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The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium
Abstract
In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas.
During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year.
In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.
... As for the course and outcome of females and males with HIV infection the results of the studies are controversial. Several studies reported rapid progression to AIDS with a worse outcome in females compared to males with HIV [13,14]. Contrary, better outcome with less mortality rates among HIV infected females compared to males were reported by other studies [15,16]. ...
... The results of previous studies aimed to compare differences in the course of HIV between females and males are controversial [13][14][15][16]. This probably due to differences between the male and female groups of HIV patients in those studies, regarding the route oh HIV acquisition, socioeconomic and educational status and access to healthcare and treatment. ...
Introduction – Gender influences the presentation and progression of various diseases. Studies regarding the impact of gender on the course and outcome of HIV demonstrate conflicting data. Studies may be biased due to socioeconomic status differences between females and males and uneven gender representation, among other factors. In order to minimize the effect of non-biological elements this study cohort compares HIV males and females with similar ethnicity and social class in 2 Israeli AIDS centers. Methods –the study is a retrospective study. The cohort consists 334 females and 223 males diagnosed with HIV during the years 2000-2015. All patients were immigrants from Ethiopia who acquired HIV heterosexually and had a similar socioeconomic status. Data regarding demographics, clinical status, virological (viral load; VL), immunological (CD4) and treatment modalities were collected for each patient. Results - At the time of HIV diagnosis, males were older (43.2 ±13.2 vs. 35.4±11.95 years; p
... Providers have been found to express greater frustration and negative attitudes towards female patients compared to males [18], perhaps due to differences in communication in the clinic [19][20][21], and other gender-related influences that create implicit biases in delivery of care [22]. This is critical as provider perceptions and attitudes impact decisions surrounding treatment [23,24]. Moreover, the patient-provider relationship is a key factor to retention in HIV care [25][26][27]. ...
... Men have also been characterized as more vulnerable to adherence issues [36,37]. Future studies should further explore this discrepancy given that gender appears to inaccurately bias provider perceptions of female patients [18,38,39], which significantly impact HIV treatment decisions [23,24]. Moreover, provider attitudes have been identified as a major barrier to HIV care in this region due to judgment and scolding of non-adherent patients [40]. ...
The disproportionate burden of HIV among women in sub-Saharan Africa reflects underlying gender inequities, which also impact patient–provider relationships, a key component to retention in HIV care. This study explored how gender shaped the patient–provider relationship and consequently, retention in HIV care in western Kenya. We recruited and consented 60 HIV care providers from three facilities in western Kenya affiliated with the Academic Model Providing Access to Healthcare (AMPATH). Trained research assistants conducted and audio recorded 1-h interviews in English or Swahili. Data were transcribed and analyzed in NVivo using inductive thematic analysis. Gender constructs, as culturally defined, emerged as an important barrier negatively impacting the patient–provider relationship through three main domains: (1) challenges establishing clear roles and sharing power due to conflicting gender versus patient/provider identities, (2) provider frustration over suboptimal patient adherence resulting from gender-influenced contextual barriers, and (3) negative provider perceptions shaped by differing male and female approaches to communication. Programmatic components addressing gender inequities in the health care setting are urgently needed to effectively leverage the patient–provider relationship and fully promote long-term adherence and retention in HIV care.
... In this study we examined the impact of clinic organizational characteristics on mental health care and substance abuse care in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of persons in care for HIV (23). Prior analyses of data from the HCSUS identified patient characteristics associated with mental health and substance abuse care, including income, education, insurance status, and HIV symptom burden (10,13). ...
... The HCSUS was a multistage probability sample of all noninstitutionalized persons who received outpatient care for HIV in the United States between 1996 and 1998. Prior publications describe the HCSUS sampling scheme in detail (23,24). The baseline survey interviewed 2,864 participants between January 1996 and April 1997. ...
Objective: Many persons with HIV do not receive needed behavioral health Servicess. This study examined the impact of medical clinic characteristics on access to mental health and substance abuse care for persons with HIV. Methods: This was a longitudinal survey of patients and clinic directors participating in the HIV Cost and Services Utilization Study, a national probability sample of persons in care for HIV between 1996 and 1998 (N=2,031). Primary outcomes were receipt of outpatient mental health specialist care, outpatient substance abuse care, and abstinence from substance use in the past 30 days. Results: After adjustment for patient characteristics, the likelihood of care by a mental health specialist was higher for patients in HIV specialty clinics (odds ratio [OR]=2.1, 95% confidence interval [CI]=1.2-3.5) and clinics with a combination of on-site case management and affiliated mental health care (OR=2.3, CI 1.3-4.4, for off-site affiliated care; OR=2.1, CI=1.2-3.7, for on-site care). Outpatient substance abuse care also was more likely for patients in clinics with on-site case management and affiliated substance abuse care (OR=4.3, CI=1.5-12.2, for off-site affiliated care; OR=3.2, CI=1.3-8.0, for on-site care). In a subgroup of persons reporting active substance use, care in clinics with on-site case management predicted 30-day abstinence from substances at follow-up (OR=1.7, CI=1.1-2.5). Conclusions: The organizational structure of medical clin-ics can have an important effect on use of mental health and substance abuse specialist care.
... 9 Increased knowledge and more favourable attitudes towards the use of condoms was reported to decrease the prevalence of HIV/AIDS in India and Uganda. [10][11][12] A low level of knowledge regarding the transmission and prevention of AIDS in adolescents is a predictor of non-use of condoms and a belief that condoms decrease pleasure. [12][13][14][15] Consistent condom use is negatively associated with being married or in a cohabiting relationship in Angola. ...
... 18 Many Islamic religious groups have accepted the use of condoms to prevent the transmission of HIV/AIDS. 11 Parent-teenager discussions about sexuality and sexual risk are associated with an increased likelihood of teenagers using condoms, but only if parents are open, skilled and feel comfortable having such discussions. 21 There are myths that uncircumcised men cannot use condoms, that religious people do not need to use condoms and that only homosexuals acquire AIDS. ...
The Democratic Republic of Congo (DRC) is experiencing increasing human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in young adults. This is despite the government's widespread campaign on HIV/AIDS awareness. In this study, high-risk university students who engage in casual sex, but who have good literacy skills, were surveyed to ascertain whether the education campaigns in the country influenced their condom use practice. This study sought to determine Goman University students’ knowledge and attitudes about and practices of condom use for the purpose of reducing HIV infection. A descriptive cross-sectional quantitative study, using a self-administered questionnaire, was carried out. The ages of the students varied between 18 and 33. Most of them were men: 111 (80%), 129 (93%) were single, and most participants were Protestants (61, 44%) and Roman Catholics (57, 41%). The majority of participants (137, 99%) knew about condoms, while 132 (96%) were aware that condoms were available from and sold by pharmacies. Seventy-two (52 %) understood that condoms helped to prevent HIV, pregnancy and sexually transmitted infections (STIs). Ninety-four (68%) said that they knew how to use a condom, while 111 (80%) stated that the price of condoms was not a barrier to usage thereof. One hundred and two (74%) suggested that the university should supply students with condoms. Ninety-one (66%) were sexually active and 98 (71%) of participants reported that they had unprotected sex. Condom awareness was high and information was available from varying sources. Condoms were accepted as a means to prevent HIV/AIDS, STIs and pregnancy. Some ethnic groups disapproved of condom use because of religious and cultural beliefs. Consistent use of condoms was low in Goma University students.
... Sex-related biological aspects, such as genetic and/or hormonal factors may also lead to heterogeneous host-responses to the virus in men and women, with, for example, variable levels of immune activation at acquisition of the virus/onset of disease and differences in tolerances to antiretroviral medications [2]. In terms of preventive strategies, WLWH may receive less attention and may be excluded in countries where the epidemic disproportionally affects men who have sex with men [3]. ...
Background
Epidemiological and immunovirological features of people living with HIV (PLWH) can vary by sex.AimTo investigate, particularly according to sex, characteristics of PLWH who consulted a tertiary hospital in Barcelona, Spain, in 1982-2020.MethodsPLWH, still in active follow-up in 2020 were retrospectively analysed by sex, age at diagnosis, age at data extraction (December 2020), birth place, CD4+ cell counts, and virological failure.ResultsIn total, 5,377 PLWH (comprising 828 women; 15%) were included. HIV diagnoses in women appeared to decrease from the 1990s, representing 7.4% (61/828) of new diagnoses in 2015-2020. From 1997, proportions of new HIV diagnoses from patients born in Latin America seemed to increase; moreover, for women born outside of Spain, the median age at diagnosis appeared to become younger than for those born in Spain, with significant differences observed in 2005-2009 and 2010-2014 (31 vs 39 years (p = 0.001), and 32 vs 42 years (p < 0.001) respectively), but not in 2015-2020 (35 vs 42 years; p = 0.254). Among women, proportions of late diagnoses (CD4+ cells/mm3 < 350) were higher than men (significantly in 2015-2020: 62% (32/52) vs 46% (300/656); p = 0.030). Initially, virological failure rates were higher in women than men, but they were similar in 2015-2020 (12% (6/52) vs 8% (55/659); p = 0.431). Women ≥ 50 years old represented 68% (564/828) of women actively followed up in 2020.Conclusions
Women still have higher rates of late HIV diagnoses than men. Among currently-followed-up women, ≥ 50 year-olds, who need age-adapted care represent a high percentage. Stratifying PLWH by sex matters for HIV prevention and control interventions.
... Notably, this analysis did not include the economic or health benefits for PWH (Pinkerton et al., 2013). Goldman and colleagues (Goldman et al., 2001) used data from the 1998 HIV Cost and Services Utilization Study (Bozzette et al., 1998) to evaluate the effects of state Medicaid and ADAP policies on the direct and indirect costs of treating PWH. They found that if states expanded ADAP by improving ART access, there would be reduction in societal medical expenditures mainly due to the reduction in medical care expenses for comorbid conditions resulting from inadequate HIV treatment. ...
As part of the Ryan White HIV/AIDs Program, the federally-funded, state-administered AIDS Drug Assistance Program (ADAP) provides prescription drug medications, including antiretroviral therapy, for people with HIV (PWH) who are uninsured/underinsured and have a low income. ADAP expenditures are ∼$2.4 billion annually, but there is a dearth of formal economic analysis supporting the societal perspective. We conducted a systematic review of economic analyses of the United States’ AIDS Drug Assistance Program to establish future research priorities based on gaps in knowledge. We searched six electronic databases for articles published before January 2022 that met inclusion criteria. We used the 2022 Consolidated Health Economic Evaluation Reporting Standards to assess the quality of reporting of the economic evaluations. We extracted data into categories to assess gaps and needs for future economic evaluation. Seven studies met inclusion criteria. Two used the same modeling approaches but were published with slightly different outcomes. The few economic analyses that focused solely on ADAP were conducted using 2008 or older data. The most recent study modeled the net cost per quality-adjusted life-year (QALY) secondary to reducing new HIV cases among those virally suppressed, but did not include the economic or health benefits for PWH. ADAP programs’ delivery of antiretroviral therapy has shifted from primarily direct provision to subsidizing insurance plans. None of the models take these shifts into account. Updated person-centered cost effectiveness models assessing ADAP are needed on a national and state-by-state level to guide policy decisions and coverage determinations.
... Routine HIV care costs are assumed to range from $260-1,150/month, depending on CD4 cell count [40][41][42]. ...
The Adolescent Medicine Trials Network for HIV/AIDS Interventions is evaluating treatment adherence interventions (AI) to improve virologic suppression (VS) among youth with HIV (YWH). Using a microsimulation model, we compared two strategies: standard-of-care (SOC) and a hypothetical 12-month AI that increased cohort-level VS in YWH in care by an absolute ten percentage points and cost $100/month/person. Projected outcomes included primary HIV transmissions, deaths and life-expectancy, lifetime HIV-related costs, and incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year [QALY]). Compared to SOC, AI would reduce HIV transmissions by 15% and deaths by 12% at 12 months. AI would improve discounted life expectancy/person by 8 months at an added lifetime cost/person of $5,300, resulting in an ICER of $7,900/QALY. AI would be cost-effective at $2,000/month/person or with efficacies as low as a 1 percentage point increase in VS. YWH-targeted adherence interventions with even modest efficacy could improve life expectancy, prevent onward HIV transmissions, and be cost-effective.
... Physical and mental health quality of life was assessed with the SF-36, a widely used measure of functional health and well-being from the patient's perspective [34]. We also administered an adaptation of the Utilization of Care module of the HIV Cost and Services Utilization Study [35]. ArcGIS software was used to calculate the distances in miles from the clinic to where participants resided. ...
With the expansion of telehealth services, there is a need for evidence-based treatment adherence interventions that can be delivered remotely to people living with HIV. Evidence-based behavioral health counseling can be delivered via telephone, as well as in-office services. However, there is limited research on counseling delivery formats and their differential outcomes. The purpose of this study was to conduct a head-to-head comparison of behavioral self-regulation counseling delivered by telephone versus behavioral self-regulation counseling delivered by in-office sessions to improve HIV treatment outcomes. Patients (N = 251) deemed at risk for discontinuing care and treatment failure living in a rural area of the southeastern USA were referred by their care provider. The trial implemented a Wennberg Randomized Preferential Design to rigorously test: (a) patient preference and (b) comparative effects on patient retention in care and treatment adherence. There was a clear patient preference for telephone-delivered counseling (69%) over in-office-delivered counseling (31%) and participants who received telephone counseling completed a greater number of sessions. There were few differences between the two intervention delivery formats on clinical appointment attendance, antiretroviral adherence, and HIV viral load. Overall improvements in health outcomes were not observed across delivery formats. Telephone-delivered counseling did show somewhat greater benefit for improving depression symptoms, whereas in-office services demonstrated greater benefits for reducing alcohol use. These results encourage offering most patients the choice of telephone and in-office behavioral health counseling and suggest that more intensive interventions may be needed to improve clinical outcomes for people living with HIV who may be at risk for discontinuing care or experiencing HIV treatment failure.
... It is noteworthy that only 48.93% of PLWH (Supplementary material online, Table S6D) were filling prescriptions for HAART at 12 months following discharge. However, medication non-adherence is a well-studied barrier to care in PLWH, with underlying reasons including medical literacy and poor integration into healthcare systems, [28][29][30]35,36 and it is likely that patient non-adherence was present as well. In this study, disparities inequality of care and outcomes persisted not just during the index hospitalization, but up to a year following hospital discharge in PLWH. ...
Aims
Persons living with HIV (PLWH) have increased cardiovascular mortality, which may in part be due to differences in the management of acute coronary syndromes (ACS). The purpose of this study was to compare the in-hospital and post-discharge management and outcomes of ACS among persons with and without HIV.
Methods and Results
This was a retrospective cohort study using data from Symphony Health, a data warehouse. All patients admitted between 1/1/2014–12/31/2016 with ACS were identified by ICD billing codes. Multivariate logistic regression models were used to examine in-hospital, 30-day and 12-month event rates between groups. 1,125,126 individuals were included, 6,612 (0.59%) with HIV. PLWH were younger (57.4 ± 10.5 vs 67.4 ± 12.9 years, p<.0001) and had more medical comorbidities. ACS type did not differ significantly with HIV status. PLWH were less likely to undergo coronary angiography (35.2% vs 37.2%, adjusted OR 0.87, 95% CI 0.83-0.92, p <.0001), and those with both HIV and STEMI underwent fewer drug eluting stents (60.1% vs 68.5%, adjusted OR 0.81, 95% CI 0.68-0.96, p = 0.016). PLWH had higher adjusted rates of inpatient mortality (OR 1.29, 95% CI 1.15-1.44, p <.0001), 30-day readmission (OR 1.18, 95% CI 1.09-1.27, p <.0001) and 12-month mortality (OR 1.32, 95% CI 1.22-1.44, p <.0001). 12 months following discharge, PLWH filled cardiac medications at lower rates.
Conclusion
In a contemporary cohort of persons hospitalized for ACS, PLWH received less guideline-supported interventional and medical therapies and had worse clinical outcomes. Strategies to optimize care are warranted in this unique population.
... • HIV-infected adults visit emergency departments (EDs) three-to-four times more frequently than the general population. 2 • Understanding the trends of health care use by the PLWHs is important for optimizing care and service delivery. 3 • Among a total of 665 million ED visits, 3.4 million visits were made by PLWHs (5.16 visits per 1,000). ...
... Our results support previous studies that have highlighted concerns regarding the 'browning' of HIV, as PLWHA are more likely to face social and structural challenges that contribute to higher rates of infection and subsequently, a higher financial burden [6]. Moreover, members of vulnerable populations may be more likely to enter HIV care at more advanced disease stages, which has been associated with greater healthcare utilization and thus higher costs [2,18]. To our knowledge, this is the first study to compare the financial burden of PLWHA and those living with other chronic conditions. ...
Background
While previous studies have examined HIV cost expenditures within the United States, the majority of these studies focused on data collected prior to or shortly after the advent and uptake of antiretroviral therapy, focused only on a short time frame, or did not provide cost comparisons between HIV/AIDS and other chronic conditions. It is critical that researchers provide accurate and updated information regarding the costs of HIV care to assist key stakeholders with economic planning, policy development, and resource allocation.
Methods
We used data from the Medical Expenditure Panel Survey-Household Component for the years 2002–2011, which represents a nationally representative U.S. civilian non-institutionalized population. Using generalized linear modeling, we estimated the adjusted direct medical expenditures by HIV/AIDS status after controlling for confounding factors.
Results
Data were from 342,732 people living with HIV/AIDS. After adjusting for socio-demographic factors, comorbidities and time trend covariates, the total direct expenditures for HIV/AIDS was $31,147 (95% CI $23,645–$38,648) or 800–900% higher when compared to those without HIV/AIDS (i.e., diabetes, stroke, and cardiovascular disease). Based on the adjusted mean, the aggregate cost of HIV/AIDS was approximately $10.7 billion higher than the costs for those without HIV/AIDS.
Conclusions
Our estimates of cost expenditures associated with HIV care over a 10-year period show a financial burden that exceeds previous estimates of direct medical costs. There is a strong need for investment in combination prevention and intervention programs, as they have the potential to reduce HIV transmission, and facilitate longer and healthier living thereby reducing the economic burden of HIV/AIDS.
... Included were ART costs ranging from $2040 to $3300 per month, HIV RNA costs of $116 per test, and CD4 cell countstratified routine care costs ranging from $236 to $2572 per month (Table 3) [32, 35,36]. Costs were updated to 2014 US dollars using the Bureau of Labor Statistics consumer price index for medical care [33,34]. ...
Background:
The US National HIV/AIDS Strategy (NHAS) aims for 72% (90% diagnosed times 80% of those virally suppressed) viral suppression among persons with human immunodeficiency virus (HIV) by 2020. We examined the clinical and economic impact of reaching this target, in the general US population and among black men who have sex with men (MSM), the group with the highest HIV prevalence.
Methods:
Using a mathematical simulation, we project the 5- and 20-year clinical outcomes, costs, and incremental cost-effectiveness ratios for (1) Current Pace of detection, linkage, retention, and virologic suppression and (2) NHAS investments in expanded testing ($24-$74 per test) and adherence ($400 per person-year), calibrated to achieve 72% suppression by 2020. We examined alternative rates of testing, retention, and suppression and the efficacy and cost of adherence interventions.
Results:
Compared with Current Pace over 20 years, NHAS averted 280000 HIV transmissions (80000 in black MSM) and 199000 (45000) deaths and saved 2138000 (453000) years of life, while increasing costs by 23%. The incremental cost-effectiveness ratio for NHAS compared with Current Pace was $68900 per quality-adjusted life-year ($38300 for black MSM) and was most sensitive to antiretroviral therapy costs.
Conclusions:
Reaching NHAS targets would yield substantial clinical benefits and be cost-effective in both the general US and black MSM populations.
... [7][8][9][10][11] Studies conducted in the years pre ceding the introduction of combination antiretroviral ther apy demonstrated that people with HIV had rates of emer gency department visits that were three to fourfold higher than those of the general population. 12,13 Although subse quent studies found persistently heightened rates of emer gency department use following the introduction of com bination antiretroviral therapy, inferences were limited by samples that were small and not populationbased. 7,9,10 A recent analysis of the US National Hospital Ambulatory Medical Survey demonstrated that rates of emergency department visits among people with HIV continue to exceed those of noninfected people (633 v. 438 visits per 1000 people), although by a smaller magnitude than during the preceding decade. ...
Background:
Emergency department use may reflect poor access to primary care. Our objective was to compare rates and causes of emergency department use between adults living with and without HIV.
Methods:
We conducted a population-based study involving Ontario residents living with and without HIV between Apr. 1, 2011, and Mar. 31, 2012. We frequency matched adults with HIV to 4 HIV-negative people by age, sex and census division, and used random-effects negative binomial regression to compare rates of emergency department use. We classified visits as low urgency or high urgency, and also examined visits for ambulatory care sensitive conditions. Hospital admission following an emergency department visit was a secondary outcome.
Results:
We identified 14 534 people with HIV and 58 136 HIV-negative individuals. Rates of emergency department use were higher among people with HIV (67.3 v. 31.2 visits per 100 person-years; adjusted rate ratio 1.58, 95% confidence interval [CI] 1.51-1.65). Similar results were observed for low-urgency visits. With the exception of hypertension, visit rates for ambulatory care sensitive conditions were higher among people with HIV. People with HIV were also more likely than HIV-negative individuals to be admitted to hospital following an emergency department visit (adjusted odds ratio 1.55, 95% CI 1.43-1.69).
Interpretation:
Compared with HIV-negative individuals, people with HIV had high rates of emergency department use, including potentially avoidable visits. These findings strongly support the need for comprehensive care for people with HIV.
... Globally, an estimated 35 million people were living with HIV in 2013, 71% of whom were in sub-Saharan Africa. 1 This increased burden, as compared to the 29.8 million in 2001, reflects continuous transmission despite a decrease in incidence and also portrays the benefits of continual expansion of access to combination antiretroviral therapy (cART) which has contributed to a significant reduction in the number of AIDS-related deaths. 1 Global efforts to scale up access to cART is a continuous process which recorded a threefold increase within a five-year period to 9.7 million in low-and middle-income countries in 2012, representing 65% of the 15 million target set for 2015. 2 The benefits of cART, which relies on its ability to chronically suppress viral replication, has dramatically altered the natural history of HIV disease by the restoration and prolonged maintenance of good health, resulting in reduced morbidity, 3,4 thereby turning HIV infection from a fatal to a chronic disease. 5,6 However, it has been shown that in order to maintain a chronic state of ensured virological suppression, adherence to treatment is a cornerstone with great impact on clinical end points including AIDS progression, hospitalisation and death. ...
Nowadays, global coverage of combination antiretroviral therapy (cART) has increased due to a continuous process to scale up access. This increase has potentially transformed HIV-infection from a fatal to a chronic disease: a transformation only possible if the prescribed medications are taken accordingly. We therefore evaluated optimal adherence to cART by three commonly used methods: visual analogue scale (VAS), four days recall (FDR) and clinic attendance (CA) for the last six months in 301 HIV-infected patients on cART for at least six months at the Douala General Hospital, Cameroon. Optimal adherence was defined to be greater than or equal to the 95th percentile estimate of each method. We found that 70.8% of our study population was female. The mean age was 40.8 years (SD 10.5) and 85% were on first line cART. Median CD4 count was 397 cells/ml (252-559). Optimal adherence by VAS, FDR and CA, was 68.1%, 83.4%, and 73.4%, respectively. VAS and FDR inter-correlated strongly (Pearson's Chi square coefficient, r = 0.58, p < 0.001). Higher CD4 count above 200 cells/ml was associated with optimal adherence by CA (Adjusted Odds Ratio [AOR]:2.6 (95% CI: 1.2-5.3, p < 0.001)). As high optimal adherence to cART is associated with good clinical outcome in HIV patients, simple methods such as the VAS for evaluating adherence, should be integrated to the HIV clinic of the Douala General Hospital.
Objectives:
To explore the health impacts of Hurricane Maria (HM) on HIV care outcomes among people living with HIV who use drugs.
Methods:
Using data from an ongoing cohort study in San Juan, Puerto Rico (Proyecto PACTo), we measured differences in HIV care outcomes (viral load, viral suppression, and CD4 counts) before and after HM using assessments conducted at 6-month intervals. Generalized estimating equations were used to assess factors associated with HIV care outcomes.
Results:
All HIV care outcomes showed a deterioration from pre-HM values to post-HM values (mean viral load increased, CD4 counts decreased, and rate of viral suppression decreased) after controlling for pre-HM sociodemographic and health characteristics. In addition to HM, age (aIRR = 1·01), being homeless (aIRR = 0·78) and having health insurance (aIRR = 1·6) were independently associated with viral suppression.
Participants:
219 participants completed follow-up visits between April 2017 and January 2018, before and after HM.
Conclusions:
People living with HIV who use drugs in Puerto Rico experienced poorer HIV outcomes following HM. Socio-environmental factors contributing to these outcomes is discussed in the context of disaster response, recovery, and program planning.
Positive psychological attributes are associated with better health outcomes, yet few studies have identified their underlying constructs and none have examined their temporal trajectories in clinical vs. non-clinical samples. From data collected over 4 years from people with HIV (PWH) and HIV-uninfected (HIV−) participants, we identified two latent factors (internal strengths; socioemotional support) based on responses to seven positive psychological attributes. Internal strengths increased over 4 years for PWH, but not for HIV− comparisons. Socioemotional support did not change significantly in either group. Lower internal strengths and worse socioemotional support were related to greater depressive symptoms. We speculate that improvement in internal strengths in PWH could reflect their being in care, but this requires further study to include PWH not in care. Given the apparent malleability of internal strengths and their association with improved health outcomes, these attributes can serve as promising intervention targets for PWH.
Background:
The HIV Prevention Trials Network (HPTN) 083 trial demonstrated the superiority of long-acting injectable cabotegravir (CAB-LA) compared with oral emtricitabine-tenofovir disoproxil fumarate (F/TDF) for HIV preexposure prophylaxis (PrEP).
Objective:
To identify the maximum price premium (that is, greatest possible price differential) that society should be willing to accept for the additional benefits of CAB-LA over tenofovir-based PrEP among men who have sex with men and transgender women (MSM/TGW) in the United States.
Design:
Simulation, cost-effectiveness analysis.
Data sources:
Trial and published data, including estimated HIV incidence (5.32, 1.33, and 0.26 per 100 person-years for off PrEP, generic F/TDF and branded emtricitabine-tenofovir alafenamide (F/TAF), and CAB-LA, respectively); 28% 6-year PrEP retention. Annual base-case drug costs: $360 and $16 800 for generic F/TDF and branded F/TAF. Fewer side effects with branded F/TAF versus generic F/TDF were assumed.
Target population:
476 700 MSM/TGW at very high risk for HIV (VHR).
Time horizon:
10 years.
Perspective:
Health care system.
Intervention:
CAB-LA versus generic F/TDF or branded F/TAF for HIV PrEP.
Outcome measures:
Primary transmissions, quality-adjusted life-years (QALYs), costs (2020 U.S. dollars), incremental cost-effectiveness ratios (ICERs; U.S. dollars per QALY), maximum price premium for CAB-LA versus tenofovir-based PrEP.
Results of base-case analysis:
Compared with generic F/TDF (or branded F/TAF), CAB-LA increased life expectancy by 28 000 QALYs (26 000 QALYs) among those at VHR. Branded F/TAF cost more per QALY gained than generic F/TDF compared with no PrEP. At 10 years, CAB-LA could achieve an ICER of at most $100 000 per QALY compared with generic F/TDF at a maximum price premium of $3700 per year over generic F/TDF (CAB-LA price <$4100 per year).
Results of sensitivity analysis:
In a PrEP-eligible population at high risk for HIV, rather than at VHR (n = 1 906 800; off PrEP incidence: 1.54 per 100 person-years), CAB-LA could achieve an ICER of at most $100 000 per QALY versus generic F/TDF at a maximum price premium of $1100 per year over generic F/TDF (CAB-LA price <$1500 per year).
Limitation:
Uncertain clinical and economic benefits of averting future transmissions.
Conclusion:
Effective oral PrEP limits the additional price society should be willing to pay for CAB-LA.
Primary funding source:
FHI 360; Eunice Kennedy Shriver National Institute of Child Health and Human Development; National Institute of Allergy and Infectious Diseases; National Heart, Lung, and Blood Institute; National Institute on Drug Abuse; the Reich HIV Scholar Award; and the Steve and Deborah Gorlin MGH Research Scholars Award.
Introduction
The Emergency Department (ED) plays a key role in linkage to and engagement in care for people with HIV (PWH) in the United States, particularly for individuals without a routine source or schedule for care. Assessing patterns of ED resource utilization by PWH can help elucidate the role of EDs across the HIV care continuum. The aim of this study was to use visit-level data to characterize resource utilization patterns for HIV-related ED visit diagnoses compared to those of other ED visit types.
Methods
HIV-related ED visits were identified as either having answered ‘have HIV’ in a survey question, been diagnosed with HIV, or had HIV noted as a reason for a visit. Weighted, pooled cross-sectional analyses were performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 2009–2018. ED visits were restricted to those aged 13 years and older. Both descriptive and multivariable regression analyses were performed using Stata 15.1 to measure differences in ED resource utilization.
Results
A weighted total of 6.10 million ED visits occurred among PWH, representing 5.5 visits per 1000 ED visits. The rates of HIV-related ED visits (per 1000 ED visits) were higher among patients aged 50–64 years (9.1), males (7.9), African Americans (11.1), Medicaid recipients (7.8), patients in the Northeast (6.8), and patients in metropolitan areas (MSA) (6.1). HIV-related ED visits reflected higher resource utilization: including higher utilization of the ambulance, diagnostic tests, blood tests, urinalysis, HIV tests, intravenous fluids, medications, consultants, critical care units, longer visits, and hospital admissions. Multivariable regression models revealed higher ED resource utilization and showed that patients making HIV-related visits were 57% more likely to result in hospital admission, spending 17% more time compared to patients making non-HIV-related visits.
Conclusion
Hospitals should be prepared to meet the unique needs of PWH presenting for ED services. Continued surveillance of resource utilization patterns among PWH in EDs is important to plan successful HIV care engagement interventions in these settings.
Background
The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project.
Methods/findings
HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm ³ ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions—including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal—were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual’s health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period.
Conclusions
These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.
Background
Understanding factors influencing retention in care (RIC) and VL improvement (VLI) in people with HIV (PWH) who are out of care and hospitalized will assist in intervention development for this vulnerable population.
Methods
The study was a post-hoc analysis of prospectively collected data. Hospitalized participants were enrolled if they were newly diagnosed with HIV during the hospitalization or out of HIV care. Participants completed surveys at baseline and 6 months post-enrollment and laboratory studies of viral load (VL). Outcomes were RIC (2 completed visits, one within 30 days of discharge) and VLI (VL<400 or at least a 1 log10 decrease) 6 months after discharge. Univariate and multivariate regression analyses were conducted examining contributions of predisposing, enabling, and need factors to outcomes.
Results
The study cohort included 417 participants enrolled between 2010 and 2013. The population was 73% male; 67% non-Hispanic Black and 19% Hispanic; 70% uninsured; 65% with a baseline CD4<200 cells/mm3; 79% with a VL>400 copies/mL or missing; and generally poor with low education attainment. After discharge from the hospital, 60% did not meet the definition for RIC, and 49% did not have VLI. Modifiable factors associated with the outcomes include drug use (including marijuana alone and other drugs), life instability (e.g., housing, employment, and life chaos), and using avoidance coping strategies in coping with HIV.
Conclusions
Hospitalized out-of-care PWH in the US are at high risk of poor re-engagement in care after discharge. Interventions for this population should focus on improving socioeconomic stability and coping with HIV and reducing drug use.
Background:
As life expectancy of patients infected with human immunodeficiency virus (HIV) approaches that of the general population, the composition of HIV management costs is likely to change.
Objectives:
To (a) review treatment and disease management costs in HIV, including costs of adverse events (AEs) related to antiretroviral therapy (ART) and long-term toxicities, and (b) explore the evolving cost drivers.
Methods:
A targeted literature review between January 2012 and November 2017 was conducted using PubMed and major conferences. Articles reporting U.S. costs of HIV management, acquired immunodeficiency syndrome (AIDS)-defining events, end of life care, and ART-associated comorbidities such as cardiovascular disease (CVD), chronic kidney disease (CKD), and osteoporosis were included. All costs were inflated to 2017 U.S. dollars. A Markov model-based analysis was conducted to estimate the effect of increased life expectancy on costs associated with HIV treatment and management.
Results:
22 studies describing HIV costs in the United States were identified, comprising 16 cost-effectiveness analysis studies, 5 retrospective analyses of health care utilization, and 1 cost analysis in a resource-limited setting. Management costs per patient per month, including routine care costs (on/off ART), non-HIV medication, opportunistic infection prophylaxis, inpatient utilization, outpatient utilization, and emergency department utilization were reported as CD4+ cell-based health state costs ranging from $1,192 for patients with CD4 > 500 cells/mm3 to $2,873 for patients with CD4 < 50 cells/mm3. Event costs for AEs ranged from $0 for headache, pain, vomiting, and lipodystrophy to $31,545 for myocardial infarction. The mean monthly per-patient costs for CVD management, CKD management, and osteoporosis were $5,898, $6,108, and $4,365, respectively. Improvements in life expectancy, approaching that of the general population in 2018, are projected to increase ART-related and AE costs by 35.4% and comorbidity costs by 175.8% compared with estimated costs with HIV life expectancy observed in 1996.
Conclusions:
This study identified and summarized holistic cost estimates appropriate for use within U.S. HIV cost-effectiveness analyses and demonstrates an increasing contribution of comorbidity outcomes, primarily associated with aging in addition to long-term treatment with ART, not typically evaluated in contemporary HIV cost-effectiveness analyses.
Disclosures:
This analysis was sponsored by ViiV Healthcare, which had no role in the analyses and interpretation of study results. Ward, Sugrue, Hayward, and McEwan are employees of HEOR Ltd, which received funding from ViiV Healthcare to conduct this study. Anderson is an employee of GlaxoSmithKline and holds shares in the company. Punekar and Oglesby are employees of ViiV Healthcare and hold shares in GlaxoSmithKline. Lopes was employed by ViiV Healthcare at the time of the study and holds shares in GlaxoSmithKline.
Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn’t know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services.
Developing countries encounter severe food shortage along with wastage of significant amount of food materials. Food is being wasted almost in every stage of food supply chain including harvesting, postharvesting, processing, and distribution, as well as in consumer level. Due to lack of facilities and availability of proper technology, a higher amount of foods are wasted in developing countries. Reduction of wastage can be possible upon facilitating different initiatives. The wastage of food causes not only scarcity of food but also adverse environmental and economic effects. Therefore, interventions for preventing food waste must be put forward to overcome the hunger problem in developing countries. An extensive discussion on food waste at different steps of the food chain has been presented in this chapter. An adverse effect of food waste has also been presented at the end of this chapter.
This study examined the association between generalized anxiety disorder (GAD) symptoms and healthcare utilization (HCU) among 801 people living with HIV (PLWH). Participants recruited from community health centers in Florida completed questionnaires assessing demographics, substance use, symptoms of GAD and depression, and HCU. Adjusted binary and multinomial logistic regressions assessed the association between moderate-severe GAD symptoms and past 6-month missed HIV-care appointments, overnight hospitalization, and emergency department (ED)/urgent care visits. Participants reporting moderate-severe GAD symptoms had a greater odds of missing an HIV-care appointment (AOR 2.03, 95% CI 1.28–3.24, p = 0.003), spending 2 (AOR 4.35, 95% CI 2.18–8.69, p < 0.001) or 3+ (AOR 2.79, 95% CI 1.20–6.45, p = 0.016) nights in the hospital, and visiting an ED/urgent care facility 2 (AOR 2.63, 95% CI 1.39–4.96, p = 0.003) or 3+ (AOR 2.59, 95% CI 1.27–5.26 p = 0.008) times compared to participants reporting none-mild anxiety. Depression was associated with fewer ED/urgent care visits and overnight hospitalizations, while no association was found with missed primary care appointments. The role of anxiety in illness management remains understudied among PLWH. Anxiety identification and the development of interventions for anxiety among PLWH may have important consequences for healthcare cost saving, patient retention in care, and HIV-disease management.
The purpose of this study was to examine the level of HIV/AIDS risk-behavior knowledge of students majoring in recreation and health-related fields. A total of 258 undergraduate and graduate students were surveyed. Over 50% of the participants believed that HIV can penetrate unbroken skin, over 40% believed that sharing kitchen utensils and a bathroom with a person with AIDS places one at risk for contracting AIDS, and nearly 25% believed that AIDS can be transmitted by mosquitoes and cockroaches. No significant relationship was found between participants' personal experience with people with AIDS and level of knowledge. Overall students demonstrated some knowledge of AIDS. However, there is still a great deal of misinformation regarding AIDS suggesting the need for incorporating HIV/AIDS information into the curriculum.
Discrimination in healthcare settings is a barrier to healthcare engagement. We analyzed two nationally representative datasets to assess change in discrimination in healthcare settings reported by HIV patients from 1996 to 2011-2013. Perceived discrimination in healthcare settings significantly decreased over time, from 24% in 1996 to 15% in 2011-2013. Improvements over time in HIV clinicians' engagement in prevention discussions with patients following federal agencies' recommendations may have been a contributing factor.
Cambridge Core - Sociology of Science and Medicine - A Handbook for the Study of Mental Health - edited by Teresa L. Scheid
A Handbook for the Study of Mental Health - edited by Teresa L. Scheid June 2017
We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.
To develop, pilot test, and conduct psychometric analyses of an innovative scale measuring the influence of perceived immigration laws on Latino migrants' HIV-testing behavior. The Immigration Law Concerns Scale (ILCS) was developed in three phases: Phase 1 involved a review of law and literature, generation of scale items, consultation with project advisors, and subsequent revision of the scale. Phase 2 involved systematic translation- back translation and consensus-based editorial processes conducted by members of a bilingual and multi-national study team. In Phase 3, 339 sexually active, HIV-negative Spanish-speaking, non-citizen Latino migrant adults (both documented and undocumented) completed the scale via audio computer-assisted self-interview. The psychometric properties of the scale were tested with exploratory factor analysis and estimates of reliability coefficients were generated. Bivariate correlations were conducted to test the discriminant and predictive validity of identified factors. Exploratory factor analysis revealed a three-factor, 17-item scale. subscale reliability ranged from 0.72 to 0.79. There were significant associations between the ILCS and the HIV-testing behaviors of participants. Results of the pilot test and psychometric analysis of the ILCS are promising. The scale is reliable and significantly associated with the HIV-testing behaviors of participants. Subscales related to unwanted government attention and concerns about meeting moral character requirements should be refined.
Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.
To describe the impact of highly active antiretroviral therapy (HAART) on mortality, morbidity, and markers of HIV disease progression in HIV infected women.
Data collected from the Women's Interagency HIV Study, a prospective cohort study that enrolled women between October 1994 and November 1995.
Six clinical consortia based in five cities in the United States (New York, NY; Washington, DC; Los Angeles, CA; San Francisco, CA; and Chicago, IL).
A total of 1691 HIV seropositive women with a study visit after April 1996.
Beginning in April 1996, the self reported use of HAART increased over time, with more than 50% of the cohort reporting HAART use in 1999. There was a 23% decline per semester in the incidence of AIDS from April 1996 (95% confidence intervals (CI) -29% to -16%). Furthermore, there was a 21% decline of the semiannual mortality rates among those with AIDS at baseline (95% CI -27% to -14%) and an 11% decline among those AIDS free at baseline (95% CI -3% to -18%). CD4+ lymphocyte counts either increased (women with baseline AIDS) or stabilised (women without baseline AIDS) after April 1996, and HIV RNA levels dramatically declined in both groups, although the percentage of women with HIV RNA above 4000 cps/ml remained stable at approximately 40% since mid-1997.
Despite concerns regarding the use of antiretroviral therapies in this population, the use of therapies led to improved immunological function, suppressed HIV disease activity, and dramatic declines in morbidity and mortality.
The major burden of the human immunodeficiency (HIV) type 1 pandemic is nowadays carried by women from sub-Saharan Africa. Differences in the manifestations of HIV-1 infection between women and men have been long reported, and might be due to both socio-economic (gender) and biological (sex) factors. Several studies have shown that women are more susceptible to HIV-1 acquisition than men. Following HIV-1 infection, women have lower viral loads during acute infection and exhibit stronger antiviral responses than men, which may contribute to differences in the size of viral reservoirs. Oestrogen receptor signalling could represent an important mediator of sex differences in HIV-1 reservoir size and may represent a potential therapeutic target. Furthermore, immune activation, a hallmark of HIV-1 infection, is generally higher in women than in men and could be a central mechanism in the sex difference observed in the speed of HIV-1 disease progression. Here, we review the literature regarding sex-based differences in HIV-1 infection and discuss how a better understanding of the underlying mechanisms could improve preventive and therapeutic strategies.
Objective: As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted. Methods: Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services. Results: HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet long-term care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts. Conclusions: Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.
Background: Insurance coverage facilitates access to life-saving medications for many patients with HIV disease. Thus, the effects of insurance coverage changes, such as the gain or loss of coverage, may be important in explaining patient access and adherence to the medications used in the treatment of HIV disease. Objectives: The study's objective was to examine whether changes in health insurance coverage affect rates of prescription drug use by patients with HIV disease. Methods: Data were ascertained from adults participating in a series of up to six interviews as part of the AIDS Costs and Services Utilization Survey (ACSUS). ACSUS was an 18-month panel survey of patients in care for HIV/AIDS at 26 sites located in 10 U.S. cities. Poisson regression analyses with generalized estimating equations were conducted to determine the effects of demographic and socioeconomic variables on the acquisition rate of antiretrovirals, antipneumocystics, and antidepressants. The analytic sample consisted of 1566 respondents who provided 6518 interviews. Results: Although changes in insurance coverage were common, complete loss of insurance was reported in only 1.5% of the interviews whereas gaining insurance was reported in 3.3% of interviews. Having no coverage was associated with significantly lower rates of antiretroviral (rate ratio [RR], 0.73), antipneumocystic (RR, 0.58) and antidepressant use (RR, 0.31). Gaining insurance coverage was associated with lower antiretroviral (RR, 0.75) and antipneumocystic (RR, 0.70) use whereas losing insurance was associated with lower antiretroviral use (RR, 0.58). In multivariate analyses, these associations remained. Conclusions: Changes in health insurance coverage are associated with lower rates of drug use for some medications used by patients with HIV disease.
Sex differences have been reported for multiple aspects of human immunodeficiency virus (HIV)-1 infection, including transmission, pathogenesis, morbidity, mortality, and responses to antiretroviral treatment. Epidemiological studies on sex differences in HIV-1 infection are numerous and in some instances controversial. The intrinsic interplay between multilayered socioeconomic factors and biological factors renders drawing definitive conclusions on sex differences in HIV-1 infection challenging. Nevertheless, some findings such as the lower viremia observed in women than in men have been consistently observed in multiple studies. It is also generally acknowledged that women display a greater susceptibility to HIV-1 acquisition. The simian immunodeficiency virus (SIV)model has been critical for understanding the biological characteristics of the female genital tract responsible for this greater susceptibility. Immune activation is another key factor in HIV-1 acquisition and pathogenesis that distinguishes men and women, with women exhibiting higher levels of immune activation. Data to date have pointed toward an important role of sex hormones in mediating these sex differences observed in the manifestation of HIV-1 disease. This chapter will focus on the discussion of (1) sex differences in HIV-1 acquisition and transmission, (2) sex differences in HIV-1 pathology, and (3) the impact of sex hormones including those exogenously delivered during contraceptive use. Sex differences related to responses to antiretroviral treatment go beyond the scope of this chapter and are reviewed in Chap. 4. © Springer International Publishing Switzerland 2015. All rights are reserved.
The development of AIDS symptoms is a gradual process whereby a diverse population of HIV-1 genomes replicate in macrophages, monocytes, and T cells, challenging the immune system to its extreme. The cellular compartments and machinery that facilitate the process are human gene products that are punctuated by allelic variation that in some cases, determines the efficiency and kinetics of disease progression. Using molecular genetic typing of epidemiologic cohorts of HIV-1-infected study participants, we have searched for host genetic variants in genes whose products participate in HIV-1 replication. To date we have discovered attributable genetic influence on HIV-1 infection, disease progression, and AIDS sequelae involving coding and promoter regions of several human genes, namely CCR5, CCR2, SDF1, HLA-A, -B, and -C. This report will highlight the discovery, characterization and functioning of the multi-genic influences on the outcomes of HIV-1 infection and the influence of these variants on epidemiologic heterogeneity of the AIDS epidemic.
This chapter discusses the evaluation of comprehensive AIDS clinical care. From the earliest days of the epidemic, several trends have emerged regarding the human-resource needs of the health-care professionals providing care for the increasing numbers of people living with HIV. With the advent of the AIDS epidemic, health-care professionals had to focus on the long-term care for HIV-infected populations and needed to train the next generation of doctors for better primary health-care services. One of the developments of AIDS activism was to encourage community support through buddy programs. AIDS changed the health-care environment through new judicial protections awarded to patients and families affected by the disease. The success of AIDS activism in creating distinct and generous federal funding that targeted HIV/AIDS services, treatment, and research has altered the way in which public health discourses are conducted around the allocation of resources for other serious and chronic illnesses.
This chapter focuses on the economics of the HIV/AIDS epidemic in the United States. The costs of the HIV epidemic in the United States are indeterminate. Utilization of health-care resources and outcomes of HIV/AIDS patients in care are known reasonably well. The flux of health services and product utilization is devoted to HIV-engendered costs in the realms of pharmaceuticals, outpatient care, hospitalization, and home care. Much of the future benefit of the response to HIV could come from investments directed at the unmet need for prevention services and improved access to care. This could increase the proportion of individuals with known and unknown infection who are in care so that prevention messages and medical therapies can be used to decrease transmission, the need for palliative care, and the burden on the affected but uninfected people while maintaining the productivity of the infected. The increases in government outlays for HIV drugs and HIV care generally could accelerate because of a number of factors, including the number and complexity of patients.
The goal of the current study is to review the published articles for pharmacoeconomic analyses of the highly active antiretroviral therapy (HAART) in patients with HIV/AIDS. Systematic literature databases search was performed in Scopus, PubMed, Google Scholar with key words HAART + pharmacoeconomics, HAART +cost of therapy. On total 77 studies were selected and analyzed. Pharmaceoconomic evaluations are necessary and important, because they are part of the therapeutic, and managerial decision rules. An important part of such evaluations is the budget impact analysis of the new therapies. Studies show that the burden of HIV infection is heavy for the society and individuals, especially in the developing countries. New therapies are developed with the aim to decrease the adverse therapeutic effects and toxicity of the new products part of the HAART. The future challenges remain the decrease in the cost of HIV medicines with the aim to ensure better access to therapy.
Ethical concerns have been a prominent feature of the debate about the HIV pandemic. Most ethical issues had already been analyzed by 1996, when HAART became available, but few of those issues have been re-analyzed since then. Also, few of the newer issues raised by HAART itself have been analyzed exhaustively. These issues include concerns about the generation and communication of personal information, rights to, care of people infected with HIV, as well as rights in relation to prevention and vaccine research. The capacity of HAART to prevent infection following a variety of HIV exposures raises concerns about HIV testing and disclosure of personal information. Some issues arise from availability of HAART, whereas others arise from its lack of availability, especially in developing countries. This chapter briefly examines the principle ethical issues that HAART highlights as a basis for encouraging future investigations and discussion.
This chapter provides an overview of the African experience of the AIDS epidemic. Large variations in the presentation of the HIV/AIDS epidemic exist among individual countries in Africa. In Somalia and Gambia, the prevalence is under 2%, whereas the national adult HIV prevalence rate in some other African countries has exceeded 30%. Throughout eastern and southern Africa, the prevalence rate of HIV in adolescent girls is over fivefold higher than in teenage boys. South Africa has been cited as the country with one of the largest absolute ratios between girls and boys. The chapter presents temporal trends in age-specific prevalence and incidence rates of HIV infection in prenatal clinics in a rural South African district. The important factors that contribute to severe HIV epidemics in sub-Saharan Africa include (1) social and political instability, (2) disruption of social support mechanisms and family structures, (3) human migration, (4) high rates of other sexually transmitted infections, (5) opportunistic infections, (6) subordinate position of women, and (7) armed conflicts. HIV/AIDS has a widespread impact on many parts of the African society-for example, on the individual, the family structure, and the society at large. HIV/AIDS dramatically affects economic activity and social progress and has become the biggest threat to the continent's development.
This chapter focuses on those facets of human immunodeficiency virus (HIV) that may differ between men and women as well as on clinical issues specific to women to provide guidelines for their care. It is emphasized that, except regarding those issues that are sex-specific, treatment algorithms for HIV-infected women do not differ from that of men. Discussions on the changing epidemiology of HIV provide the clinician with a framework to determine who may be at risk and to inform the application of guidelines to prevent subsequent HIV transmission. Although antiretroviral recommendations currently remain the same for men and women, the review of findings regarding early HIV infection and the reported discrepancy in HIV viral load can allow the clinician to interpret forthcoming data appropriately and to address misinformation or misinterpretation of these data by patients. Finally, the chapter also deals with sex-specific issues, such as the differential presentation of gynecologic problems in the HIV-infected woman and a brief summary of obstetric considerations.
The Multicenter AIDS Cohort Study was designed to 1) elucidate the natural history of the infection causing acquired immunodeficiency
syndrome (AIDS), 2) identify risk factors for occurrence and clinical expression of the infection, and 3) establish a repository
of biologic specimens for future study. A variety of recruitment techniques, including special assurance of confidentiality,
were used to enroll participants. Nearly 5,000 homosexual men volunteered for semiannual interview, physical examination,
and laboratory testing in four metropolitan areas. A significant majority of these men in each center (69–83%) reported having
50 or more lifetime sexual partners, and over 80% had engaged in receptive anal intercourse with at least some of their partners
in the previous two years. By the time of the participants' initial evaluation (April 1984-April 1985), infection with the
human immunodeficiency virus (HIV) had occurred in higher proportions of men in Los Angeles (51%) and Chicago (43%) than in
Baltimore/Washington, DC (31%) and Pittsburgh (21%), presumably as a result of the higher number of partners and proportion
with whom these men had engaged in high-risk practices (e.g., receptive anal intercourse). Follow-up evaluations are underway
in this comprehensive longitudinal investigation of HIV infection.
To provide recommendations for antiretroviral therapy based on information available in mid-1998.
An international panel of physicians with expertise in antiretroviral research and care of patients with human immunodeficiency virus (HIV) infection, first convened by the International AIDS Society-USA in December 1995.
The panel reviewed available clinical and basic science study results (including phase 3 controlled trials; clinical, virologic, and immunologic end point data; data presented at research conferences; and studies of HIV pathophysiology); opinions of panel members were also considered. Recommendations were limited to drugs available in mid-1998.
Panel members monitor new clinical research reports and interim results. The full panel meets regularly to discuss how the new information may change treatment recommendations. Updated recommendations are developed through consensus of the entire panel at each stage of development.
Accumulating data from clinical and pathogenesis studies continue to support early institution of potent antiretroviral therapy in patients with HIV infection. A variety of combination regimens show potency, expanding choices for initial regimens for individual patients. Plasma HIV RNA assays with increased sensitivity are important in monitoring therapeutic response; however, more data are needed to determine precisely the HIV RNA levels that define treatment failure. Long-term adverse drug effects are beginning to emerge, requiring ongoing attention. Some issues regarding optimal long-term approaches to antiretroviral management are unresolved. The increased complexity in HIV management requires ongoing monitoring of new data for optimal treatment of HIV infection.
The classical geographic research problem of regionalization and resource allocation is most commonly tackled by means of location-allocation methods. This paper introduces the spatial-order method as an alternative for creating regions or clusters. The spatial-order method utilizes space-filling curves, also known as Peano curves, to determine the nearness or spatial order of areal units, such as counties. Given a capacity constraint, the areal units are grouped consecutively according to their spatial order values. We applied the method to create clusters of rural counties for a national sampling survey of HIV/AIDS patients in the United States. Using the criteria that each cluster had approximately 50 new AIDS cases in 1991–1993 and that contiguity of areal units was maximized, 226 clusters were created from the 1,853 rural counties or health districts. The rural clusters generated by this method have been adopted as the national rural sampling frame in the HIV Cost and Services Utilization Study (HCSUS) being undertaken by RAND. In addition to its simplicity and fast computational speed, the spatial-order method produces satisfactory results. With minor modifications, this method can be an efficient alternative to the location-allocation method for solving a wide variety of locational problems, such as routing, political districting, and facilities location and allocation. This paper also demonstrates how a classical geographic research methodology, with the enhancement of GIS, can contribute to the multidisciplinary study of a pressing societal problem in our nation.
The design of complex samples induces correlations between element values. In stratification negative correlation reduces the variance; but that gain is less for subclass means, and even less for their differences and for complex statistics. Clustering induces larger and positive correlations between element values. The resulting increase in variance is measured by the ratio deff, and is often severe. This is reduced but persists for subclass means, their differences, and for analytical statistics. Three methods for computing variances are compared in a large empirical study. The results are encouraging and useful.
National surveillance data show recent, marked reductions in morbidity and mortality associated with the acquired immunodeficiency syndrome (AIDS). To evaluate these declines, we analyzed data on 1255 patients, each of whom had at least one CD4+ count below 100 cells per cubic millimeter, who were seen at nine clinics specializing in the treatment of human immunodeficiency virus (HIV) infection in eight U.S. cities from January 1994 through June 1997.
Mortality among the patients declined from 29.4 per 100 person-years in the first quarter of 1995 to 8.8 per 100 in the second quarter of 1997. There were reductions in mortality regardless of sex, race, age, and risk factors for transmission of HIV. The incidence of any of three major opportunistic infections (Pneumocystis carinii pneumonia, Mycobacterium avium complex disease, and cytomegalovirus retinitis) declined from 21.9 per 100 person-years in 1994 to 3.7 per 100 person-years by mid-1997. In a failure-rate model, increases in the intensity of antiretroviral therapy (classified as none, monotherapy, combination therapy without a protease inhibitor, and combination therapy with a protease inhibitor) were associated with stepwise reductions in morbidity and mortality. Combination antiretroviral therapy was associated with the most benefit; the inclusion of protease inhibitors in such regimens conferred additional benefit. Patients with private insurance were more often prescribed protease inhibitors and had lower mortality rates than those insured by Medicare or Medicaid.
The recent declines in morbidity and mortality due to AIDS are attributable to the use of more intensive antiretroviral therapies.
The volume and cost of services consumed by persons with AIDS (PWAs) during their last months of life are examined in this study.
This study utilizes data from the AIDS Costs and Service Utilization Survey (ACSUS). The ACSUS is the most comprehensive survey of medical services that are consumed by persons with HIV.
This study is restricted to persons with AIDS who survived the fifth time period (an approximately three-month period in the early spring and summer of 1992). The types and costs of services consumed during the fifth time period by PWAs who did survive (609) and who did not survive (79) the sixth time period are compared.
The ACSUS consists of six interviews over an 18-month period from Spring 1991 to Fall 1992.
Decedents were hospitalized more than four times as many days and experienced more than four times the number of home health visits as survivors. Both the average length of stay (19.3 days for decedents and 10.3 for survivors) and the frequency of hospitalization during the fifth time period (.70 for decedents and .28 for survivors) were higher for decedents than survivors. The levels of outpatient care (including emergency room care) and of prescription drug use were similar for decedents and survivors.
This study shows that the cost of treating decedents is more than three times the cost of treating survivors.
To estimate the number of persons infected with the human immunodeficiency virus (HIV) living in the United States and the change in HIV infection prevalence since 1984.
We estimated HIV prevalence from 3 data sources. We estimated past HIV infection rates from a statistical procedure based on national acquired immunodeficiency syndrome (AIDS) case surveillance data and estimates of the time from HIV infection to AIDS diagnosis. We also analyzed HIV prevalence data from 2 national surveys, a survey of childbearing woman and a household survey of current health status. We used other data sources to adjust these survey estimates to include groups not covered in the surveys.
Approximately 0.3% of US residents (650,000-900,000 persons) were infected with HIV in 1992. Approximately 0.6% of men (including adolescent boys > or = 13 years of age) were infected, including approximately 2% of non-Hispanic black men and 1% of Hispanic men. Approximately 0.1% of women (including adolescent girls > or = 13 years of age) were infected, including approximately 0.6% of non-Hispanic black women. Approximately half of all infected persons were men who had sex with men, and one fourth were injecting drug users. The prevalence of HIV infection increased from 1984 to 1992, with a greater relative increase among women than men.
The 3 different data sources and methods are consistent in estimating that 650,000 to 900,000 persons were infected with HIV in the United States in 1992. Among adolescents and adults of both sexes, the proportion infected was substantially higher among non-Hispanic blacks and Hispanics than among non-Hispanic whites. HIV-related illness will be a major clinical and public health problem in the United States for years to come.
The Division of HIV/AIDS Prevention at the United States Centers for Disease Control (CDC) has several observational databases through which it collects individual level data that can be used to evaluate the spectrum of HIV-related diseases and the utilization of HIV-related health care services. The HIV Epidemiology Research Study (HERS) is a multisite, prospective cohort study of HIV-infected women and uninfected women reporting HIV risk behavior. By interview, clinical examination, specimen collection and storage, laboratory testing, and medical record abstraction. HERS is examining the manifestations, correlates and predictors of HIV disease in women. In addition to the basic visits, a variety of nested studies are under way and several more are planned. Three additional observational databases collect individual level data primarily through systematic medical record abstraction. The Adult Spectrum of Disease (ASD) Study and the Pediatric Spectrum of Disease (PSD) Study collect data from a national sample of hospital and clinic medical records. The ASD also has a supplementary interview administered to consenting patients with new AIDS diagnoses in a subset of their study sites. The HIV Out-Patient Study (HOPS) collects data from an electronic charting system on outpatient findings and clinical care for patients attending a national sample of infectious disease clinics.
The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS.
One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation.
To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies.
Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records.
It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population.
It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.
To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS.
A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study.
Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium.
Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.
Address reprint requests to Dr Bozzette or Dr University of California at Los Angeles
- Project Hope
- Bethesda
- Md
- Shapiro
- Rand Office
- Main St
- M D Santa Monica
- M P H Marvin Marcus
- Neil S Wenger
Project Hope, Bethesda, Md. (M.L.B.); and the Agency for Health Care Policy and Re-search, Rockville, Md. (D.L.). Address reprint requests to Dr. Bozzette or Dr. Shapiro, HCSUS Office, RAND, 1700 Main St., Santa Monica, CA 90407-2138. Other authors were Ronald M. Andersen, Ph.D., William E. Cunning-ham, M.D., M.P.H., Marvin Marcus, D.D.S., M.P.H., and Neil S. Wenger, M.D., University of California at Los Angeles; Leslie A. Athey, M.S., and Stephen M. Smith, M.A., National Opinion Research Center, Chicago; Eric G. Bing, M.D., Drew University, Los Angeles; Julie A. Brown, B.A., M. Audrey Burnham, Ph.D., Dana P. Goldman, Ph.D., David E. Kanouse, Ph.D., Joan W. Keesey, B.A., Daniel F. McCaffrey, Ph.D., Judith F. Perlman, M.A., and Mark A. Schuster, M.D., Ph.D., RAND Health, Santa Monica, Calif.; Paul D. Cleary, Ph.D., Harvard Medical School, Boston; John A.
S.); the Veterans Affairs San Diego Healthcare System
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- Santa From Rand Health
- Calif Monica
©1998, Massachusetts Medical Society. From RAND Health, Santa Monica, Calif. (S.A.B., S.H.B., N.D., A.A.L., J.W.S., S.C.M., M.F.S.); the Veterans Affairs San Diego Healthcare System, San Diego, Calif., and the University of California at San Diego, La Jolla (S.A.B.); the University of California at Los Angeles (A.A.L., M.F.S.); the National Opinion Research Center, Chicago (M.R.F., C.-A.E.); Baruch College, City University of New York, New York (M.R.F.);
Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection
- Palella JF Jr
- Delaney KM
- Moorman AC
Palella JF Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998;338:853-60.
For personal use only. No other uses without permission. Copyright © 1998 Massachusetts Medical Society. All rights reserved 98 The New Eng land Jour nal of Medicine Study, and the Spectrum of Disease Studies
- D Smith
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Smith D. The HIV Epidemiology Research Study, HIV Out-Patient The New England Journal of Medicine Downloaded from nejm.org at UC SHARED JOURNAL COLLECTION on October 31, 2014. For personal use only. No other uses without permission. Copyright © 1998 Massachusetts Medical Society. All rights reserved. 1904 · December 24, 19 98 The New Eng land Jour nal of Medicine Study, and the Spectrum of Disease Studies. J Acquir Immune Defic Syndr Hum Retrovirol 1998;17:Suppl 1:S17-S19.
Injury chartbook: health, United States
- La Fingerhut
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Fingerhut LA, Warner M. Injury chartbook: health, United States, 1996–97.
National probability samples in studies of low-prevalence diseases. I. Perspectives and lessons from the HIV Cost and Services Utilization Study
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Shapiro MF, Berk ML, Berry SH, et al. National probability samples in studies of low-prevalence diseases. I. Perspectives and lessons from the HIV Cost and Services Utilization Study. Health Serv Res 1997.
HCSUS baseline patient questionnaire documentation
- Sh Berry
- Ja Brown
- L Athey
Berry SH, Brown JA, Athey L, et al. HCSUS baseline patient ques-tionnaire documentation. Santa Monica, Calif.: RAND (in press).
Compensating for missing survey data Ann Arbor: Survey Research Center
- G Kalton
Kalton G. Compensating for missing survey data. Ann Arbor: Survey Research Center, Institute for Social Research, University of Michigan, 1983.
HCSUS baseline methods technical report
- N Duan
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Duan N, McCaffrey DF, Frankel MR, et al. HCSUS baseline methods technical report. Santa Monica, Calif.: RAND (in press).
Educational attainment in the United States Current population reports. Series P-20. No. 489
- J Day
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Injury chartbook: health, United States, 1996-97
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22 Projections of the number of persons diagnosed with AIDS and the number of immunosuppressed HIV-infected persons-United States, 1992-1994
- Projections of the number of persons diagnosed with AIDS and the number of immunosuppressed HIV-infected persons -- United States