AIDS therapy has evolved significantly in recent years. In addition to health education and prevention campaigns, drug treatment options in particular have led to a decline in deaths. Thanks to new drugs being approved almost every year, the quality of life of AIDS patients has also improved significantly. The significant regional differences in morbidity and prescription prevalence within Germany are noteworthy.
> The global HIV/AIDS epidemic has become one of the biggest health problems of our time within 20 years.
This is how Volume 31 of the Federal Health Report “HIV and AIDS” from June 2006, published by the Robert Koch Institute (RKI), begins. Even though the number of new HIV infections and HIV-related deaths has fallen worldwide in recent years, the 2009 figures still show the extent of this epidemic: 33.3 million people infected with HIV, 2.6 million new infections annually (equivalent to around 38 per 100,000 inhabitants) and 1.8 million deaths (cf. UNAIDS Report on the global AIDS epidemic 2010).
In contrast, the situation in Germany remains comparatively favorable – not least thanks to effective prevention measures initiated early on: The Robert Koch Institute (RKI) estimates the number of HIV-infected people living in Germany at the end of 2010 at approximately 70,000 – with 3,000 new infections (equivalent to approximately 3.8 per 100,000 inhabitants) and 550 HIV-related deaths in 2010. It is noteworthy that the proportion of new infections in Germany is 90 percent of men, while worldwide there is a nearly equal gender distribution. This is primarily due to sub-Saharan Africa, where almost 60 percent of new infections affect women (cf. RKI 2006, 2010; UNAIDS 2010).
AIDS – the disease
the most economically productive population group
As with other indications, there are large regional differences within Germany with regard to prevalence and drug prescriptions. For the majority of diseases, an increased incidence can be observed in those federal states where the average age of the population is relatively high. With AIDS, the picture is almost the opposite: HIV infections in Germany occur predominantly in the 25- to 50-year-old age group, the most economically productive population group. Over 80 percent of all AIDS cases occur in this age group (RKI 2006). It can also be seen that in federal states with a relatively high proportion of 25- to 50-year-olds (such as Hamburg and Berlin in particular, but also Hesse), the infection rate tends to be higher than average, and in those with a low proportion of 25- to 50-year-olds (such as the eastern and northern federal states), the infection rate tends to be lower.
The high proportion of young people affected is one of the main factors contributing to the health and sociopolitical relevance of AIDS. In addition, a cure remains elusive, although, according to the Federal Center for Health Education's "DON'T GIVE AIDS A CHANCE" campaign, there is a tendency to treat AIDS as a chronic disease. However, this still requires lifelong therapy, which is associated with high drug costs, treatment-related complications, and considerable medical care expenditure (cf. RKI 2006). Depending on the study, the direct costs of HIV range between €11,000 and €25,000 per year, with drug costs accounting for approximately two-thirds to three-quarters of the expenditure (cf. Enninghorst et al. 2009, Hoffmann/Rockstroh 2010, Stoll et al. 2002).
4 out of 7 HIV-infected people on antiretroviral therapy
According to the Robert Koch Institute (RKI) (2010), 40,000 of the 70,000 HIV-infected people in 2010 were receiving antiretroviral therapy. According to figures from INSIGHT Health, patients nationwide receive an average of 16.4 prescriptions for HIV medications per year. However, there are large regional differences. Prescriptions in the five new federal states, with an average of 12 per HIV patient, are significantly lower than those in the western states, with 15 per HIV patient. In contrast, in the west, packs with a shorter range – measured in defined daily doses (DDD) per pack – are prescribed on average. Therefore, the effect of lower prescription numbers per patient per year is largely offset by the increased prescription of larger packs in the new federal states. The basis for this analysis is the INSIGHT Health "Patient Tracking" database, which can be used to display the medication history of approximately 40 million anonymized outpatients (billed statutory health insurance prescriptions in community pharmacies). All medications from the ATC group J05C "Antivirals against HIV" (according to EphMRA) were used.
Increasing treatment options – decreasing mortality
The increasingly successful options for drug treatment of AIDS patients are reflected, on the one hand, in the declining number of HIV-associated deaths: Since 1995, AIDS mortality in Germany has been declining almost continuously, from approximately 2,600 deaths in 2004 to approximately 550 deaths in 2010 (RKI 2010). On the other hand, the rising prescription sales also point in the same direction: Antivirals for HIV are among the drug groups with the highest growth rates within the statutory health insurance system. Among the 30 highest-selling (four-digit) ATC groups (based on pharmacy selling price), the ATC group J05C "Antivirals for HIV" has the fourth-highest growth rate at 10.1 percent – with an average growth of 2.6 percent. The NVI database from INSIGHT Health shows outpatient statutory health insurance expenditures for antiviral drugs against HIV amounting to EUR 720 million for the past twelve months (source: NVI, INSIGHT Health, MAT May 2011, sales according to AVP without deduction of discounts).
Table 1 shows the ten J05C active ingredients (including five drug combinations) with the highest statutory health insurance expenditures (based on the pharmacy selling price - AVP) in the last twelve months. They alone account for 86 percent of total expenditures within the ATC group J05C "Antivirals against HIV." The first eight active ingredients listed here have all only entered the German market within the last ten years (source: NVI, INSIGHT Health).
City-states with the highest HIV prevalence
Not surprisingly, there is a high correlation between HIV prevalence and HIV drug therapy: Regions with relatively high numbers of HIV-infected individuals are also characterized by a high number of billed statutory health insurance prescriptions for antiviral drugs against HIV. For example, the city-states of Hamburg, Berlin, and Bremen lead not only in prescriptions per insured person due to the surrounding area effect, but also in the number of HIV cases reported and extrapolated to the Robert Koch Institute (RKI) (see Figure 1).
The urban-rural effect appears to play a prominent role here: According to figures from the Robert Koch Institute (RKI) in 2009, cities with over 250,000 inhabitants had an average incidence 200 percent higher than the national average – especially Cologne, Frankfurt/Main, Berlin, Hamburg and Munich, the five most populous cities in Germany.
It is striking that the new federal states have significantly fewer AIDS cases than the old ones. According to figures from the Robert Koch Institute (RKI), fewer than three percent of AIDS patients receiving antiretroviral therapy live in the new federal states, which together account for almost 16 percent of Germany's population. It is also striking that Hesse is the only large federal state with an above-average HIV prevalence (RKI 2010).
outlook
From a health services research perspective, HIV offers a diverse range of topics. Prevention and education will continue to be of paramount importance in the future, despite individual studies suggesting that AIDS medications not only inhibit the replication of HIV viruses after infection but can also reduce the risk of infection with the pathogen (see, for example, Spiegel Online, July 14, 2011).
by: Dr. Andre Kleinfeld
Christian Bensing*
