A total of 45,465, 47,482, 51,460, 49,869, 51,592, and 54,530 PWH and 136,395, 142,446, 154,380, 149,607, 154,776, and 163,590 matched non-HIV persons were identified for the respective annual cohorts for each year from 2018 through 2023, respectively (Table 1). The mean age for the matched PWH and non-HIV cohorts ranged from 47.4 to 48.9 years, and over 50% of persons were aged 40–59 years. A vast majority of persons in the matched pairs of PWH and non-HIV cohorts were men (~ 81%). Most persons were commercially insured, and more than half had a preferred provider organization (PPO) health plan coverage.

After matching, each annual PWH cohort had a higher mean CCI score than the matched non-HIV cohorts. With regards to relevant comorbidities, the annual PWH cohorts had a higher prevalence of alcohol/drug abuse, anxiety, asthma, chronic kidney disease, chronic pain/fibromyalgia, depression, dyslipidemia, hepatitis, hypertension, disease of liver/gall bladder/pancreas, and smoking/history of smoking compared to the matched non-HIV cohorts in most annual cohorts. A large proportion (> 60%) in the PWH and matched non-HIV cohorts had a CCI score (excluding HIV/acquired immunodeficiency syndrome [AIDS]) of 0 across all years, with a mean score ranging from 0.69 (2018) to 0.81 (2022) among PWH and 0.45 (2018) to 0.54 (2022) among non-HIV persons (Table 2). The most common opportunistic infection was recurrent pneumonia, occurring at a much higher rate of 2.1–3.3% in PWH compared to 0.9–1.9% in non-HIV persons between 2018 and 2023.

In the PWH cohort, the mean undiscounted LTC per person was $2,895,020 (median $2,893,312; 95% CI 2,847,453–2,947,867). On the other hand, the mean undiscounted LTC for the matched non-HIV cohort was $482,522 (median $482,271; 95% CI 453,114–513,44) per person. The mean undiscounted incremental cost difference was $2,412,498 (median $2,412,167; 95% CI 2,354,674–2,474,024). After applying the 3% discount rate, the PWH cohort had a mean discounted LTC of $1,299,210 (median $1,298,786; 95% CI 1,279,397–1,321,458), and among the matched non-HIV cohort, it was $181,481 (median $181,236; 95% CI 169,392–194,036), with a mean incremental cost difference of $1,117,729 (median $1,118,207; 95% CI 1,093,606–1,143,350) (Table 3).

In the sensitivity analysis, results were robust and similar to the base analysis among 13,673 PWH and 73,402 non-HIV controls with continuous enrollment from 2018 to 2023. The mean discounted LTC for these PWH was $1,286,055 (median $1,285,889; 95% CI 1,269,095–1,304,954), with the mean discounted LTC for the non-HIV controls of $173,162 (median $172,906; 95% CI 156,209–192,380). The mean discounted incremental cost of HIV was $1,112,892 (median $1,112,929; 95% CI 1,085,940–1,138,969) (Table 4).

The average annual total healthcare costs from 2018 to 2023 were higher among older age groups, increasing from a mean cost of $38,308 per person among those aged 18–24 years to $62,359 per person among those aged 70–74 years in the PWH cohort. The ratio of mean average total healthcare costs in PWH and matched non-HIV controls decreased with increasing age, with mean average total healthcare costs in PWH accounting for ~ 11 times that for non-HIV controls among those aged 18–24 years and only ~ 4 times that for non-HIV controls among persons aged 70–74 years (Fig. 1). Table 5 provides details regarding the annual healthcare costs stratified by age groups.

Average all-cause annual healthcare costs among PWH and matched non-HIV cohorts by age group. HIV human immunodeficiency virus, PWH persons with HIV, USD United States dollars

Overall, there was a net increase in the mean total annual all-cause healthcare costs per person among PWH from $50,048 in 2018 to $53,945 in 2023. While the mean cost of telehealth visits did not account for a large proportion of the total costs, there was an increase in the mean telehealth visit costs from 2020 to 2023. Table 6 provides details regarding the annual healthcare costs stratified by type of service. For matched non-HIV controls, there was a corresponding increase in mean total annual healthcare costs from $7446 in 2018 to $9376 in 2023. The mean total all-cause outpatient services costs accounted for over half of the total mean annual all-cause costs for these patients.

The mean annual all-cause healthcare costs were about six times higher during 2019, 2021, 2022, and 2023 and seven times higher during 2018 and 2020 among PWH compared to non-HIV controls (Fig. 2). The mean total outpatient pharmacy costs accounted for about 80% of the total healthcare costs among PWH compared with 25–30% among non-HIV controls. PWH had > 70% higher non-pharmacy-related all-cause costs across all years compared with non-HIV persons. For each year, the mean inpatient costs for PWH were two times those for matched non-HIV cohorts, ranging from $3274 (2019) to $3644 (2023) per patient in the PWH cohort and $1614 (2018) to $1739 (2023) for the non-HIV cohort.

Mean total annual all-cause healthcare costs among PWH and matched non-HIV cohorts. HIV human immunodeficiency virus, PWH persons with HIV, USD United States dollars

During each year of evaluation, the PWH cohort had a significantly higher proportion of persons with one or more visits for inpatient, outpatient, ER, and telehealth services as well as one or more outpatient pharmacy prescriptions. The proportion of PWH with one or more inpatient stays each year was twice that of those in the matched non-HIV controls and significantly higher for each pairwise comparison of annual matched PWH and non-HIV cohorts. While the utilization of outpatient services was high among both PWH and non-HIV cohorts, the proportion of persons with any outpatient service utilization was significantly higher in the former for each annual pairwise comparison. Each annual PWH cohort had twice the proportion of persons with one or more ER visits and about thrice the proportion with one or more telehealth visits compared with the matched non-HIV controls. A vast majority of all annual cohorts had one or more prescriptions during each year; however, this proportion was significantly higher among PWH compared with the matched non-HIV controls. Telehealth use increased among persons after 2020, with peak utilization during 2020. Table 7 provides details regarding the annual HCRU by type of service.