Background: Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs. Methods: The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants’ responses to the baseline VIDUS questionnaire and, from medical records at St. Paul’s Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants. Results: A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul’s Hospital during the study period. Of these 440, 265 (60.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2–2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6–5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1–2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2–3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1–2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4–8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4–6.0); and female sex (adjusted OR 1.8, 95% CI 1.1–3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year. Interpretation: Hospital utilization was significantly higher among communitybased IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.

/pdf/hospital-utilization-and-costs-in-a-cohort-of-injection-drug-21gqwdp8bc.pdf

Hospital utilization and costs in a cohort of injection drug users

Adolescents are at risk for HIV primarily through their sexual behavior A comprehensive prevention strategy includes a national HIV campaign based on social marketing principles; targeted social marketing, intensive skill building, and sexually transmitted disease control programs for youth at high risk; programs targeting institutions (eg, school health clinics), providers, and parents; and interventions to identify and reduce risk acts among seropositive youth The US focus for HIV prevention has been single-session educational classes (an ineffective strategy) or intensive multi-session, small-group interventions for youth at high risk (demonstrated to increase condom use by about 30%) There is a need to expand the range, modalities, and dissemination of HIV prevention programs nationally, to recognize (especially by policymakers) limitations of abstinence programs, and to increase early detection of HIV among youth

Prevention of HIV among adolescents.

This review of published studies on the costs of HIV treatment and care describes some of the recent developments that have influenced these costs in industrialised and industrialising countries, especially within the context of changing drug treatments. Some of the different approaches to estimating the economic impact of HIV infection are briefly presented. The methods used to review the literature are described, particularly the criteria of a scoring system that was specifically developed to systematically screen some of the studies identified. The mean review score for studies dealing with direct hospital costs increased significantly (p = 0.003) over the 3 periods analysed (before 1987, 1987 to 1995, and 1996 and beyond), indicating that the overall ‘quality’ of studies increased over time. All cost estimates, other than those from non-industrialised regions, were converted to 1996 US dollars using country-specific total health expenditure inflaters and country-specific Gross Domestic Product Purchasing Power Parity converters. A summary of hospital cost estimates over time and by region demonstrated that the costs of treating asymptomatic individuals and people with symptomatic non-AIDS increased over the period, but that the costs of treating individuals with AIDS appears to have stabilised since the late 1980s. As fewer studies could be identified on the costs of community and informal care, indirect productivity costs and population cost estimates, and costs of care for children with HIV infection, all of these studies were reviewed without the use of the scoring system. Finally, the discussion explores the evidence on the global costs of HIV in non-industrialised economies and the affordability of HIV treatment and care. Some suggestions for the direction of future HIV costing studies are also presented. A need remains for good quality cost data. Adequate research effort should be directed to improving the scope and quality of information on costs of HIV service provision around the world.

The cost of HIV treatment and care. A global review.

The aim of this study was to assess the correlation and average cost of total lymphocyte count compared with CD4 count as a broad estimate of immunosuppression in HIV-1 infected individuals. Spearman's partial rank correlation were calculated between total lymphocyte count, absolute CD4 count and CD4 per cent stratified by stage of HIV-1 infection for routinely collected samples. Data were collected prospectively from a T cell-subset register combined with clinical data obtained retrospectively from case notes of HIV-infected patients managed at St Mary's Hospital, London 1982-1991. Costing data were obtained through a survey of the departments of haematology and immunology 1989 90 prices . The correlation between 1534 paired absolute lymphocyte count and CD4 lymphocyte count was found to be high R 0.76 . When analysed by stage of HIV infection, the correlation increased from R 0.64 for asymptomatic patients, to R 0.72 for patients with symptomatic non-AIDS HIV infection and R 0.73 for AIDS patients. Corr...

Correlation between total and CD4 lymphocyte counts in HIV infection: not making the good an enemy of the not so perfect.

Aim: To estimate the cost-effectiveness ratio of highly-active antiretroviral therapy (HAART) in Canada. Design: A before-and-after analysis to calculate incremental cost of life year gained (LYG) between 1991 and 1995 (pre-HAART period) and between 1997 and 2001 (HAART period) for non-AIDS and AIDS groups (CDC stage of HIV infection). Methods: For two Quebec HIV hospital clinics, mean inpatient (IP) days, outpatient (OP) visits and direct health care costs per patient-year (PPY) were calculated. Cox's proportional hazards models calculated disease progression, stratified by study periods and adjusted for gender, age at cohort entry, sexual orientation, injecting drug use and baseline CD4 cell count. Results: For non-AIDS patients, mean IP days was 1.6 (pre-HAART period) compared with 0.8 PPY (HAART period); mean OP visits increased from 2.8 to 5.5 PPY. Total cost was US$ 4265 (pre-HAART period) and IJS$ 9445 PPY (HAART period) of which 66 and 84%, respectively were spent on antiretroviral drugs. Median progression time was 6.3 years in the pre-HAART period compared with 12.5 years in HAART period (log rank X 2 =270, P<0.0001). Incremental cost per LYG between periods was US$ 14 587. For AIDS patients, mean IP days decreased from 13.3 to 4.4 PPY between periods; OP visits increased from 8.3 to 9.2 PPY. Total costs increased from US$ 9099 to US$11 754 PPY, while expenditure cn antiretroviral drugs increased from 29 to 72% of total cost. Median progression time was 3.8 years in the pre-HAART period, which increased to 13.3 years in the HAART period (log rank X 2 = 158, P < 0.0001); incremental cost per LYG between periods was US$ 12 813. Conclusion: HAART appeared a cost-effective intervention in Canada.

/pdf/the-cost-effectiveness-of-highly-active-antiretroviral-4tecq2l005.pdf

The cost-effectiveness of highly active antiretroviral therapy, Canada 1991-2001.

Objective.To describe the use of hospilal-based services and associated costs over time for HIV-infected individuals by disease stage and year of treatment. Methods: Data on service use were abstracted from inpalient and outpatient case-notes of 459 HIV-infected patients (121 asymptomatic and 338 AI

Changing use of hospital services and costs at a London AIDS referral centre, 1983-1989.

OBJECTIVE To describe the use of services and associated costs for HIV-infected patients by stage of infection in the context of changing patterns of presentation and survival. METHODS A retrospective analysis of inpatient and outpatient case-notes of 335 AIDS patients and a survey of HIV-related care provided by 37 departments at St Mary's Hospital, London. Survival from time of diagnosis of AIDS, time from diagnosis of HIV infection to AIDS, and use and costs of services per patient-year were outcome measures. RESULTS During the study period 1 January 1982 to 30 September 1989, 152 AIDS patients were diagnosed before 1987 (group 1) and 183 since 1987 (group 2), most of whom were homosexual men. The median interval of first HIV-related visit to diagnosis of AIDS increased from 0 (group 1) to 264 days (group 2; P < 0.0001). Median survival from AIDS diagnosis increased from 14.6 (group 1) to 21.0 months (group 2; P < 0.02). Group 2 patients used fewer inpatient services than group 1 patients irrespective of disease stage. Symptomatic patients in group 2 used more outpatient services than group 1 patients. Total HIV-related expenditure was lower for patients without AIDS in group 2 than in group 1, while expenditure for AIDS patients remained similar. CONCLUSION Earlier patient presentation, a shift from inpatient- to outpatient-based clinical care and increased survival from time of AIDS diagnosis has occurred. Increased drug expenditure was offset by reduced inpatient expenditure. Total expenditure per patient-year was stable; increased survival and introduction of new drugs will increase future lifetime use of resources.

Changing presentation and survival, service utilization and costs for AIDS patients: insights from a London referral centre.

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Changing use of hospital services and costs at a London AIDS referral centre, 1983-1989.

Changing presentation and survival, service utilization and costs for AIDS patients: insights from a London referral centre.