Ambulatory HIV Care and Pre-exposure Prophylaxis Between 2014 and 2023

An Analysis of Nationwide Billing Data From the German Statutory Health Care System

Until now, comprehensive data on ambulatory HIV care and pre-exposure prophylaxis (PrEP) have been unavailable in Germany. The present analysis of billing data from the German statutory health care system between 2014 and 2023 provides an insight into the healthcare situation of people living with HIV and their utilization of HIV-specific healthcare services at national and regional levels, while also offering a demographic characterization of these patients (1).

Methods

The analyses were based on nationwide, pseudonymized outpatient billing data from statutory health insurance authorized physicians, pursuant to Section 295 of the German Social Code Book V (SGB V). These data include all patients covered by the German statutory health insurance scheme who have had at least one outpatient physician contact per calendar year.

For the present analysis, individuals were identified by an HIV diagnosis (ICD-10: B20–B24, Z21), receipt of HIV-specific healthcare (German Uniform Assessment Standard [EBM], Section 30.10: fee schedule items 30920, 30922, and 30924), or receipt of HIV pre-exposure prophylaxis (PrEP)-related care (EBM, Section 1.7.8: fee schedule items 01920–01922 and 01930–01936, available since 2019). The prevalence estimate was based on the so-called M2Q criterion (documentation of the diagnosis in at least two separate billing quarters) (2). Data covering the period from 2014 to 2023 were included. According to the Federal Collective Agreement for Physicians (BMV-Ä) pursuant to Section 87(1) of the SGB V, a reported treatment case is defined as the entire outpatient treatment of an insured individual by the same physician practice during the same calendar quarter billed to the same statutory health insurance fund (3). For the presentation of standardized prevalence differences in comorbidities, the age and sex distribution of individuals receiving specialized HIV care was applied to the general population.

Results

Trends in healthcare delivery

Between 2014 and 2023, the number of individuals with an HIV diagnosis in the German statutory health insurance system increased from 63 517 to 84 431 (+ 33%). The number of treatment cases also rose continuously and, for the first time, exceeded 520 000 cases in 2023. The number of individuals receiving specialized outpatient HIV care grew from 49 523 in 2014 to 68 455 in 2023. The proportion of these patients receiving specialized HIV care among all individuals with an HIV diagnosis was approximately 78% in 2023. Since the introduction of statutory reimbursement for PrEP-related services in September 2019, the number of individuals with at least one billed PrEP-related service in a given calendar year (henceforth referred to as PrEP users) quadrupled from 12 859 in 2019 to 51 598 in 2023.

Demographic characteristics

In 2023 the proportion of males was 76.6% among individuals with a confirmed HIV diagnosis, 79.3% among individuals with billed services in specialized HIV care, and 96.7% among PrEP users. The largest proportion was in the age group 55 to 59 years (general care: 16.3%; specialized care: 17.5%). The proportion of individuals younger than 30 years was 2.3% among those in general HIV care, 3.7% among those in specialized care, and 13.5% among PrEP users. Overall, PrEP care had a markedly younger age profile (25 to 39 years: 59%).

Distribution of diagnoses

Analysis of the distribution of diagnoses showed that cardiovascular and metabolic diseases, such as hypertension (I10; 12.3% in 2014 to 20.1% in 2023) and lipid metabolism disorders (E78; 10.9% in 2014 to 17.2% in 2023) were becoming increasingly common among patients receiving specialized HIV care. At the same time, mental health diagnoses, especially depressive episodes (F32), also remained at a high level over the 10-year period (data not shown).

In comparison with the general population, and even after standardized adjustment for differences in age and sex, certain clinical conditions or reasons for treatment occurred markedly more frequently among individuals receiving specialized HIV care (Table). In 2023, for example, depressive episodes (F32) were diagnosed in 17.4% of individuals receiving specialized HIV care, more than three times as frequently as in the standardized comparison population (4.9%). With 17.2%, lipid metabolism disorders (E78) present in individuals receiving specialized HIV care markedly more often than in the standardized comparison population (11.6%) (Table).

Table

Top 10 comorbidities among individuals receiving specialized HIV care in 2023*

Regional differences

The analysis of the regional distribution of the HIV population in 2023 shows a concentration in urban areas. In relation to the numbers of insured persons based on the KM6 statistical reporting system of the Federal Ministry of Health, Berlin and Hamburg recorded the highest rates with 373 and 257 HIV patients, respectively, per 100 000 insured persons. The frequencies were lowest in Mecklenburg–Western Pomerania and Thuringia (60 and 40 per 100 000 insured individuals, respectively). At the same time, the number of PrEP users in Berlin was 508, and in Mecklenburg–Western Pomerania 15, per 100 000 insured persons.

Patient flow

Although care was primarily provided close to patients’ homes, the patient flow analysis revealed patient migration to neighboring centers. Thus, for example, 66% of all treatment cases in Brandenburg were billed outside the patient’s area of residence, with more than 90% of these cases billed in Berlin. In Schleswig-Holstein 59% were billed outside the patient’s area of residence, predominantly in Hamburg. In general, urban areas take on a large proportion of HIV and PrEP care for neighboring regions.

Discussion

The findings demonstrate a continuous increase in outpatient utilization related to HIV-care and PrEP-related services over the past decade. The growing number of patients diagnosed with HIV and the expansion of specialized care services reflect the growing healthcare needs of an aging HIV population. The increased prevalence of cardiovascular, metabolic, and mental comorbidities in patients with HIV emphasizes the need for interdisciplinary and long-term coordinated care services.

Regional differences in the patient flow analysis may indicate both potential regional healthcare gaps, particularly with respect to disparities in the density of specialized healthcare services between urban and rural areas, as well as a preference among patients for seeking anonymized care outside their area of residence due to fears of stigmatization.

The dynamic development of PrEP use since 2019 highlights the successful incorporation of preventive services into routine care.

Clarissa Graf, Jan Lipovsek, Thomas Czihal, Monika Sander, Martin Albrecht, Markus Bickel, Dorian Doumit, Nikola Hanhoff, Anne von Fallois, Stefan Esser, Mandy Schulz

Conflict of interest statement
The present analysis is part of an expert report on medical healthcare facilities in the field of HIV/AIDS, prepared by the IGES Institute in collaboration with the Central Research Institute of Ambulatory Health Care in Germany (Zi) on behalf of a consortium comprising the German Aids Foundation (DAS), the German Association of Physicians Specialized in Infectious Diseases and HIV Care (dagnä), and the German AIDS Society (DAIG).

The authors declare that no conflict of interest exists.

Manuscript received on 25 November 2025, revised version accepted on 24 March 2026.

Translated from the original German by Dr. Grahame Larkin.

Cite this as:
Graf C, Lipovsek J, Czihal T, Sander M, Albrecht M, Bickel M, Doumit D, Hanhoff N, von Fallois A, Esser S, Schulz M: Ambulatory HIV care and pre-exposure prophylaxis between 2014 and 2023: An analysis of nationwide billing data from the German statutory health care system. Dtsch Arztebl Int 2026; 123: 364–5. DOI: 10.3238/arztebl.m2026.0054

References

1. Albrecht M, Sander M, Loos S, et al.: Medizinische Versorgungsstrukturen im Bereich HIV/AIDS: Quantitative und qualitative Entwicklungen und Herausforderungen. Ergebnisbericht für das Konsortium aus DAS, dagnä und DAIG. Berlin: IGES Institut. HIV_Ergebnisbericht_final___ger.pdf (last accessed on 4 March 2026).

2. Schubert I, Ihle P, Köster I: Interne Validierung von Diagnosen in GKV-Routinedaten: Konzeption mit Beispielen und Falldefinition. Das Gesundheitswesen 2010; 72: 316–22

3. Kassenärztliche Bundesvereinigung, GKV-Spitzenverband: Bundesmantelvertrag – Ärzte (BMV-Ä) gemäß § 87 Abs. 1 SGB V (April 1, 2025) https://www.kbv.de/documents/infothek/rechtsquellen/bundesmantelvertrag/BMV-Aerzte.pdf (last accessed on 4 March 2026).