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Medicare Ineligible PLHIV
Lessons from the ATRAS Study
Mobility Conference
Tony Maynard
May 30th, 2016
‘Medicare Ineligible’
• In Australia legally
• No Access to PBS subsidised ARVs
• Existing provisions for this group vary ...
A AHOD
T Temporary
R Residents
A Access
S Study
Aims
• To describe the population of HIV+ temporary
residents
• To describe the HIV disease status of this group
• To mode...
The Sample
• Recruited 180 people from 21 sites
• 74% male, 26% female
• 46% SE Asia, 19% SS Africa, 11% S America, 11% S
...
HIV transmission
53% detectable VL at baseline
After 12months (12% detectable)
• 77.4% reduction in detectable viral load ...
Transition to Medicare Eligibility
• At July 2013 – 39 patients had left ATRAS
• At July 2014 – 79 patients had left ATRAS...
Modelling
• Estimated 450 - 480 Medicare Ineligible people in
Australia at any time.
• Total Treatment cost over 5 years e...
Why do we Care?
• It’s not just about Human Rights, it’s also about
Public Health
• We care a lot in Australia about Publi...
It doesn’t make sense
• Comparisons with other diseases
• National Strategy Commitments
• Enormous amounts of wasted time ...
The time before ATRAS….
• Series of Band-Aid solutions… Band-Aids on
Band-Aids
• Compassionate access schemes
• ‘Under the...
Since ATRAS
• We know where they are and how many
• The time it takes to transition to Medicare
eligibility is short: medi...
Jurisdictional Arrangements
Jurisdiction Arrangements for managing Medicare Ineligible HIV +ve patients
NSW Patients are a...
TAS
As yet there have not been cases requiring ARV treatment for Medicare
ineligible HIV people but are considering option...
Gaps in the response
• Medicare Ineligible people are not recognised
as a priority population by the National Strategy
• ‘...
Possible Solutions
• Agreement of the Federal Government to
reimburse State and Territory Governments for
Medicare Ineligi...
Possible Solutions
• Other, more complicated arrangements have
been suggested, but politically they would be
unpopular in ...
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Medicare Ineligible PLHIV: Lessons from the ATRAS Study

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This presentation on findings from a trial of providing HIV medication to people not eligible for Medicare was given by Tony Maynard from the National Association of People With HIV Australia (NAPWHA) at AFAO'S HIV and Mobility Forum on 30 May 2016.

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Medicare Ineligible PLHIV: Lessons from the ATRAS Study

  1. 1. Medicare Ineligible PLHIV Lessons from the ATRAS Study Mobility Conference Tony Maynard May 30th, 2016
  2. 2. ‘Medicare Ineligible’ • In Australia legally • No Access to PBS subsidised ARVs • Existing provisions for this group vary significantly across jurisdictions • Only 60% of HIV+ people who need treatment are getting it • 31% are on sub-optimal combinations
  3. 3. A AHOD T Temporary R Residents A Access S Study
  4. 4. Aims • To describe the population of HIV+ temporary residents • To describe the HIV disease status of this group • To model HIV transmission rates • To provide compassionate ARV access for up to 4 years (ended in Nov 2015)
  5. 5. The Sample • Recruited 180 people from 21 sites • 74% male, 26% female • 46% SE Asia, 19% SS Africa, 11% S America, 11% S Pacific, 9% Europe, 6% N America • 31% Student visa, 33% Working visa, 14% Bridging visa, 13% Spousal Visa, 13% other visa • Route of transmission; 49% MSM, 39% Heterosexual contact, 12% Other
  6. 6. HIV transmission 53% detectable VL at baseline After 12months (12% detectable) • 77.4% reduction in detectable viral load and who have a substantial risk of onward transmission After 24 months (6% detectable) • 93% reduction in the risk of onwards transmission
  7. 7. Transition to Medicare Eligibility • At July 2013 – 39 patients had left ATRAS • At July 2014 – 79 patients had left ATRAS • At November 2015 – 90 patients had left ATRAS Thus leaving 80 ATRAS patients and a further 450 Medicare Ineligible PLHIV without an alternative scheme to access their ARV.
  8. 8. Modelling • Estimated 450 - 480 Medicare Ineligible people in Australia at any time. • Total Treatment cost over 5 years estimated at $29,642,230. or $320,000 per infection averted. • Potential to avert a median 81 new infections over 5 years. • Equivalent to a cost saving of $69,412,098 over their lifetime Broadly cost-neutral
  9. 9. Why do we Care? • It’s not just about Human Rights, it’s also about Public Health • We care a lot in Australia about Public Health; $ 2.3 billion dollars annually • So why is one particular group of people being excluded from this herculean effort to secure public health?
  10. 10. It doesn’t make sense • Comparisons with other diseases • National Strategy Commitments • Enormous amounts of wasted time trying to access medications impact negatively on the Health Service and Community Organisations • Financial considerations are misleading
  11. 11. The time before ATRAS…. • Series of Band-Aid solutions… Band-Aids on Band-Aids • Compassionate access schemes • ‘Under the radar’ arrangements through clinics • Trials • Benevolent pharmaceutical companies
  12. 12. Since ATRAS • We know where they are and how many • The time it takes to transition to Medicare eligibility is short: median 4 years • We have made the issue visible • We have achieved some sort of jurisdictional standardisation.
  13. 13. Jurisdictional Arrangements Jurisdiction Arrangements for managing Medicare Ineligible HIV +ve patients NSW Patients are advised if the cost of starting or staying on HIV medications is getting in the way of their being on treatment to please talk to their doctor/prescriber for advice, support and referral services. ASHM also targets the s100 prescribers and advises where a patient is experiencing financial barriers to treatment access, clinicians should telephone their local HIV/Sexual Health Service to discuss options for support with HIV medications. The rationale for directing people and/or their clinicians to the sexual health clinics is that some of the Clinic Directors have the discretion to approve the purchase of treatments for patients in need. The sexual health clinic will also be able to link people to other options such as charities (like the Bobby Goldsmith Foundation). The HIV Support Program provides a safety mechanism. The program follows up each new diagnosis and in particular enables/challenges to treatment uptake.
  14. 14. TAS As yet there have not been cases requiring ARV treatment for Medicare ineligible HIV people but are considering options currently. SA All treatment and medication costs for Medicare ineligible HIV+ve people are met by SA Health WA An Operational Directive is in place whereby funds must be recouped from health insurance companies. If this is not possible, then approval must be provided by the director of an area health service for treatment costs in excessive of $10,000. http://www.health.wa.gov.au/CircularsNew/circular.cfm?Circ_ID=12895 QLD Different arrangements across services and regions; a decentralised health system that results in a local decision. Ranges from full support to applying for welfare grants. The process is unwieldy and time consuming for staff. ACT 17 HIV+ve patients who are ineligible for Medicare, of which 16 are receiving ART through ‘compassionate access’. NT ARVs are obtained from companies under “compassionate access” arrangements on an individual basis. Less than a handful involved per annum. VIC Victoria does not have a formal system-wide approach; Medicare ineligible patients are referred to the Melbourne Sexual Health Centre, where HIV drugs are provided at no cost to the patient.
  15. 15. Gaps in the response • Medicare Ineligible people are not recognised as a priority population by the National Strategy • ‘Measured progress’ is not ‘actual progress’ • Politically unpopular subject and there is no permanent solution on the horizon • Federation ‘dance’
  16. 16. Possible Solutions • Agreement of the Federal Government to reimburse State and Territory Governments for Medicare Ineligible PLHIV on the basis of “Public Health Protection” • Currently, Reciprocal Health Care Agreements exist between Australia and New Zealand, the United Kingdom, the Republic of Ireland, Sweden, the Netherlands, Finland, Italy, Belgium, Malta, Slovenia and Norway. Hospitals and Sexual Health Clinics have special Medicare numbers to use in these cases and get reimbursed.
  17. 17. Possible Solutions • Other, more complicated arrangements have been suggested, but politically they would be unpopular in that allowing Medicare for all Visa holders would ‘open the flood gates’ to all conditions. • Using the “Public Health Protection” rationale would be politically palatable and the case for it strengthened by using the economic modelling which shows it would be cost-saving in terms of new HIV infections averted

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