As antiretroviral therapy has transformed HIV from a frequently fatal infection into a manageable chronic condition, a growing number of people living with the virus are reaching older age in the United States. A new modeling study projects that this demographic shift will place substantially greater demands on Medicare over the next decade, with both enrollment and spending expected to rise sharply among beneficiaries aged 65 years or older who are receiving HIV care.
The analysis, published in JAMA Network Open, estimates that nearly 122,000 older adults receiving HIV treatment could be enrolled in Medicare by the end of 2026. By the end of 2035, that number may reach approximately 193,600. The increase reflects improvements in survival associated with modern antiretroviral therapy, as well as the aging of people who acquired HIV during earlier decades of the epidemic.
Researchers from the Medical Practice Evaluation Center within the Mass General Brigham Department of Medicine developed a new simulation model called CHARMED to estimate the future size and cost of this population. CHARMED was populated using projections from the previously validated CEPAC model, Medicare claims data, and publicly available demographic and health-care information. The model simulated Medicare beneficiaries living with HIV, aged 65 years and older, who were receiving antiretroviral therapy, and estimated their treatment and medical expenditures over time.
The projections indicate that annual Medicare spending for this population could increase from $10.9 billion at the end of 2026 to $27.3 billion by the end of 2035. Across the full 10-year period, cumulative spending was estimated at $187.2 billion. Antiretroviral therapy accounted for approximately 63 percent of the projected total, highlighting the central role of drug prices in determining the financial impact of HIV care for Medicare.
The high proportion attributed to antiretroviral therapy reflects the distinctive economics of HIV treatment. Unlike many therapies prescribed for limited periods, antiretroviral medicines must be taken continuously to suppress viral replication. Effective suppression prevents progression to AIDS and sharply reduces the likelihood of transmitting HIV, but it also creates a lifelong pharmaceutical expense. Interruptions in treatment can allow the virus to rebound and may increase the risk of drug resistance, making sustained access essential for both individual and public health.
The investigators also modeled scenarios in which antiretroviral prices declined. A 60 percent reduction in treatment costs could save Medicare an estimated $70.3 billion over the next decade. Under current prescribing patterns, policies already expected to influence HIV drug prices could produce more modest but still substantial savings. The Inflation Reduction Act allows Medicare to negotiate the price of Biktarvy, the most commonly prescribed antiretroviral regimen in the United States, with negotiated prices scheduled to take effect in 2028. In addition, generic dolutegravir is expected to become available in 2031, potentially enabling a highly effective, well-tolerated, and fully generic treatment regimen.
If those developments occur as anticipated, the model estimates that Medicare could save approximately $19 billion between 2026 and 2035. The analysis suggests that lowering drug prices could reduce public spending without requiring patients to pay more or face tighter restrictions on access. Such approaches contrast with proposals that would shift costs to beneficiaries through higher premiums, narrower drug coverage, or stricter eligibility for medication-assistance programs.
The study’s implications extend beyond the price of antiretroviral drugs. Older adults living with HIV have elevated risks of conditions such as cardiovascular disease, kidney disease, metabolic disorders, cancer, and neurocognitive impairment. Long-term HIV infection and the effects of chronic inflammation may contribute to these risks, while aging itself increases the likelihood of multiple simultaneous health problems. As a result, many Medicare beneficiaries with HIV may require coordinated management of several chronic conditions and may take multiple medications, increasing the possibility of drug interactions and treatment complications.
Clinicians and health systems will therefore need to prepare for a larger population requiring comprehensive, person-centered care. The researchers emphasize that future Medicare planning should account for both the rising number of older beneficiaries with HIV and the complex medical needs associated with aging while receiving lifelong treatment. Because the findings are based on simulation rather than observed future events, the exact figures will depend on changes in HIV incidence, survival, prescribing practices, drug prices, insurance policy, and access to care. Nevertheless, the projections identify antiretroviral pricing as a major and potentially modifiable driver of future Medicare spending.
Subject of Research: People
Article Title: Ten-Year Cost Projections for Medicare Beneficiaries 65 Years or Older with HIV
Web References: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2851282; https://mpec.massgeneral.org/
References: Hyle EP, et al. “Ten-Year Cost Projections for Medicare Beneficiaries 65 Years or Older with HIV.” JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.21966
Keywords: HIV, human immunodeficiency virus, antiretroviral therapy, Medicare, older adults, aging population, health-care costs, medical economics, HIV policy, viral suppression, generic medicines, drug pricing
