Profile of South African HIV/AIDS patients in a medical scheme environment

Abstract

This study aimed to determine the demographic, clinical and medicine claims profile of people living with HIV/AIDS (PLWHA) in the private healthcare sector of South Africa using medicine claims data from 2016 obtained from a pharmaceutical benefit management (PBM) company. The demographic profile includes patients' demography, such as age, gender, geographic location, type of antiretroviral treatment (ART) prescriber and provider. The clinical profile includes the prevalence of co-existing chronic disease list (CDL) conditions and antiretroviral (ARV) prescribing patterns. The medicine claims profile focuses on the active ingredients of ARV medication prescribed, the type of medicine benefit claimed, the number of ARV prescriptions and medicine items claimed.The study followed a cross-sectional study design using retrospective medicine claims data from 1 January 2016 to 31 December 2016 obtained from a PBM company. The study population included all PLWHA (N = 16 763) on the database with an International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) diagnosis-code for HIV (diagnoses codes B20-B24) in conjunction with a claim for ARV medication.The demographic and medicine claims profile were addressed in the first manuscript. The study population consisted of 8 871 female PLWHA (52.3%) and 7 992 male PLWHA (47.7%) with an average age of 42.3 years (SD 11.5; 95% Cl 41.9−42.3). Female PLWHA were younger [40.21 years (SD 10.9; 95% Cl 39.9-40.4)] than male PLWHA [44.3 years (SD 11.9; 95% Cl 44.0-44.5)] (p < 0.0001; Cohen's d = 0.3). The highest prevalence rate (78 per 1 000) was in the age group ≥ 45 and < 65 years. The highest prevalence of PLWHA resided in the North West province (36.8 per 1 000 beneficiaries), followed by the Free State (29.7 per 1 000 medical scheme beneficiaries). PLWHA received an average of 10.9 (SD 7.6; 95% Cl 10.8-11.0) ART regimens (N = 175 317)during the study period, containing an average of 1.1 (SD 0.4; 95% Cl 1.1-1.1) ARV items (N = 190 903). Of these items, 127 248 (66.4%) were fixed-dose combination products (FDC), 145 804 (76.1%) were generic products, and most (90.4%; n = 173 131) were reimbursed through the HIV-benefits of the patient's medical scheme. FDC products containing efavirenz, emtricitabine, and tenofovir were claimed the most (n = 71 251; 37.2%), followed by products (vi)containing the single-active ingredient efavirenz (n = 19 359; 10.1%) and FDC products containing lopinavir and ritonavir (n = 16 577; 8.7%). The prescribers were mostly general medical practitioners (n = 152 308; 79.5%), paediatricians (n = 4 449; 2.3%) and other specialists (n = 34 784;18.2%). Community pharmacies provided most of the ARV medication (n = 190 903; 99.7%)followed by only 0.3% (n = 638) dispensing medical practitioners.Manuscript two addressed the clinical profile of HIV/AIDS beneficiaries. The results showed that the median (IQR) number of CDL conditions per PLWHA was 0(0), indicating that the majority of PLWHA (n = 14 426; 86.1%) did not present with any CDL condition. Among those diagnosed with one or more CDL conditions (n = 2 337; 13.9%), the majority had one other CDL condition (n = 1 848; 79.1%), followed by 17.4% (n = 407) who had two, and 3.5% (n = 82) who had three. A statistically significant association between gender and type of CDL conditions (p < 0.0001; Cramer's V = 0.3) was found, with hypertension more prevalent in female PLWHA compared to male PLWHA (n = 629, 56.8% vs n = 658, 53.5%). The same trend was experienced with asthma (n = 61, 5.5% vs 45, 3.6%) and epilepsy (n = 39, 3.5% vs 31, 2.5%). More men than women were diagnosed with hyperlipidaemia (n = 112, 9.1% vs 52, 4.7%) and with the combination of hyperlipidaemia and hypertension (n = 146, 11.9% vs 59, 5.3%). Based on analysis by age group, hypertension (n = 1 287; 55.1%), hyperlipidaemia (n = 164; 7.0%) or a combination of these (n = 205; 8.8%) were more prevalent among PLWHA ≥ 18 years (p < 0.0001; Cramér's V = 0.3). PLWHA <18 years presented with co-existing asthma and epilepsy. The majority of regimens contained one ARV item, primarily the FDC consisting of efavirenz, emtricitabine and tenofovir. In conclusion, prescribing generic and FDC products through pharmacies and reimbursing these products from the HIV-benefit category of PLWHA's medical aid schemes are standard practices to decrease the possible riskprofile of an increased number of PLWHA in the medical scheme environment. Prescribers followed the first- and second-line regimens suggested as per the standard treatment guidelines of the South African Department of Health and of the World Health Organization. Only 13.9% of PLWHA presented with co-existing CDL conditions that can influence their treatment patterns. (vi)LIST OF ABBREVIATIONS AND ACRONYMS 3TC Lamivudin