versus 6.2 cases per 100,000 inhabitants in 2004) in cities such as Bogotá, progress is still not satisfactory.⁷

In general, studies on the costs associated with HIV in Colombia are scarce. Furthermore, the existing studies have been conducted mainly from the perspective of the third-party payer or the patient and his or her family. In this way, and despite recognizing the economic impact of care for people living with HIV (PLHIV) in the hospital setting, few studies analyze the costs of this care.^8–11

The secondary costs involved in the hospital management of HIV show a high variability between countries and according to the clinical stage of the disease. Thus, according to a systematic review of studies conducted in five European countries, the average direct medical costs ranged from €7241 (SD: €6249) in the United Kingdom to €985 (SD: €997) in Spain.¹² Additionally, the cost of hospital care increased as the CD4 T lymphocyte count decreased, from USD 260 (> 500 cells/mm³) to USD 1325 (<50 cells/mm³) in studies conducted in the USA, and this cost in patients with AIDS was up to twice than the one observed in patients without AIDS.^13,14

In the case of Colombia, an analysis of the economic impact of caring for a population with HIV from the point of view of a domestic insurer showed an average hospital cost of USD 1616 per patient, among those who had a CD4 cell count <200 cells/mm³ or AIDS.¹⁵ After analyzing the costs of care for 1026 PLHIV for an insurer in Colombia, Acosta and Suescún-Giraldo¹⁶ found that 11% of the costs were related to hospital care.

Although the burden of disease and the costs of care are key indicators for the management of AIDS, studies available on the economic impact of this disease in Colombia are still limited. Therefore, this study seeks to evaluate the following: (1) the direct medical costs derived from the hospital care of patients with HIV affiliated with a health insurer, between 2011 and 2015, and (2) the excess of direct medical costs derived from hospitalizations of PLHIV with AIDS compared with those without AIDS during the same period.

Methods

This is an analysis of the direct medical costs associated with the care of PLHIV who were admitted in the hospital network of an insurer belonging to the Colombian contributory scheme. The institutions corresponded to highly complex acute care centers located in six regional areas around the country with availability of services for the management of this condition, such as infectious diseases and ICU, which served a population of around 2500 patients with diagnosis of HIV infection in an insured population of 1.4 million people at the time of the study.

Hospitalizations were identified based on the PLHIV registry of the insurer’s comprehensive care program, the registry of its members’ hospital discharges, and the corresponding uses of the billed services, between January 2011 and December 2015.

Clinical and administrative information was collected from these sources, such as the main diagnosis of discharge, CD4 T lymphocyte count closest to the date of hospitalization, AIDS stage, and direct medical costs. The latter was defined as the use of resources derived from interventions made during the patient’s hospital stay (e.g. medical fees, clinical and pathology laboratory, diagnostic imaging, medications, among others). The costs were expressed in Colombian pesos and corrected for inflation on the basis of the 2017 Consumer Price Index of the Bank of the Republic of Colombia. Subsequently, the costs were converted to US dollars at the 2017 Market Representative Foreign Exchange Rate.

The main diagnosis upon admission was regrouped following a system-based diagnostic classification previously proposed by Ribeiro et al.¹⁷ The identification of AIDS-defining conditions was based on the classification made by the Centers for Disease Control and Prevention of 1993.¹⁸

We conducted descriptive analyses of variables such as age, gender, region of hospitalization, main diagnosis, AIDS stage, CD4 T lymphocyte count, hospital stay, hospital services, and death. For categorical variables we report absolute numbers and percentages and for continuous variables we report measures of central tendency and dispersion, depending on their statistical normality. Likewise, this study indirectly evaluated the opportunity for diagnosis of HIV in the insured population, based on the calculation of the proportion of new cases in patients hospitalized for this disease.

Comparisons of costs between groups were made, according to whether they were admissions of patients in the AIDS category or not. Likewise, these groups were used to establish differences in the median cost of the hospital services used. In both cases, the 95% confidence intervals of the median cost were calculated. The data were analyzed with the Stata 13.0 statistical program.

The protocol of this study was approved by the Research Ethics Committee of the Fundación Universitaria Sanitas.

Results

There were 1129 hospitalizations in 612 patients with HIV infection between January 2011 and December 2015, of which 519 (46%) occurred in patients with AIDS. The average age was 44.8 years (SD: 12.2 years) and the predominant gender of patients admitted was male, with 1030 cases (91.2%). The median hospital stay was six days (25th and 75th percentiles: 3–11), with 4.8% of deaths within the period (n = 54). Admissions occurred more frequently in the cities of Bogotá, Medellín, and Cali, which grouped 88% (n = 989) of these. On the other hand, in 12% of the PLHIV who required hospitalization, the diagnosis of the disease occurred during that period, and 63% started with the AIDS stage.

The first cause of hospitalization corresponded to the nondefining bacterial diseases of AIDS, followed by the definitive diagnosis of AIDS (Table 1). Among these, opportunistic tuberculosis infections stood out because of their frequency, especially those of pulmonary origin. In 15.5% of these patients, cerebral toxoplasmosis (11.6%) and cryptococcosis also occurred in the brain (6.6%), while neoplasias accounted for 3% of these hospitalizations. Of the 746 (66%) admissions from which information was obtained about the CD4 T cell count, 56.4% showed values lower than 200 cells/mm³ (median value of 176 cells/mm³, 25th and 75th percentiles: 65–329 cells/mm³) Table 1.

Table 1.

Frequency of the diagnostic groups, AIDS stage, and CD4 cell count in the 1129 hospitalizations.

Diagnosis	n (%)
Bacterial, non-AIDS	258 (22.9)
AIDS-defining condition	181 (16)
Signs and syndromes^a	136 (12.1)
Digestive	83 (7.4)
Cardiovascular	64 (5.7)
Parasite, non-AIDS	58 (5.1)
Psychiatric	44 (3.9)
Other^b	38 (3.4)
Viral, non-AIDS	38 (3.4)
Neurological	36 (3.2)
Endocrine	26 (2.3)
Hematological	25 (2.2)
Kidney	25 (2.2)
Gynecological/Obstetric	19 (1.7)
Rheumatological	19 (1.7)
Respiratory	18 (1.6)
Trauma	16 (1.4)
Mycotic, non-AIDS	10 (0.9)
Cancer non-AIDS,	8 (0.7)
Poisoning	7 (0.6)
Hepatic viral	7 (0.6)
Ophthalmological	6 (0.5)
Dermatological	4 (0.4)
Hepatic nonviral	3 (0.3)
AIDS, n (%)
Yes	519 (54)
No	610 (46)
CD4 T lymphocyte count, n (%)^c
>500 cells/mm³	155 (20.8)
200–499 cells/mm³	266 (35.7)
50–199 cells/mm³	270 (36.2)
<50 cells/mm³	55 (7.4)

^aSigns and syndromes: A68, A68.9, B23.0, B23.1, H81.3, I84.2, L04.0, R00.0, R00.1, R07.1, R07.2, R07.3, R07.4, R10.4, R16.1, R17, R19.0, R50, R50.8, R50.9, R51, R52.1, R55, R56, R56.8, R57.0, R57.1, R57.9, R58, R75, Z03.0.

^bOther: Includes CIE-10 A08.5, A09, B22, B23.8, B24, C73, C77, C79.5, D13.4, D14.4, D17.0, D33.2, D38.1, D42, D44.3, H81.4, H95, J06, J16.8, J18.8, J21.8, K10.9, K40.3, K43, K44, M75.8, N40, Z21.

^cn = 746 (hospitalizations).

Regarding the consumption of health services, the median of the overall cost of hospitalizations was US$1509 (25th and 75th percentiles: US$711–US$3254), where the most frequently used services were in this order: clinical and pathological laboratory (36.7%), medications (27.5%), procedures (10.5%), fees (10.2%), diagnostic images (7.0%), hospital services (5.4%), and nonpharmacological therapies (2.6%). The median annual costs are shown in Table 2. The median cost of hospitalizations had an increasing gradient with a decrease in the CD4 T lymphocyte count. Thus, for a cell count >500 cells/mm³, the median cost of admission was US$958 (25th and 75th percentiles: US$362–US$2679); for 200–499 cells/mm³, it was of US$1216 (25th and 75th percentiles: US$690–US$2494), for 50–199 cells/mm³, it was of US$1692 (25th and 75th percentiles: US$1066–US$4727), and of $2261 (25th and 75th percentiles: US$1131–US$5015) for a CD4 T lymphocyte count <50 cells/mm³.

Table 2.

Annual costs of hospitalizations (USD).

Year	Median	95% confidence interval
2011	1487	1156; 1839
2012	1682	1514; 1988
2013	1622	1365; 2118
2014	1478	1218; 1742
2015	1935	1514; 2323

On the other hand, the admission of patients in the AIDS category was US$912 (median cost) more expensive than those in patients without AIDS. The median cost of hospitalizations and for each of the hospital services is shown in Table 3 according to the AIDS stage.

Table 3.

Cost of hospitalizations and service consumption according to AIDS stage.

	AIDS	Non-AIDS
Cost (USD), median (95% CI)	2067 (1806; 2318)	1155 (1051; 1279)
Stay (days), median (95% CI)	8 (7; 8)	5 (5; 5)
Services (USD), median (95% CI)
Clinical/pathological laboratory	474 (424; 538)	311 (278; 339)
Medicines	375 (257; 474)	237 (187; 273)
Procedures	336 (295; 386)	223 (191; 242)
Hospital services	177 (142; 249)	119 (100; 161)
Diagnostic Imaging	115 (100; 134)	85 (72; 98)
Cross-consultations/fees	90 (77; 103)	50 (44; 55)
Nonpharmacological therapies	19 (17; 26)	13 (12; 17)

Among the main AIDS-defining opportunistic infections, hospitalization for tuberculosis represented a median cost of US$2272 (25th and 75th percentiles: US$1161–US$4095), cerebral cryptococcosis US$8538 (25th and 75th percentiles: US$4178–US$11,762), and cerebral toxoplasmosis $3755 (25th and 75th percentiles: $2250–$6395). On the other hand, neoplasias represented a median cost of US$3653 (25th and 75th percentiles: US$1389–US$6822).

Discussion

This study constitutes the first analysis focused on the direct medical cost secondary to the hospitalization of a PLHIV, affiliated to an insurer of the contributory regime of the Colombian SGSSS during a five-year period.

The costs associated with PLHIV care have been described in the world literature, but only a few of them include information from Latin America and, in particular, from Colombia.^{9,10,12,19,20} Studies conducted within the country have focused on the cost of outpatient care from the perspective of the health system as well as the patient and his or her family, especially regarding ART. However, with the decrease in costs of antiretroviral drugs after the emergence of generic drugs, the cost of hospital care for PLHIV has become more relevant.¹⁵ The diagnosis of the disease is late in a high percentage of patients in Colombia and Latin America.²¹ According to the most recent report by the High Cost Account (CAC, for its Spanish acronym), about half of PLHIV were at an advanced stage (AIDS, stage 3), and therefore had a higher risk of complications at the time of diagnosis.³

The median direct medical cost of HIV hospitalization shows significant differences in function of the country, ranging from US$2056 in Portugal to US$6322 in the USA.^22,23 This study showed that the median annual cost showed discrete variations in the period analyzed, without statistical differences between the years studied. However, the trend of the cost of hospitalization for HIV according to the CD4 T cell count is consistent between studies, and independent of the country of origin, observing a growing gradient in cost as the cell count decreases.

The ratio between the costs of hospital admissions for counts less than 50 cells/mm³ with respect to counts above 500 cells/mm³ can be up to 16:1 in France.²⁴ In our study, this ratio was 2.3:1, closer to that observed by other authors^14,25; although in contrast to that of a previous study on the hospital cost in Bogotá (Colombia) where, inexplicably, a higher cost was seen in patients with a higher CD4 T cell count.¹⁰ In the study conducted by Guarín et al.,²⁰ it was found that the costs of inpatient and outpatient care in Colombia ranged from US$3050 to US$6359 in PLHIV with CD4 cell count below 50 cells/mm³ versus US$1749 to US$2054 in patients with CD4 cell count greater than 500 cells/mm³.

The evidence described above supports the importance of strengthening not only the early detection of the disease, but also the continuity of the care of PLHIV in the health system, in order to achieve a virological success defined by an undetectable viral load. This translates into a better immune response (higher CD4 cell count) and, therefore, a lower risk of complications including hospitalizations.²⁶

Regarding the length of hospitalization, the median stay was similar to that seen in other studies, with an average cost sometimes lower than that of our study, especially in developing countries.^27,28 However, a longer stay has been previously described in six hospitals in Medellín, also in the Colombian context.⁶ This could be explained by socioeconomic and immunological differences between the populations studied, even in the same country. On the other hand, analyses carried out in developed countries have also shown hospital stays quite similar to those of this study, although with a higher average direct medical cost.^29,30

The higher cost of hospitalization for PLHIV in the AIDS stage can be explained by several factors, and the most important ones include longer hospital stays, incidence of serious complications (e.g. cryptococcosis and toxoplasmosis), greater need for medical procedures and laboratory tests, as well as a higher proportion of patients with a CD4 T lymphocyte count <200 cells/mm³. These factors have been associated with a higher direct hospital cost in this and other studies.^31,32 Levy et al.³³ have estimated that an increase of 100 CD4 T lymphocytes per mm³ can lead to an average decrease of US$562 (US$329) per hospitalization.

In Colombia, the epidemiological information of PLHIV is administered by the CAC, an institution independent of the health system but regulated by it. In its most recent report, the CAC reported that the proportion of patients with HIV and CD4 T lymphocyte count <200 cells/mm³ was of 36.2% in the contributory regime of the SGSSS.³ Although the proportion of patients with this cell count was higher in this study, a previous study on patients hospitalized with HIV in Colombia found that > 50% had CD4 T lymphocyte count <200 cells/mm³.¹⁵

The cost of treatment for patients with HIV according to the stage of the disease also shows a constant pattern in the literature, with a higher cost in subjects with AIDS compared to those without AIDS. However, differences in the cost of care between these groups of patients can vary significantly depending on the country analyzed. Thus, in a review based on European studies, the average difference in the annual cost between patients with and without AIDS ranged from €2485 in Spain to €27,976 in the United Kingdom.¹² In this study, the difference observed in the cost of care was only US$912 in median in favor of the group of patients with AIDS. This finding is more similar to that of another Latin American study previously published.³⁴

Despite the decrease in mortality associated with the HIV infection and the improvement in access to ART, the impact of opportunistic infections in patients with HIV is still important in this and other studies from low- and middle-income regions of the world.²⁶ We found that hospitalizations due to meningeal cryptococcosis, cerebral toxoplasmosis, tuberculosis, and neoplasias had a high cost, not only because of the high value of each event but also because of its frequency. If a projection of the cost of hospital care is made for the number of cases of each of these pathologies disclosed by the CAC,³ the cost of care exceeds 24 million dollars per year. It should be noted that early diagnosis and early initiation of ART become the most cost-effective measures, given that it is the best way to lower the incidence of these diseases and avoid their complications, especially as, in the case of cryptococcosis, this is linked to a high mortality in Latin America.^35–37 Likewise, promoting frequent HIV testing among the most affected populations (e.g. men who have sex with men), is another key fact in the fight against HIV.

Among the limitations of this work we can find that the analysis only considered the direct hospital medical cost derived from the care of patients with HIV, excluding indirect costs secondary to the reduction of labor productivity due to the disease. This is equally important from the perspective of SGSSS insurers in Colombia, since they are also responsible for the coverage of disabilities caused by a general illness.

Furthermore, our study did not analyze variables such as the degree of adherence to ART or the presence of viral resistance, which have been described as determinants of disease control in hospitalized patients.⁶ These characteristics would have been useful to understand if the subjects at a worse stage of AIDS or lower CD4 T cell count necessarily corresponded to therapy failures that could be intervened within the program for HIV patients in primary care. Understanding the dynamics of adherence to HIV care programs is essential to avoid clinical complications due to socioeconomic conditions, including unemployment and alcohol abuse, among others.³⁸

Among the strengths of this study we should note that, in addition to the quantification of the cost of hospitalizations for HIV for an insurer of the Colombian SGSSS, an indirect indicator of the opportunity in the diagnosis of HIV is proposed, calculated as the division between the number of new cases with the disease during a hospitalization out of the total number of HIV patients hospitalized in the same period. This indicator would be interpreted as the proportion of new diagnoses of the disease in patients with HIV who required hospitalization. The relevance of this new measurement must be assessed in the context of the 90–90–90 target (90% diagnosed, 90% in ART, and 90% with undetectable viral load) for the approach to HIV in the world.³⁹

Likewise, programs aimed at caring for HIV patients at the national level should reinforce the follow-up strategy in those cases where there is hospitalization due to poor control of the disease, in order to study the possible causes of this condition. Regarding the implications for research, the results of this study highlight the need to investigate the causes of HIV hospitalizations in the Colombian context, beyond the main diagnosis that originates it.

Conclusions

In conclusion, the results of this study demonstrate the high cost of hospitalization of PLHIV and its relationship with the immune status. These findings can guide intervention strategies from the program for patients with HIV, aimed at lowering the cost derived from the complications of the disease. Similarly, the proposed indicator of the proportion of new cases with HIV in the hospitalized population can serve to monitor the screening strategies and timely diagnosis implemented, as well as their impact on the cost of care for the disease.

Footnotes

Acknowledgments

We are grateful to Planning and Control Department of EPS Sanitas for its support regarding data supply required for the present study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

UNAIDS 2015. AIDS by the numbers 2015, http://www.unaids.org/en/resources/documents/2015/AIDS_by_the_numbers_2015 (accessed 13 October 2018).

UNAIDS 2017. Colombia, http://www.unaids.org/en/regionscountries/countries/colombia (accessed 13 October 2018).

Cuenta de Alto Costo 2017. Publicaciones, https://cuentadealtocosto.org/site/index.php/publicaciones#vih (accessed 13 October 2018).

Colombia. Ministerio de Salud y Protección Social. Dirección de Financiamiento Sectorial. Fuentes de financiación y usos de los recursos del sistema General de seguridad social en salud –SGSSS, https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VP/FS/fuentes-y-usos-de-recursos-del-sgsss.pdf (accessed 13 October 2018).

Colombia. Congreso de la República, Colombia. Ministerio de Hacienda y Crédito Público; Colombia. Ministerio de la Protección Social; Colombia. Ministerio de Hacienda y Crédito Público; RID-TAGCLOUD. Ley 0972 de, https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/Ley_0972_de_2005.pdf (2005, 15 July 2005).

Álvarez Barreneche

Restrepo Castro

Hidrón Botero

et al . Hospitalization causes and outcomes in HIV patients in the late antiretroviral era in Colombia. AIDS Res Ther 2017; 14: 60.

Secretaría Distrital de Salud de Bogotá Inicio Salud Sexual y Reproductiva. 2017, http://www.saludcapital.gov.co/Paginas2/Inicio.aspx (accessed 13 October 2018)

Lopera-Medina

Martínez-Escalante

Ray-Einarson

Access of people with HIV to the Colombian healthcare system and its related costs from an individual and family perspective, Bogotá, 20I0. Rev Gerenc Políticas Salud 2011; 10: 81–96.

Lopera

Einarson

Iván Bula

Out-of-pocket expenditures and coping strategies for people living with HIV: Bogotá, Colombia, 2009. AIDS Care 2011; 23: 1602–1608.

10.

Kuhlmann

Keaei

Conde

et al . A cost-of-illness study of patients with HIV/AIDS in Bogotá, Colombia. Value Health Reg Issues 2017; 14: 103–107.

11.

Durán J del

Duarte

SJS

Quintero L del

et al . Estudio de los costos en que incurren las entidades promotoras de salud en Colombia por la prevención y el tratamiento del VIH/sida. Cienc Tecnol Para Salud Vis Ocul 2014; 12: 51–63.

12.

Trapero-Bertran

Oliva-Moreno

Economic impact of HIV/AIDS: a systematic review in five European countries. Health Econ Rev 2014; 4: 15.

13.

Gebo

Chaisson

Folkemer

et al . Costs of HIV medical care in the era of highly active antiretroviral therapy. AIDS 1999; 13: 963–969.

14.

HIV Research Network. Hospital and outpatient health services utilization among HIV-infected patients in care in 1999. J Acquir Immune Defic Syndr 2002; 30: 21–26.

15.

Colombia. Ministerio de Salud y Protección Social. Guía de práctica clínica (GPC) basada en la evidencia científica para la atención de la infección por VIH/Sida en adolescentes (con 13 años o más de edad) y adultos, http://gpc.minsalud.gov.co/gpc_sites/Repositorio/Otros_conv/GPC_VIH_adolescentes/gpc_vih_adolescentes.aspx (accessed 13 October 2018).

16.

Acosta-Restrepo

Suescún-Giraldo

Evaluación del costo de un programa de VIH/sida de asegurador en Colombia. CES, http://bdigital.ces.edu.co:8080/jspui/handle/10946/471 (accessed 7 October 2018).

17.

Ribeiro

Luz

Campos

et al . Incidence and determinants of severe morbidity among HIV-infected patients from Rio de Janeiro, Brazil, 2000–2010. Antivir Ther 2014; 19: 387–397.

18.

CDC. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep 1992; 41: 1–19.

19.

Beck

Harling

Gerbase

et al . The cost of treatment and care for people living with HIV infection: implications of published studies, 1999–2008. Curr Opin HIV AIDS 2010; 5: 215–224.

20.

Guarín Téllez

Moreno Calderón

Muñoz-Galindo

et al . Cost-effectiveness of a care program for HIV/AIDS patients affiliated with a health insurer in Colombia, comparing three health care providers nationwide. Value Health Reg Issues 2016; 11: 1–8.

21.

Beltrán

Zitko

Wolff

et al . [Evolution of epidemiological and clinical characteristics of adults patients belonging to the national program at start of antiretroviral therapy in the Chilean AIDS Cohort, 2001–2015]. Rev Chilena Infectol 2016; 33: 2–10. [Mismatch]

22.

Perelman

Alves

Miranda

et al . Direct treatment costs of HIV/AIDS in Portugal. Rev Saude Publica 2013; 47: 865–872.

23.

Roberts

Kampe

Hammerman

et al . The cost of care for patients with HIV from the provider economic perspective. AIDS Patient Care STDS 2006; 20: 876–886.

24.

Sloan

Champenois

Choisy

et al . Newer drugs and earlier treatment: impact on lifetime cost of care for HIV-infected adults. AIDS 2012; 26: 45–56.

25.

Gebo

Fleishman

Conviser

et al . Contemporary costs of HIV healthcare in the HAART era. AIDS 2010; 24: 2705–2715.

26.

Wolff

Giganti

Cortes

et al . A decade of HAART in Latin America: long term outcomes among the first wave of HIV patients to receive combination therapy. PLoS One 2017; 12: e0179769.

27.

Long

Fox

Sauls

et al . The high cost of HIV-positive inpatient care at an urban hospital in Johannesburg, South Africa. PLoS One 2016; 11: e0148546.

28.

Tshamba

a Kaut

Kyalubile

et al . Cost of hospital care for HIV/AIDS infected patients in three general reference hospitals in Lubumbashi, DR Congo: prospective cohort study. Pan Afr Med J 2013; 15: 76.

29.

Catumbela

Freitas

Lopes

et al . HIV disease burden, cost, and length of stay in Portuguese hospitals from 2000 to 2010: a cross-sectional study. BMC Health Serv Res 2015; 15: 144.

30.

Hellinger

FJ.

Hospital use by persons with HIV in the 21st century: a 5-state study. Med Care 2016; 54: 639–644.

31.

Barnett

Chow

Joyce

et al . Determinants of the cost of health services used by veterans with HIV. Med Care 2011; 49: 848–856.

32.

Beck

Miners

Tolley

The cost of HIV treatment and care. A global review. Pharmacoeconomics 2001; 19: 13–39.

33.

Levy

Johnston

Annemans

et al . The impact of disease stage on direct medical costs of HIV management: a review of the international literature. Pharmacoeconomics 2010; 28: 35–47.

34.

Bautista-Arredondo

Dmytraczenko

Kombe

et al . Costing of scaling up HIV/AIDS treatment in Mexico. Salud Publica Mex 2008; 50: S437–S444.

35.

Crabtree-Ramírez

Caro-Vega

Shepherd

et al . Time to HAART initiation after diagnosis and treatment of opportunistic infections in patients with AIDS in Latin America. PLoS One 2016; 11: e0153921.

36.

Low

Gavriilidis

Larke

et al . Incidence of opportunistic infections and the impact of antiretroviral therapy among HIV-infected adults in low- and middle-income countries: a systematic review and meta-analysis. Clin Infect Dis 2016; 62: 1595–1603.

37.

Vidal

Penalva de Oliveira

Dauar

et al . Strategies to reduce mortality and morbidity due to AIDS-related cryptococcal meningitis in Latin America. Braz J Infect Dis 2013; 17: 353–362.

38.

Támara-Ramírez

Álvarez

Rodríguez

Loss of follow-up and associated factors in patients enrolled in the HIV/AIDS program of the Hospital Universitario San Ignacio, Colombia, 2012–2013. Biomedica 2016; 36: 265–275.

39.

UNAIDS 2016. Get on the Fast-Track – The life-cycle approach to HIV | UNAIDS, http://www.unaids.org/en/resources/documents/2016/get-on-the-fast-track (accessed 13 October 2018).