Original research article

International Journal of STD & AIDS

2019, Vol. 30(7) 696–702
The cost of hospital care for HIV patients ! The Author(s) 2019
Article reuse guidelines:
in Colombia: an insurer’s perspective sagepub.com/journals-permissions
DOI: 10.1177/0956462419835636
journals.sagepub.com/home/std

Carlos A Alvarez-Moreno 1
, Abel E González-Vélez2 ,
Claudia C Colmenares-Mej
ıa3, Karen L Rinc
on-Ram
ırez4,
Javier A Garc
ıa-Buitrago , Paola A Rengifo-Bobadilla4 and
1

Mario A Isaza-Ruget2

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
Date received: 24 October 2018; accepted: 13 February 2019

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 treat-
ment only accounted for 40% in 2015, and it is esti-
mated that at least 22 million patients with the
infection did not receive ART.1 In Colombia, the prev-
alence 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 pro-
vides 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 associ-
ation is made through the payment of a subsidized
contribution with fiscal or solidarity resources, mem-
bership is to the subsidized regime.4
1
Cl
ınica Universitaria Colombia, Cl
ınica Colsanitas S.A.,
Bogotá, Colombia
2
Keralty, Bogotá, Colombia
3
Center for Research in Health Sciences, Fundaci
on Universitaria Sanitas,
Bogotá, Colombia
4
EPS Sanitas S.A., Bogotá, Colombia
Corresponding author:
Abel E González-Vélez, Keralty, Calle 100 No. 11b-67, Bogotá, D.C.,
Colombia.
Email: abegonzalez@colsanitas.com


Alvarez-Moreno et al.
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 prior-
ity, 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, espe-
cially 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 mor-
tality 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 stud-
ies 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 eco-
nomic 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 dis-
ease. Thus, according to a systematic review of studies
conducted in five European countries, the average
direct medical costs ranged from e7241 (SD: e6249)
in the United Kingdom to e985 (SD: e997) 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
Suesc
un-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
697
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 hos-
pital network of an insurer belonging to the Colombian
contributory scheme. The institutions corresponded to
highly complex acute care centers located in six region-
al areas around the country with availability of services
for the management of this condition, such as infec-
tious 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 dis-
charges, and the corresponding uses of the billed serv-
ices, between January 2011 and December 2015.
Clinical and administrative information was collect-
ed 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 pre-
viously proposed by Ribeiro et al.17 The identification
of AIDS-defining conditions was based on the classifi-
cation 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 diagno-
sis, AIDS stage, CD4 T lymphocyte count, hospital
stay, hospital services, and death. For categorical var-
iables 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
698 International Journal of STD & AIDS 30(7)

population, based on the calculation of the proportion Table 1. Frequency of the diagnostic groups, AIDS stage, and
of new cases in patients hospitalized for this disease. CD4 cell count in the 1129 hospitalizations.
Comparisons of costs between groups were made, Diagnosis n (%)
according to whether they were admissions of patients
in the AIDS category or not. Likewise, these groups Bacterial, non-AIDS 258 (22.9)
were used to establish differences in the median cost of AIDS-defining condition 181 (16)
the hospital services used. In both cases, the 95% con- Signs and syndromesa 136 (12.1)
Digestive 83 (7.4)
fidence intervals of the median cost were calculated.
Cardiovascular 64 (5.7)
The data were analyzed with the Stata 13.0 statisti-
Parasite, non-AIDS 58 (5.1)
cal program. Psychiatric 44 (3.9)
The protocol of this study was approved by the Otherb 38 (3.4)
Research Ethics Committee of the Fundaci
on Viral, non-AIDS 38 (3.4)
Universitaria Sanitas. Neurological 36 (3.2)
Endocrine 26 (2.3)
Hematological 25 (2.2)
Results Kidney 25 (2.2)
There were 1129 hospitalizations in 612 patients with Gynecological/Obstetric 19 (1.7)
HIV infection between January 2011 and December Rheumatological 19 (1.7)
2015, of which 519 (46%) occurred in patients with Respiratory 18 (1.6)
Trauma 16 (1.4)
AIDS. The average age was 44.8 years (SD: 12.2
Mycotic, non-AIDS 10 (0.9)
years) and the predominant gender of patients admit-
Cancer non-AIDS, 8 (0.7)
ted was male, with 1030 cases (91.2%). The median Poisoning 7 (0.6)
hospital stay was six days (25th and 75th percentiles: Hepatic viral 7 (0.6)
3–11), with 4.8% of deaths within the period (n ¼ 54). Ophthalmological 6 (0.5)
Admissions occurred more frequently in the cities of Dermatological 4 (0.4)
Bogotá, Medell
ın, and Cali, which grouped 88% Hepatic nonviral 3 (0.3)
(n ¼ 989) of these. On the other hand, in 12% of the AIDS, n (%)
PLHIV who required hospitalization, the diagnosis of Yes 519 (54)
the disease occurred during that period, and 63% No 610 (46)
started with the AIDS stage. CD4 T lymphocyte count, n (%)c
>500 cells/mm3 155 (20.8)
The first cause of hospitalization corresponded to
200–499 cells/mm3 266 (35.7)
the nondefining bacterial diseases of AIDS, followed 50–199 cells/mm3 270 (36.2)
by the definitive diagnosis of AIDS (Table 1). Among <50 cells/mm3 55 (7.4)
these, opportunistic tuberculosis infections stood out
a
because of their frequency, especially those of pulmo- Signs 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,
nary origin. In 15.5% of these patients, cerebral toxo-
R50.8, R50.9, R51, R52.1, R55, R56, R56.8, R57.0, R57.1, R57.9, R58,
plasmosis (11.6%) and cryptococcosis also occurred in R75, Z03.0.
the brain (6.6%), while neoplasias accounted for 3% of b
Other: Includes CIE-10 A08.5, A09, B22, B23.8, B24, C73, C77, C79.5,
these hospitalizations. Of the 746 (66%) admissions D13.4, D14.4, D17.0, D33.2, D38.1, D42, D44.3, H81.4, H95, J06, J16.8,
from which information was obtained about the CD4 J18.8, J21.8, K10.9, K40.3, K43, K44, M75.8, N40, Z21.
c
n ¼ 746 (hospitalizations).
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 2. Annual costs of hospitalizations (USD).
Regarding the consumption of health services, the Year Median 95% confidence interval
median of the overall cost of hospitalizations was
US$1509 (25th and 75th percentiles: US$711–US$3254), 2011 1487 1156; 1839
where the most frequently used services were in this 2012 1682 1514; 1988
2013 1622 1365; 2118
order: clinical and pathological laboratory (36.7%),
2014 1478 1218; 1742
medications (27.5%), procedures (10.5%), fees (10.2%), 2015 1935 1514; 2323
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 cost of admission was US$958 (25th and 75th percen-
of hospitalizations had an increasing gradient with tiles: US$362–US$2679); for 200–499 cells/mm3, it was
a decrease in the CD4 T lymphocyte count. of US$1216 (25th and 75th percentiles: US$690–
Thus, for a cell count >500 cells/mm3, the median US$2494), for 50–199 cells/mm3, it was of US$1692


Alvarez-Moreno et al.
Table 3. Cost of hospitalizations and service consumption according to AIDS stage.
Cost (USD), median (95% CI)
Stay (days), median (95% CI)
Services (USD), median (95% CI)
Clinical/pathological laboratory
Medicines
Procedures
Hospital services
Diagnostic Imaging
Cross-consultations/fees
Nonpharmacological therapies
(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.
On the other hand, the admission of patients in the
AIDS category was US$912 (median cost) more expen-
sive 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.
Among the main AIDS-defining opportunistic infec-
tions, 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 percen-
tiles: $2250–$6395). On the other hand, neoplasias rep-
resented 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 con-
ducted 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 acro-
nym), about half of PLHIV were at an advanced stage
699
AIDS Non-AIDS
2067 (1806; 2318) 1155 (1051; 1279)
8 (7; 8) 5 (5; 5)
474 (424; 538) 311 (278; 339)
375 (257; 474) 237 (187; 273)
336 (295; 386) 223 (191; 242)
177 (142; 249) 119 (100; 161)
115 (100; 134) 85 (72; 98)
90 (77; 103) 50 (44; 55)
19 (17; 26) 13 (12; 17)
(AIDS, stage 3), and therefore had a higher risk of
complications at the time of diagnosis.3
The median direct medical cost of HIV hospitaliza-
tion 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 authors14,25; 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 Guar
ın 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 impor-
tance 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 viro-
logical success defined by an undetectable viral load.
This translates into a better immune response (higher
CD4 cell count) and, therefore, a lower risk of compli-
cations 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 hospi-
tals in Medell
ın, also in the Colombian context.6
700
This could be explained by socioeconomic and immu-
nological 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, inci-
dence 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 lympho-
cyte count <200 cells/mm3 was of 36.2% in the con-
tributory 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 accord-
ing 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 e2485 in Spain to e27,976 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 sim-
ilar 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 crypto-
coccosis, cerebral toxoplasmosis, tuberculosis, and neo-
plasias 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
International Journal of STD & AIDS 30(7)
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 complica-
tions, 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 cov-
erage 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 deter-
minants of disease control in hospitalized patients.6
These characteristics would have been useful to under-
stand 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 essen-
tial to avoid clinical complications due to socioeco-
nomic 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 oppor-
tunity 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 pro-
portion 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 hospi-
talization 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.


Alvarez-Moreno et al.
Conclusions
In conclusion, the results of this study demonstrate the
high cost of hospitalization of PLHIV and its relation-
ship 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 pro-
posed indicator of the proportion of new cases with
HIV in the hospitalized population can serve to mon-
itor the screening strategies and timely diagnosis imple-
mented, as well as their impact on the cost of care for
the disease.
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.
ORCID iD
Abel E González-Vélez http://orcid.org/0000-0001-
6459-8919
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