QALYs, Comorbidities, and Cost-effectiveness of HIV Care in the Department of Defense vs the
Veterans Health Administration
I. ABSTRACT
The challenges faced by people with HIV (PWH) are changing. Modern HIV treatment and care have reduced
AIDS and extended lifespans. Throughout these longer lifespans, however, PWH are more likely to be diagnosed
with non-AIDS comorbidities than people without HIV. The focus of HIV research and treatment must therefore
shift away from AIDS and mortality towards non-AIDS comorbidities and the quality of this extended lifespan.
Treatment of these non-AIDS comorbidities constitutes a substantial share of long-term HIV care cost. We will
assess the cost-effectiveness of HIV care in two large single-payer systems using a novel approach focusing on
the challenges of non-AIDS comorbidities and quality of life faced by PWH today.
Health records for over 4,268 patients from the US Military HIV Natural History Study (NHS) and over 55,880
patients from the Veterans Aging Cohort Study (VACS) will be derived for the year range 2002-2022. Quality-
adjusted life-years (QALYs) will be employed to take into account patient preferences for their current health
state relative to perfect health. Health states will be identified as combinations of stages of HIV and permutations
of comorbidities. The QALY for surviving an additional year in each health state will be estimated. QALYs will be
estimated using traditionally employed and novel methods. As we demonstrate, our machine learning application
allows us to accurately measure QALYs in the absence of quality of life questionnaire data. The time of
progressing from one health state to another will be estimated. A model of HIV progression capable of
determining the patient's risk of future non-AIDS comorbidities will be developed. The cost-effectiveness of
modern era HIV care in the DoD vs the VA will be assessed using this new model.
This work will produce several solutions for researchers, clinicians, and policymakers. The study will produce
formulas enabling researchers to accurately measure QALYs in the absence of health-related quality of life
data. The study will produce a new model of HIV progression enabling clinicians to predict and prevent the
non-AIDS comorbidities the patient is at highest risk of developing. Employing access to Kaiser Permanente,
Ryan White Care, and other data with propensity score methods will allow us to estimate custom models for
those populations and generalize our findings to those populations. The study will inform DoD and VA
policymakers whether it is more cost-effective to retain PWH in the DoD or transfer them to the VA.
The proposal addresses the Office of AIDS Research priority area of “Addressing HIV-Associated
Comorbidities, Coinfections, & Complications”, the National Institute of Aging research priority area of
“Understanding the Dynamics of the Aging Process” Goal A, Goal E, and Goal F by studying comorbidity
progression paths among PWH as they age, informing of future complications and possible preventive efforts,
and determining cost-effective systems for the management of those comorbidities.
