Protocol for HIV treatment and care for people who are not eligible for Medicare

Protocol number: QH-HSDPTL-055-1:2023
Effective date: 9 October 2023
Review date: 9 October 2026
Supersedes: N/A

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1. Purpose

This Protocol describes the mandatory steps for delivery of the HIV treatment and care for people with HIV who are not eligible for Medicare program.

2. Scope

This Protocol applies to all Hospital and Health Service (HHS) employees and all Queensland Health (QH) employees working in or for HHSs. This Protocol also applies to all organisations and individuals acting as an agent for HHSs (including Visiting Medical Officers and other partners, contractors, consultants, and volunteers).

This Program is a joint initiative of the Commonwealth, States and Territories to be delivered through jurisdictional public health infrastructure and excludes care or treatment through private health services. The Federation Funding Agreement – Health (FFA) for Access to HIV treatment for people who are not eligible for Medicare specifies eligibility for the program, roles and responsibilities of the Commonwealth, States and Territories and reporting requirements.

3. Patient eligibility

To be eligible under this Program, a person shall be:

3.1 Ineligible for Medicare and living with HIV. Once a person transitions to Medicare, they are no longer eligible to access their outpatient-delivered HIV treatment and care under this Program.

3.2 Currently residing in Australia beyond a short-term stay. Short-stay visitors and tourists are excluded under this Program. A person is eligible to access this Program only while residing in Australia.

3.3 Receiving appropriate specialist medical care as an outpatient in a public health service, such as a sexual health clinic or public hospital. In-patient care is excluded from this Program.

Medicare-ineligible patients who are visiting from interstate or who have recently moved interstate are eligible to receive HIV antiretroviral medications under the Program in Queensland if they meet the above criteria.

4. Prescriber responsibilities

4.1 Prescribers shall advise eligible patients that they can initiate or continue HIV antiretroviral medication for the duration of their stay in Australia or until they transition to another program, such as Medicare. At each six-monthly medical review, prescribers shall ask patients about their Medicare status.

4.2 Prescribers shall advise prospective patients that medications made available under the Program are to be used only for the purpose of HIV treatment of the specified individual while they are resident in Queensland.

4.3 Prescribers shall advise prospective patients that free HIV medication accessed under the Program can only be dispensed from a public hospital pharmacy.

4.4 Prospective patients shall be advised that they can only access this Program through public health facilities, such as sexual health clinics. Free HIV-related medical care and treatment under this Program is only available through public health facilities. The cost of medical care and treatment through a private s100 general practitioner is not covered under this Program and may incur a fee.

4.5 When consulting with prospective patients under this Program, prescribers shall advise of the risks associated with HIV treatment and explain that only the cost of HIV medication directly related to antiretroviral treatment will be free.

4.6 Prescribers shall advise eligible patients that any costs incurred for services involving comorbidities or any health condition arising from taking HIV medications will not be subsidised under this Program and are to be funded through alternative arrangements such as self-funded or private health insurance.

4.7 Prescribers shall ensure that patients with English as a second language understand the information provided and are able to engage in treatment under this Program with informed consent.

5. Eligible medicines

HIV antiretroviral medication dispensed under this Program shall be restricted to PBS-listed medications available through the QH List of Approved Medicines (LAM). If the patient is currently on a non-PBS listed medication, the clinician shall support them to transition to a suitable medication to access this Program.

Under this Program, HIV antiretroviral medications shall be prescribed up to the PBS authorised maximum quantity and number of repeats to reflect the recommended review cycle for people with HIV (i.e., two months of medication with five repeats to enable follow-up medical review and pathology at least every twelve months). If a patient is leaving Queensland to travel/live elsewhere in Australia or returning overseas, the clinician shall provide a bridging supply of two months medication to ensure the patient has sufficient time to engage with local healthcare services.

6. Clinical flow

Prospective patients may present at any public health service or sexual health clinic that provides HIV-related treatment and care (see Figure 1. Clinical flowchart). The clinician shall determine if the prospective patient meets the eligibility criteria listed in Patient eligibility based on self-reporting by the patient. If deemed eligible, the clinician shall advise the patient of the parameters of the Program as detailed under Prescriber responsibilities. If the patient gives informed consent to participate in the Program, the clinician shall prescribe medication as specified in Eligible medicines.

The prescriber shall annotate the script with ‘HIV Medicare Ineligible OUTP’ and the patient must then present the script at a public hospital pharmacy to receive the medication at no cost.

Figure 1. Clinical flowchart

7. Dispensing from public hospital pharmacies

Scripts that have been annotated with ‘HIV Medicare Ineligible OUTP’ by the prescriber shall be endorsed for inclusion in this Program. From 1 July 2023, pharmacists shall dispense under the classification ‘HIV Medicare Ineligible OUTP’ for all patients accessing medication as a part of this Program (see Figure 2. i.Pharmacy screenshot).

Figure 2. i.Pharmacy screenshot

8. Reporting and reimbursement

The Department of Health shall reimburse HHSs for the total cost of HIV antiretroviral medications dispensed under this Program as per the QH LAM. Reimbursement will occur biannually, with one payment made during the financial year in which the funds are expended, and the second payment made in arrears in the following financial year.

Public hospital pharmacies shall submit reports for reimbursement from their HHS via their local business processes. Pharmacies will be able to generate these reports in i.Pharmacy using the report called “dispensing by store and script classification”, which will identify the dispensing completed under this Program for the required time period. This report contains all the information required for the annual activity report including drug cost and can be used to determine the number of patients accessing this service and the range of medicines dispensed.

The Department, via QPHaSS will submit an annual activity report to the Commonwealth Department of Health. Each HHS shall email their annual activity report to BBVCDU@health.qld.gov.au by 10 July each year (see Table 1. Annual activity report template).

Table 1. Annual activity report template

1. A person is counted if at least one script has been issued and medications dispensed. We accept there might be some over counting due to movement of clients between jurisdictions. For example, a client might reside in Tasmania for 2 months of the year and have at least 1 script issued, and medications dispensed but reside in Victoria for remaining 10 months of the reporting period. The client will be counted in Victoria’s total and Tasmania’s total.

2. Figure to be provided by extracting total cost of ART medications dispensed under the Program for the financial year. Total cost is to exclude any patient co-payment received.

9. Supporting and related documents

• Federation Funding Schedule: Communicable diseases of public health concern – Access to HIV treatment for people who are not eligible for Medicare.
• Supporting Health Service Directive: HIV treatment and care for people who are not eligible for Medicare QH-HSD-055.
• Health Service Directive: Co-payment waiver for HIV medication QH-HSD-056.
• Note: HIV treatment and care for people who are not eligible for Medicare- Statewide guideline QH-GDL-972 has been rescinded and replaced by Health Service Directive QH-HSD-055.

10. Definition of terms

1. Source:  Federation Funding Agreement – Health for Access to HIV treatment for people who are not eligible for Medicare

11. Approval and implementation

Executive Director, Communicable Diseases Branch, Queensland Public Health and Scientific Services.

Effective from: 9 October 2023

12. Human rights

This Program is a public health program intended to support the national and international objective of the virtual elimination of HIV in Australia. It will enable people living with HIV to meaningfully reduce their viral load and risk of ongoing HIV transmission for the duration of their stay in Australia or until they transition to another program such as Medicare.

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