Unlocking the medicine cabinet
Unlocking the medicine cabinet
HIV Australia | Vol. 13 No. 1 | April 2015
By Kathy Petoumenos and Aaron Cogle
Your Medicare card is one of the most important cards in your wallet. Medicare is the only way people in Australia can access subsidised medications through the Pharmaceutical Benefits Scheme.
For people living with HIV (PLHIV), a Medicare card is the key to the medicine cabinet. Without this little piece of inauspicious green plastic, the cost of treating HIV, alongside many other conditions, is beyond the reach of the average person.
However, some people living in Australia are denied what most of us take for granted. Temporary residents, students, people on business and employer-sponsored work visas, for instance, are not eligible for a Medicare card.
HIV-positive people in these circumstances cannot access subsidised antiretroviral treatment (ART) through the Medicare system.
Without access to effective HIV treatment, health outcomes for these individuals are further complicated and compromised across the country,and the risk of onward transmission of HIV is increased.
It also puts increasing pressures on individual doctors and health professionals across public and private clinical settings about how to respond to these individual cases.
This is at odds with the efforts of all governments and community partners to virtually eliminate HIV transmission in Australia by 2020.
For the first time, targets have been included in the National HIV Strategy by which we can measure our success and promote accountability. However, by their nature, targets represent only narrow aspects of what are in reality complex systems.
This representative deficit has the potential to distort priorities and preference ‘measured improvements’ over ‘actual improvements’. Our challenge is to ensure that the way we implement the Strategy recognises the diversity and breadth of the entire PLHIV population in Australia, regardless of visa status.
Sexual transmission remains the primary mode of HIV infection in Australia, and the main focus for eliminating new cases of HIV.
The current National HIV Strategy rightly targets priority populations such as people living with HIV, gay men and other men who have sex with men, people from HIV prevalence countries and their partners, sex workers, people who inject drugs, and people in custodial settings for the purpose of containing and eliminating HIV in Australia.
But how can key objectives of the Strategy be attained – such as increasing treatment uptake by people living with HIV to 90% and increasing the proportion of people on treatments with undetectable viral load (UVL) – when there are still HIV-positive people living in Australia who are being denied subsidised ART for their health maintenance?
The extent of this inequity and the potential impact on Australia is not fully understood. It is not known, for instance, precisely how many HIV-positive temporary residents there are in Australia (although, according to estimates, there are around 450 HIV-positive patients who are Medicare ineligible in Australia at any one time1).
Which is why, in November 2011 – in collaboration with the Kirby Institute – the National Association of People with HIV Australia (NAPWHA) initiated ATRAS: the Australian HIV Observational Database Temporary Residents Access Study.
ATRAS was established with the objective to systematically collect information on HIV-positive temporary residents ineligible for ART via Medicare.
Many HIV-positive people who are ineligible for Medicare are unable to afford the full price of antiretrovirals (cost estimates of first-line regimen such as Atripla come in at around $12,438 per year2).
People in these circumstances are therefore required to access treatment from a variety of sources including ordering from overseas, compassionate access, or by participating in clinical trials.
This is not ideal, as participation in trials and other access schemes is limited (particularly for people from culturally and linguistically diverse backgrounds). Also, ordering drugs from overseas can be risky – supplies can be delayed and interrupted.
As well, treatment options can be limited or unavailable in generic form, leaving patients to settle for combinations which are not ideal for their individual needs, or which today we would consider harsher or less effective drug options than the best standard of care an Australian patient can expect.
In recognition of these issues, creating access to optimal treatment for this population was another important objective of ATRAS.
With this aim in mind, NAPWHA engaged all seven pharmaceutical companies with registered ART in Australia (AbbVie, MSD, Boehringer-Ingelheim, ViiV Healthcare, Gilead Sciences, Bristol Meyers Squibb and Jannsen Pharmaceuticals) to commit to providing free treatment to HIV-positive temporary residents for the duration of the study (up to four years).
Between November 2011 and July 2012, 180 participants were recruited from clinical sites participating in the Australian HIV Observational Database (AHOD commenced in 1999 and is a collaboration of 28 currently active tertiary referral centres, sexual health clinics and specialist general practices throughout most states and territories of Australia). For inclusion into ATRAS patients had to be in both clinical and financial need.
It is unclear how representative patients recruited to ATRAS are of the entire HIV temporary resident population, but the study is a predominately male cohort (74%) with an average age for both men and women of 35 years.
Almost half of the patients were from Asia/South East Asia (46%), a further 19% from sub-Saharan Africa, with the remaining from South America, the South Pacific, Europe and North America. Student and working visas proved to be the most common (35% and 34% respectively) followed by bridging visa (14%), spousal (13%) and other (13%).
The main mode of reported HIV exposure among men was through homosexual sex (66%), followed by heterosexual transmission (23%). Among women, the majority reported heterosexual contact (85%).
Less than 2% of ATRAS participants reported injecting drug use as a mode of HIV exposure.
At entry, only 63% of participants were on ART and less than half (47%) of the entire 180 had UVL. After one year of follow-up, however – where all participants were receiving effective and uninterrupted ART – 88% had UVL, with CD4 cell count increases on average of 123 cells/ml.
After two years, the proportion with a UVL had increased to 96%, with CD4 cell counts up to an average of 185 cells/ml. These immunological and virological improvements clearly highlight the importance of supplying ART to this population in need.
In April 2015, the AHOD investigators, in collaboration with the ATRAS reference group, will be releasing two years of follow-up data. The data focuses on long-term outcomes of patients, including changes in their Medicare eligibility status.
It also includes updated estimates of the current number of HIV-positive patients who are ineligible for Medicare in Australia, while living here legally as temporary residents.
By November 2015, it is estimated that 61 of the 180 ATRAS patients will still be Medicare ineligible and therefore will not have access to an ongoing supply of ART. As there will no longer be this study, or any other type of national scheme in place, alternative arrangements are required.
Without a clear policy in place – one that is not only applicable to people living with HIV, but also to others, such as those living with hepatitis C, or other chronic illnesses – the situation presents an obvious deficit in current public health policy. Such a deficit will compromise the National HIV Strategy’s overarching goal of virtually eliminating HIV by 2020.
The ATRAS report provides convincing evidence to justify providing antiretroviral treatment to all temporary residents living with HIV, based not only on patient health outcomes but also public health objectives – mathematical modelling demonstrates that providing treatment to people in such circumstances will avert a median of 80 new infections over six years.
In Australia, our response to HIV is guided by major national strategies focused on the control and elimination of communicable disease at the population level. We cannot ignore vulnerable groups at risk, and clinicians should not be left to try and manage these issues alone.
Let’s get behind a truly national response to HIV, one which addresses the needs of all Australian residents, however temporary they may be. These people cannot be left behind.
References
1 The Australian HIV Observational Database Temporary Residents Access Study – one-year follow-up.
2 Department of Health and Ageing. Pharmaceutical Benefits Schedule. (2012).Available from: www.pbs.gov.au [Accessed 8 March 2012].
3 An interim report on one-year follow-up is also available at: kirby.unsw.edu.au
Dr Kathy Petoumenos is Senior Lecturer in the Biostatistics and Databases Program at the Kirby Institute. She is the study leader for the Australian HIV Observational Database and lead statistician on the HIV and Hepatitis C clinical trials conducted through The Kirby Institute, NSW.
Aaron Cogle is Executive Director at the National Association of People with HIV Australia (NAPWHA).