Ten-Year Cost Projections for Medicare Beneficiaries 65 Years or Older With HIV

1. Emily P. Hyle, MD, MSc1,2,3; Luke Ang, BS1; Grace Luu, BA1
2. et al

1. Author Affiliations 
2. Article Information

JAMA Netw Open

Published Online: July 7, 2026

2026;9;(7):e2621966. doi:10.1001/jamanetworkopen.2026.21966

Key Points

Question  Over the next decade, what will be the costs associated with Medicare beneficiaries aged 65 years or older with HIV, including antiretroviral therapy (ART) costs?

Findings  In this economic evaluation using microsimulation modeling with 111 600 Medicare beneficiaries with HIV at model start, the number of beneficiaries aged 65 years or older receiving care for HIV is projected to increase from 121 890 at the end of 2026 to 193 560 at the end of 2035. Given current ART costs and health care–associated inflation, 10-year cumulative costs to Medicare would be $187.2 billion; however, reducing ART costs by 60% could lower Medicare spending by 38%.

Meaning  These findings suggest that nearly 200 000 people aged 65 years or older with HIV would be enrolled in Medicare by 2035; reducing ART costs while maintaining access to high-quality ART is critical.

With contemporary antiretroviral therapy (ART), people with HIV (PWH) in the US are aging due to improved survival among individuals linked to care and ART initiation soon after infection.1-3 Most PWH aged 65 years or older are enrolled in Medicare, qualifying with eligible conditions before age 65 years or through age eligibility at 65 years.4-6 This population is expected to grow substantially over the next decade, and medical complexity and care costs will rise with a high burden incurred by Medicare.7-9 However, the extent of that increase remains uncertain.

Moreover, ART costs continue to rise, and their overall contribution to Medicare costs for PWH are unknown. The Inflation Reduction Act (IRA), passed in 2022, offers new opportunities for the federal government to negotiate the price of drugs for Medicare.10 One of the selected drugs for price negotiation, bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy), is an ART regimen estimated to have cost Medicare more than $3.1 billion in 2023 alone and is the most frequently prescribed ART regimen in the US.11-13 Additionally, a highly effective, well-tolerated, generic ART regimen is expected to become available in 2031 (eg, dolutegravir and tenofovir disoproxil/lamivudine).14,15 Reducing ART costs among PWH in Medicare offers an opportunity to decrease costs of the growing population of PWH in Medicare without compromising clinical care. Our goal was to project the number of PWH 65 years or older on Medicare in the US over the next decade and the costs of their care, using 2 complementary microsimulation models.

In this economic evaluation, we first used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, a previously validated microsimulation model of HIV disease, to project the total number and age distributions of PWH in the US from 2026 to 2035, assuming current trends in the care continuum.16-19 We then developed the Cardiovascular, HIV, Aging, Hearing Loss, Mental Health, and Dementia (CHARMED) model, a novel multimorbidity simulation model of clinical and economic outcomes among PWH. We populated the newly developed CHARMED model with CEPAC projections of the age distribution and population size of PWH aged 65 years or older at the beginning of January 2026, as well as the monthly number of PWH turning 65 years from 2026 to 2035. Using the CHARMED model, we limited the simulated population to Medicare beneficiaries aged 65 years or older receiving care for HIV and then projected the annual population size and age distribution from 2026 to 2035, as well as annual, undiscounted costs incurred over 10 years by Medicare, accounting for inflation. We performed sensitivity analyses to examine uncertainty in parameter estimates and their effects on outcomes.

This analysis was approved by Mass General Brigham’s Human Research Committee, who waived the need for informed consent, as no individual-level data were used in the models. We used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines.20

We populated the CEPAC model for US adults aged 20 years or older with Centers for Disease Control and Prevention (CDC) surveillance data from 2014 (eTable 1 in Supplement 1). We then calibrated projected transmissions to CDC HIV incidence data from 2014 to 2022, reflecting the impact of rising preexposure prophylaxis use from 2014 to 2022 and validated model outcomes (eMethods and eTable 2 in Supplement 1).19 ,21,22 We validated CEPAC model projections to CDC surveillance data for 4 distinct outcomes (eTables 7 and 8 in Supplement 1).22

The CHARMED model is a novel multimorbidity microsimulation model that simulates clinical care for people aged 65 years or older taking ART and projects clinical and cost outcomes. At model start, simulated individuals are in care and taking ART per US guidelines; we assumed that people remain in care throughout their lifetime.23 Each individual draws from prespecified distributions for clinical characteristics, as well as likelihood of attaining virologic suppression with ART and experiencing virologic nonsuppression due to resistance or intermittent adherence. People are at risk for death monthly due to HIV-related mortality (eg, cryptococcal meningitis) and non–HIV-related mortality (eg, stroke), which is age- and sex-stratified and reflects the increased risks of noncommunicable diseases among PWH.24 We validated the CHARMED model projections of PWH aged 65 years or older living with diagnosed HIV and receiving care to 2021 to 2023 CDC data (eTable 9 in Supplement 1).22

To project the number of PWH aged 65 years or older taking ART enrolled in traditional Medicare or Medicare Advantage from 2026 to 2035, we constructed 3 cohorts in the CHARMED model: Medicare beneficiaries aged 65 years or older receiving care in 2026, PWH turning age 65 years each month after 2026 who are Medicare-enrolled and in care, and Medicare-enrolled people aged 65 years or older initiating ART after a new HIV diagnosis (eMethods in Supplement 1). We weighted these 3 cohorts to create the population of all Medicare beneficiaries with HIV aged 65 years or older receiving care and then projected their clinical outcomes and costs (eMethods in Supplement 1).

Using enrollment data from the Centers for Medicare & Medicaid Services (CMS) and CDC data, we estimated that 74% of PWH aged 65 years or older receiving care are enrolled in traditional Medicare with Part D or Medicare Advantage coverage (eMethods in Supplement 1).5,25 The remaining 26% are unable to acquire and maintain Medicare coverage, including Part D (eg, due to permanent residency requirements, prohibitive costs, or work credit requirements) or do not apply for Medicare (eg, they have employer-sponsored insurance).26-29

Using the CEPAC-projected number of PWH aged 65 years or older at the end of 2025, we estimated 111 600 Medicare beneficiaries with HIV at CHARMED model start in January 2026; the mean (SD) age was 70.9 (5.0) years and 77% of beneficiaries were male. We estimated the number of beneficiaries in 4 age categories: 65 to 69 years (n = 57 370), 70 to 74 years (n = 32 940), 75 to 79 years (n = 14 670) and 80 years and older (n = 6610) (Table 1).

The mean (SD) CD4 count was 576 (267) cells/mm3 for PWH in care and 363 (203) cells/mm3 for people newly diagnosed with HIV initiating care.30 -32 Throughout the simulation, Medicare beneficiaries with HIV enter the cohort monthly: Medicare-enrolled PWH turning 65 years (321-1354 people per month) and newly diagnosed PWH entering care and enrolled in Medicare aged 65 years or older (37 people per month) (Table 1).33 We incorporated virologic suppression, HIV-related mortality, and non–HIV-related mortality (eMethods in Supplement 1).24,34-38

To estimate annual age- and sex-stratified clinical costs for beneficiaries enrolled in traditional Medicare, we used 2023 traditional Medicare claims data for PWH enrolled in Part D and who had any ART use in the calendar year. We separately estimated costs in each year of life and in the 12 months before death because costs are usually substantially higher in the year before death (eTables 3 and 4 in Supplement 1). The amount paid by Medicare for people enrolled in Medicare Advantage is uncertain but is estimated to be 22% more than their traditional Medicare counterparts.39 We therefore weighted clinical care costs by the proportion of beneficiaries with an HIV diagnosis or any ART prescriptions filled who were enrolled in traditional Medicare (38.5%) or Medicare Advantage (61.5%) based on January 2022 enrollment (Table 1).5 To account for increasing health care costs over time, we applied a 6% annual increase to ART costs based on historical trends,11 ,40 and increased clinical care costs as per CMS projections of the Personal Health Care index (2026-2035) (eTable 5 in Supplement 1).41,42

We performed 1-way sensitivity analyses to evaluate parameter uncertainty on outcomes, varying parameters individually within plausible ranges while holding other parameters at baseline values (eTable 6 in Supplement 1). We then simultaneously varied parameters in multiway sensitivity analyses, including combinations of the most influential parameters from 1-way sensitivity analyses. We examined the effects of parameter variation on 2 outcomes: number of Medicare beneficiaries taking ART aged 65 years or older and costs incurred to Medicare by this population. Projected costs will be sensitive to both the total number of projected Medicare beneficiaries on ART and cost inputs.

We investigated the potential impact on ART costs from Medicare price negotiations under the IRA and generic dolutegravir, which would likely affect 68% of Medicare beneficiaries 65 years or older with HIV (eMethods in Supplement 1). We also performed scenario analyses with costs not adjusted for Medicare Advantage or inflation. All analyses were performed from September 2023 to May 2026. Microsimulation modeling was performed using C++98 standard (ISO/IEC JTC 1) and GCC 4.8.5-44 (Red Hat). R, version 4.4.3 (R Foundation) and RStudio software, version 2024.12.1 + 563 (Posit PBC) were used to summarize microsimulation outcomes and generate figures.

Compared with CDC data from 2017 to 2022, the CEPAC model projected similar numbers of people living with diagnosed HIV, percentage of people receiving care with virologic suppression, and deaths (eTable 7 and 8 in Supplement 1).22 Compared with 2021 to 2023 CDC data, the CHARMED model projected similar numbers of PWH aged 65 years or older living with diagnosed HIV and receiving care (eTable 9 in Supplement 1).22

We projected that Medicare beneficiaries with HIV aged 65 years or older taking ART would increase from 121 890 to 193 560 between 2026 and 2035, with increases in every age category over the decade: 60 390 to 70 490 (65-69 years); 36 340 to 62 820 (70-74 years); 17 200 to 38 290 (75-79 years); and 7970 to 21 960 (80 years and older) (Figure 1A). The magnitude of increases in Medicare beneficiaries with HIV in each age category rises at older ages; by 2035, the number of Medicare beneficiaries with HIV aged 65 to 69 years taking ART would increase 1.2-fold, compared with 1.7-fold (70-74 years), 2.2-fold (75-79 years), and 2.8-fold (80 years or older) (Table 2). Deaths among Medicare beneficiaries with HIV aged 65 years or older would also increase, from 5500 in 2026 to 9640 in 2035 (eTable 10 in Supplement 1). Medicare spending for Medicare beneficiaries with HIV would increase from $10.9 billion in 2026 to $27.3 billion in 2035, including ART costs ($6.4 billion in 2026 to $17.8 billion in 2035), direct HIV-related care ($0.4 billion in 2026 to $0.9 billion in 2035), and other non–HIV-related costs ($4.1 billion in 2026 to $8.7 billion in 2035) (Figure 1B). Adjusted for inflation and Medicare Advantage, projected costs for Medicare beneficiaries with HIV 65 years or older would be $187.2 billion over the next 10 years, with 63% of cumulative costs due to ART.

The most influential parameter in projecting the number of Medicare beneficiaries with HIV aged 65 years or older in care by 2035 is the percentage enrolled in Medicare (Figure 2A). If 68% are in Medicare, there would be 177 860 Medicare beneficiaries with HIV aged 65 years or older in care in 2035; however, this number would increase to 245 340 if 94% are enrolled in Medicare. Non–HIV-related mortality rates are also influential; if those rates among PWH are no higher than among people without HIV, there would be 215 340 Medicare beneficiaries with HIV aged 65 years or older in 2035, compared with 174 750 if non–HIV-related relative mortality rates are 2.2 times higher than people without HIV. Other parameters would have a smaller impact (from 160 580 to 273 540 beneficiaries in 2035).

When projecting Medicare costs, the most influential parameters are ART costs and percentage of PWH aged 65 years or older taking ART enrolled in Medicare (Figure 2B). Reducing per-person ART costs by 40% would reduce Medicare spending to 10-year cumulative costs of $116.9 billion; a 20% increase in ART costs would result in 10-year cumulative costs increasing to $210.6 billion (eFigure 1 in Supplement 1). Costs to Medicare would range from $25.1 billion to $34.7 billion in 2035, if 68% to 94% of PWH aged 65 years or older taking ART are enrolled in Medicare. Varying the numbers of Medicare beneficiaries turning 65 years each year, non–HIV-related mortality, and the number of Medicare beneficiaries aged 65 years or older receiving care at model start have less cost impact.

In multiway sensitivity analyses, we varied population parameters and non–HIV-related mortality to project the number of Medicare beneficiaries aged 65 years or older taking ART in 2035 (eFigure 2 in Supplement 1). Varying the percentage of PWH aged 65 years or older enrolled in Medicare and non–HIV-related mortality has the most substantial impact, resulting in 160 580 to 273 540 projected Medicare beneficiaries with HIV in 2035. When varying cost and population parameters across plausible ranges, we found that 10-year costs to Medicare would range from $103.3 billion to $267.5 billion (eFigure 3 in Supplement 1).

Medicare price negotiations for Biktarvy via minimum IRA-proposed discounts would save Medicare a cumulative $12.7 billion relative to the base case (Figure 3A); generic dolutegravir in 2031 is projected to save $5.2 billion to $15.5 billion (Figure 3B; eTable 11 in Supplement 1). The impact of both policies together is expected to be $19.4 billion (range, $17.9 billion-$28.2 billion) over the next 10 years (Figure 3C and D).

We also examined adjusting for increased costs paid for Medicare Advantage patients or health care–associated inflation (eTable 12 in Supplement 1). Without the 22% cost increase for Medicare Advantage, 10-year cumulative costs would be $22.2 billion less than the base case. Cumulative costs over 10 years would be $58.0 billion lower if health care–associated inflation was not included in the model. Additional details are available in the eResults in Supplement 1.

In this economic evaluation using microsimulation modeling, we projected that the number of Medicare beneficiaries with HIV aged 65 or older in the US and engaged in care over the next decade would increase 1.6-fold, reaching nearly 200 000 by 2035. The financial burden on Medicare would increase substantially, with annual costs for Medicare beneficiaries aged 65 years or older increasing from $10.9 billion in 2026 to $27.3 billion in 2035. Cumulative costs over 10 years would be $187.2 billion, with 63% of that due to ART. A 60% reduction in ART costs would result in savings of $70.3 billion over 10 years compared with base case projections; drug price negotiations in the IRA or a switch to generic regimens when generic dolutegravir becomes available in the US could lead to $19.4 billion in savings.43,44

The growing number of Medicare-enrolled PWH is anticipated to affect Medicare substantially, with 1.6-fold the number of PWH aged 65 years or older enrolled in Medicare by 2035 compared with 2026; between 160 580 and 273 540 Medicare beneficiaries are likely to be aged 65 years or older in 2035. Additionally, more Medicare beneficiaries taking ART will reach their 70s and 80s, with a 2.8-fold increase in people older than 80 years by 2035 compared with 2026. Improvements in virologic suppression and fewer ART-related toxic effects support the likelihood that the number of PWH surviving to older ages will increase.3,45,46 Clinicians must better understand the care needs of people aging with HIV given the increased risk of comorbidities and benefits of considering multimorbidity and polypharmacy.47-49 Health care systems will need to offer comprehensive, person-centered care to address the rising burden of comorbidities and health care use.48-50

This analysis highlights that cumulative Medicare costs for PWH could reach $187 billion over the next 10 years, reflecting a more rapid increase in per-person costs than population size. This increase could be due to more people reaching their 70s and 80s as well as health care inflation. These per-capita Medicare spending estimates are similar to those among people with cancer in the year of diagnosis or death but are much higher annually because of ART being needed over the lifetime.51

Rising Medicare costs over the next decade must be addressed without decreasing quality of care for PWH. Annual per-person ART costs to Medicare ($43 590-$46 820) represent the majority of spending for Medicare beneficiaries with HIV. Because lifetime ART is recommended for all PWH, it is critical to reduce Medicare ART costs without transferring costs to beneficiaries not eligible for patient assistance programs that are available to people who are insured commercially.23,52 Opportunities for ART cost reductions are on the horizon, including the IRA and an all-generic, well-tolerated ART regimen due in 2031, when generic dolutegravir becomes available.14,43,44 These model-projected reductions in ART costs are conservative if the IRA negotiation program remains in place; CMS has historically negotiated below the statutory minimum discounts,53,54 and more PWH could switch to less costly, well tolerated, and effective regimens when available.

Although this analysis details how reduced ART costs would lead to savings to Medicare, policymakers should consider the interactions between ART cost reductions and the 340B program.55,56 The 340B program allows disproportionate share hospitals, nonprofit organizations, and others to purchase medications at substantially discounted prices, enabling them to retain revenue to provide care for underserved populations.56-58 Current estimates suggest that 340B revenue from ART cost reductions may decrease by 45% to 50% through reduced reimbursement due to the IRA55; similar reductions would likely occur with a switch to generic ART. Although there is mixed evidence on the impact of the 340B program in increasing care access,59-63 ART cost reductions would lead to substantially lower reimbursement, which could necessitate alternative funding, such as increased federal grants, to ensure that PWH continue to receive the care they need.56

This analysis has several limitations. First, we limited model projections to Medicare beneficiaries aged 65 years or older receiving care to eliminate the heterogeneity introduced by younger PWH enrolled in Medicare, given their wide range in health conditions, or costs of care for people disengaged from HIV care.4 Ten-year costs to Medicare would be even higher if additional Medicare beneficiaries with HIV were included; whether PWH disengaged from care would incur higher costs than PWH in care due to more ER visits and opportunistic infections or whether they would incur lower costs without ART prescribed is unknown. Proposed and enacted cuts to programs such as the Ending the HIV Epidemic initiative, the Ryan White HIV/AIDS Program, and CDC prevention activities would also affect these estimates, as such policy changes could result in fewer people surviving to 65 years or more people living with HIV given increased HIV incidence.64-67 We used traditional Medicare data for spending and accounted for likely higher costs associated with Medicare Advantage plans with capitated payments made to private insurers; costs to insurers for clinical care are not public.39,68 Cumulative costs could be lower than projected if Medicare Advantage plans are less costly than current estimates, if inflation is lower than anticipated, or if there is decreasing enrollment in Medicare Advantage. To capture the effect of ART costs, we limited the analysis to Medicare beneficiaries with Part D in care. Because of our focus on Medicare spending, additional costs to the patient, Medicaid, commercial insurance, or the uninsured are not included (eg, long-term care costs), although costs to Medicare of dual-eligible PWH are included in full.

In this economic evaluation using microsimulation modeling, we projected that the number of Medicare beneficiaries aged 65 years or older receiving care for HIV in the US could increase 1.6-fold over the next decade. Medicare could insure nearly 200 000 older individuals by 2035, resulting in $187.2 billion in cumulative costs to Medicare over the decade. Reductions in ART costs, based on recent legislation and near-term generic availability, have the potential to lead to substantial decreases in Medicare spending for older beneficiaries with HIV.

Accepted for Publication: May 13, 2026.

Published: July 7, 2026. doi:10.1001/jamanetworkopen.2026.21966

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License, which does not permit alteration or commercial use, including those for text and data mining, AI training, and similar technologies. © 2026 Hyle EP et al. JAMA Network Open.

Corresponding Author: Emily P. Hyle, MD, MSc, Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (ehyle@mgh.harvard.edu).

Author Contributions: Drs Hyle and Freedberg had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hyle, Ebem, Sax, Pandya.

Acquisition, analysis, or interpretation of data: Hyle, Ang, Luu, Kasaie, Dai, Ebem, Phelan, Koiso, Duggan, Humes, Molozanov, Sax, Gerace, Giardina, Orav, Horn, Neilan, Figueroa, Althoff, Freedberg.

Drafting of the manuscript: Hyle, Ang, Luu, Ebem, Sax, Gerace.

Critical review of the manuscript for important intellectual content: Hyle, Ang, Luu, Kasaie, Dai, Ebem, Phelan, Koiso, Duggan, Humes, Molozanov, Sax, Giardina, Orav, Horn, Neilan, Pandya, Figueroa, Althoff, Freedberg.

Statistical analysis: Ang, Luu, Dai, Ebem, Phelan, Koiso, Giardina, Orav, Pandya.

Obtained funding: Hyle, Ebem, Figueroa, Freedberg.

Administrative, technical, or material support: Hyle, Luu, Ebem, Humes, Gerace, Althoff, Freedberg.

Supervision: Hyle, Sax.

Conflict of Interest Disclosures: Dr Hyle reported receiving grants from the National Institute of Health (NIH) and Massachusetts General Hospital during the conduct of the study and receiving personal fees from UpToDate in the form of royalties for an unrelated topic outside the submitted work. Dr Humes reported receiving grants from NIH during the conduct of the study. Dr Sax reported receiving grants from Gilead and ViiV and receiving personal fees from Gilead, Merck, and ViiV outside the submitted work. Dr Giardina reported receiving grants from NIH/National Institute of Aging during the conduct of the study. Dr Figueroa reported receiving grants from National Institute of Aging during the conduct of the study; grants from the Laura and John Arnold Foundation, Robert Wood Johnson Foundation, SCAN Foundation, US Department of Veterans of Affairs, and personal fees from Project Hope editorial services outside the submitted work. Dr Althoff reported receiving grants from NIH during the conduct of the study. Dr Freedberg reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was funded by the National Institutes of Health through grants R01AG069575 (Dr Hyle), R01AI042006 (Dr Freedberg), R01AG081151 (Dr Figeuroa), U01AI069918 and R01AG053100 (Dr Althoff), and R01AI179776 (Dr Kasaie); and the Massachusetts General Hospital Jerome and Celia Reich HIV Scholar Award (Dr Hyle).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding sources.

Data Sharing Statement: See Supplement 2.

Additional Contributions: The coauthors would like to acknowledge Dr Laura Cheever, MD, ScM (retired) for her insightful comments on the manuscript. Thank you to Ms Run Xiang, MPH, MS (Medical Practice Evaluation Center, Massachusetts General Hospital) for her administrative assistance with preparing the analysis and manuscript. Ms Xiang contributed as part of her institutional role. Both Dr Cheever and Ms Xiang did not receive additional compensation for their contributions.