Human Immunodeficiency Virus Cost Research Articles

Navigating Barriers and Opportunities: Perceptions of the Non-Occupational Post-Exposure Prophylaxis Care Continuum Among Young Sexual Minority Men, Aged 17-24, in the United States.

Human immunodeficiency virus (HIV) is a public health concern among young sexual minority men (YSMM), ages 17 to 24, in the United States. Biomedical prevention methods, such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP), can help reduce the risk of HIV transmission among this population. However, there is limited awareness and use of nPEP by YSMM. This study aims to explore the perceptions of YSMM regarding the nPEP care continuum, which consists of three areas of focus: awareness, uptake, and linkage to other HIV prevention services. This study draws on synchronous online focus groups with a sample of 41 YSMM in the United States. Transcripts from the focus groups were analyzed using reflexive thematic analysis. Participants reported limited nPEP awareness and prior use, a process of personal appraisal of nPEP need based on HIV risk and costs, and a preference for PrEP over PEP for long-term HIV prevention. Interventions should be tailored to increase awareness of nPEP among YSMM and reduce addressable barriers to nPEP use for YSMM, including cost and confidentiality concerns, in situations where nPEP is warranted. Finally, more research is needed on how nPEP use can act as a bridge to PrEP initiation for this population.

Using adult care visits to diagnose HIV infection in children, Burkina Faso.

To estimate the feasibility, positivity rate and cost of offering child testing for human immunodeficiency virus (HIV) to mothers living with HIV attending outpatient clinics in Burkina Faso. We conducted this implementation study in nine outpatient clinics between October 2021 and June 2022. We identified all women ≤ 45 years who were attending these clinics for their routine HIV care and who had at least one living child aged between 18months and 5years whose HIV status was not known. We offered these mothers an HIV test for their child at their next outpatient visit. We calculated intervention uptake, HIV positivity rate and costs. Of 799 eligible children, we tested 663 (83.0%) and identified 16 new HIV infections: 2.5% (95% confidence interval, CI: 1.5-4.1). Compared with HIV-negative children, significantly more HIV-infected children were breastfed beyond 12 months (P-value: 0.003) and they had not been tested before (P-value: 0.003). A significantly greater proportion of mothers of HIV-infected children were unaware of the availability of child testing at 18 months (P-value: < 0.001) and had more recently learnt their HIV status (P-value: 0.01) than mothers of HIV-negative children. The intervention cost 98.1 United States dollars for one child testing HIV-positive. Barriers to implementing this strategy included shortages of HIV tests, increased workload for health-care workers and difficulty accessing children not living with their mothers. Testing HIV-exposed children through their mothers in outpatient clinics is feasible and effective in a low HIV-prevalence setting such as Burkina Faso. Implementation of this strategy to detect undiagnosed HIV-infected children is recommended.

Patient perspectives and needs regarding contraception in female patients with HIV: A qualitative study

BackgroundWomen with human immunodeficiency virus (HIV) are at risk of unintended pregnancy and may experience barriers to accessing contraception such as social stigma, concern for drug-drug interactions with HIV regimens, cost, and access to care. As pharmacist prescriptive authority for contraception becomes more prevalent, pharmacists may play a role in expanding access to contraception for women with HIV. Little is known about perspectives in this population regarding pharmacists prescribing contraception. ObjectivesThe objective of our study was to explore participants’ experiences with contraception and childbearing, identify barriers to receiving contraception and unmet needs for contraceptive services, and explore perspectives on pharmacists prescribing contraception among women with HIV receiving care at a specialty HIV clinic. MethodsThis qualitative study used semistructured phone interviews with female patients receiving care at the University of New Mexico Truman Health Services in Albuquerque, New Mexico (NM). Interviews were transcribed verbatim and analyzed by 2 independent coders using Dedoose software. ResultsContraception use was high in our population, with 75% of participants reporting a current contraceptive method. Among our population, participants were supportive of pharmacists prescribing contraception. Participants appreciated that pharmacies were accessible and convenient and that pharmacists are well trained and able to manage drug-drug interactions. Participants expressed a preference for pharmacists to explain all available contraceptive options and to have a thorough understanding of their medical history and medications. Participants expressed concern about privacy and disclosure of their HIV status when receiving contraception from a pharmacist. ConclusionAmong our population of women with HIV receiving care at a specialty clinic in NM, participants were supportive of pharmacists prescribing contraception. Pharmacists should consider the preferences of this population when prescribing contraception. Further research is warranted in additional populations of women with HIV to further explore unique perspectives among non-English speaking patients and those who do not receive care at specialty clinics.

Treatment and comorbidity burden among people living with HIV: a review of systematic literature reviews

Background As the human immunodeficiency virus (HIV) treatment landscape continues to evolve, the prolonged life expectancy and long-term exposure to antiretroviral drugs have modified the burden associated with living with HIV. Objective To better understand the current treatment and comorbidity burden in people living with HIV (PLWH). Methods Peer-reviewed systematic literature reviews (SLRs) between 2017 and 2020 that included US studies and examined drug adherence/pill burden, resistance burden, or comorbidities in PLWH were identified. Methods and findings were extracted for the overall studies and examined in the subset of US studies. Results Among 665 publications identified, 47 met the inclusion criteria (drug adherence/pill burden: 5; resistance: 3; comorbidities: 40). While antiretroviral drug adherence levels varied across SLRs, single-tablet regimens (STR) were associated with higher adherence versus multiple-tablet regimens. STRs were also associated with lower risk of treatment discontinuation, higher cost-effectiveness, and lower risk of hospitalization. Longer survival resulted in a high comorbidity burden, with non-AIDS causes accounting for 47% of deaths among PLWH in the US. HIV doubled the risk of cardiovascular disease and was associated with other health problems, including bone and muscle diseases, depression, and cancers. Several antiretroviral regimens were associated with chronic diseases, including cardiometabolic conditions. Lifetime HIV costs are substantially increasing, driven by antiretroviral, adverse event, and comorbidity treatment costs cumulated due to longer survival times. Conclusions There is a considerable burden associated with HIV and antiretroviral treatment, highlighting the benefits of less complex and safer regimens, and the unmet need for effective preventative interventions.

Associations between HIV stigma and social support for people living with HIV in Hyderabad, India

AbstractThe present study examined the association between social support and Human Immunodeficiency Virus (HIV) stigma through a survey of 150 people living with HIV (PLWH) in Hyderabad, India. Survey items to assess social support were adapted from the HIV Cost Services and Utilization Survey. HIV stigma was measured using Zelaya and Jeyaseelan scales that were previously validated in India. Multiple linear regression analysis revealed an inverse association between social support and HIV stigma across both stigma scales. Depression further intensified the level of stigma faced by PLWH who had lower levels of social support. Third‐gender individuals experienced significantly higher HIV stigma and lower social support than cisgender men. Social support must be used as a protective factor in current HIV stigma reduction interventions. Findings highlight the need to adopt a gender‐sensitive social support framework in HIV care policies to better address HIV stigma in the Indian context.

Cost of Human Immunodeficiency Virus (HIV) and Determinants of Healthcare Costs in HIV-Infected Treatment-Naive Patients Initiated on Antiretroviral Therapy in Germany: Experiences of the PROPHET Study

The purpose of the prospective clinical and pharmacoeconomic outcomes study of different first-line antiretroviral treatment strategies (PROPHET) was to examine the healthcare costs of human immunodeficiency virus (HIV)-infected persons in Germany treated with different antiretroviral therapy (ART) strategies and to identify variables associated with high costs. The setting was a 24-month prospective multicenter observational cohort study in a German HIV-specialized care setting from 2014 to 2017. A microcosting approach was used for the estimation of healthcare costs. Data were obtained via electronic case report forms. The costs were calculated from both the societal and the statutory health insurance perspective. Regression models were performed that took into consideration the impact of several independent variables. Four hundred thirty-four patients from 24 centers throughout Germany were included. Average annual healthcare costs were €20 118 (standard deviation [SD] €6451) per patient from the societal perspective (n= 336) and €17 306 (SD €4106) from the statutory health insurance perspective (n= 292). Expenditures for the ART medication had the highest impact. Total costs declined in the second year of therapy. There was a significant association between the amount of total cost and clinical or therapeutic variables from both perspectives; a diagnosis of acquired immune deficiency syndrome (AIDS) led to higher costs as well as the chosen ART strategy. Age also increased cost from the statutory health insurance perspective. The main cost driver of the healthcare costs for HIV-positive patients was antiretroviral drug expenses. Further variables that influenced the costs were identified. The results provide a detailed overview of the resource use of patients in the PROPHET cohort.

Estimating HIV Management and Comorbidity Costs Among Aging HIV Patients in the United States: A Systematic Review.

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. 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. 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. 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. 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. 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.

Cost-effectiveness of Injectable Preexposure Prophylaxis for HIV Prevention in South Africa.

Long-acting injectable antiretrovirals such as rilpivirine (RPV) could promote adherence to preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. However, the cost-effectiveness of injectable PrEP is unclear. We constructed a dynamic model of the heterosexual HIV epidemic in KwaZulu-Natal, South Africa, and analyzed scenarios of RPV PrEP scale-up for combination HIV prevention in comparison with a reference scenario without PrEP. We estimated new HIV infections, life-years and costs, and incremental cost-effectiveness ratios (ICERs), over 10-year and lifetime horizons, assuming a societal perspective. Compared with no PrEP, unprioritized scale-up of RVP PrEP covering 2.5%-15% of adults prevented up to 9% of new infections over 10 years. HIV prevention doubled (17%) when the same coverage was prioritized to 20- to 29-year-old women, costing $10 880-$19 213 per infection prevented. Prioritization of PrEP to 80% of individuals at highest behavioral risk achieved comparable prevention (4%-8%) at <1% overall coverage, costing $298-$1242 per infection prevented. Over lifetime, PrEP scale-up among 20- to 29-year-old women was very cost-effective (<$1600 per life-year gained), dominating unprioritized PrEP, while risk prioritization was cost-saving. PrEP's 10-year impact decreased by almost 50% with increases in ICERs (up to 4.2-fold) in conservative base-case analysis. Sensitivity analysis identified PrEP's costs, efficacy, and reliability of delivery as the principal drivers of uncertainty in PrEP's cost-effectiveness, and PrEP remained cost-effective under the assumption of universal access to second-line antiretroviral therapy. Compared with no PrEP, prioritized scale-up of RPV PrEP in KwaZulu-Natal could be very cost-effective or cost-saving, but suboptimal PrEP would erode benefits and increase costs.

Crowdsourcing HIV Test Promotion Videos: A Noninferiority Randomized Controlled Trial in China.

Crowdsourcing, the process of shifting individual tasks to a large group, may enhance human immunodeficiency virus (HIV) testing interventions. We conducted a noninferiority, randomized controlled trial to compare first-time HIV testing rates among men who have sex with men (MSM) and transgender individuals who received a crowdsourced or a health marketing HIV test promotion video. Seven hundred twenty-one MSM and transgender participants (≥16 years old, never before tested for HIV) were recruited through 3 Chinese MSM Web portals and randomly assigned to 1 of 2 videos. The crowdsourced video was developed using an open contest and formal transparent judging while the evidence-based health marketing video was designed by experts. Study objectives were to measure HIV test uptake within 3 weeks of watching either HIV test promotion video and cost per new HIV test and diagnosis. Overall, 624 of 721 (87%) participants from 31 provinces in 217 Chinese cities completed the study. HIV test uptake was similar between the crowdsourced arm (37% [114/307]) and the health marketing arm (35% [111/317]). The estimated difference between the interventions was 2.1% (95% confidence interval, -5.4% to 9.7%). Among those tested, 31% (69/225) reported a new HIV diagnosis. The crowdsourced intervention cost substantially less than the health marketing intervention per first-time HIV test (US$131 vs US$238 per person) and per new HIV diagnosis (US$415 vs US$799 per person). Our nationwide study demonstrates that crowdsourcing may be an effective tool for improving HIV testing messaging campaigns and could increase community engagement in health campaigns. NCT02248558.

The Epidemiologic and Economic Impact of Improving HIV Testing, Linkage, and Retention in Care in the United States

Recent guidelines advocate early antiretroviral therapy (ART) to decrease human immunodeficiency virus (HIV) morbidity and prevent transmission, but suboptimal engagement in care may compromise impact. We sought to determine the economic and epidemiologic impact of incomplete engagement in HIV care in the United States. We constructed a dynamic transmission model of HIV among US adults (aged 15-65 years) and conducted a cost-effectiveness analysis of improvements along the HIV care continuum : We evaluated enhanced HIV testing (annual for high-risk groups), increased 3-month linkage to care (to 90%), and improved retention (50% relative reduction in yearly disengagement and 50% increase in reengagement). Our primary outcomes were HIV incidence, mortality, costs and quality-adjusted life-years (QALYs). Despite early ART initiation, a projected 1.39 million (95% uncertainty range [UR], 0.91-2.2 million) new HIV infections will occur at a (discounted) cost of $256 billion ($199-298 billion) over 2 decades at existing levels of HIV care engagement. Enhanced testing with increased linkage has modest epidemiologic benefits and could reduce incident HIV infections by 21% (95% UR, 13%-26%) at a cost of $65 700 per QALY gained ($44 500-111 000). By contrast, comprehensive improvements that couples enhanced testing and linkage with improved retention would reduce HIV incidence by 54% (95% UR, 37%-68%) and mortality rate by 64% (46%-78%), at a cost-effectiveness ratio of $45 300 per QALY gained ($27 800-72 300). Failure to improve engagement in HIV care in the United States leads to excess infections, treatment costs, and deaths. Interventions that improve not just HIV screening but also retention in care are needed to optimize epidemiologic impact and cost-effectiveness.

What determines health-related quality of life among people living with HIV: an updated review of the literature.

BackgroundAs infection with the Human Immunodeficiency Virus (HIV) has evolved to a chronic disease, perceived health-related quality of life (HRQoL) is becoming a prominent and important patient-reported outcome measure in HIV care. Literature discusses different factors influencing HRQoL in this population, however, currently no consensus exists about the main determinants. In this review a clear, up-to-date overview of the determinants influencing HRQOL among people living with HIV is provided.MethodsAll studies published before July 2013 that identified determinants of HRQoL among people living with HIV in high-income countries, were considered in this narrative review. PubMed, Web of Science and The Cochrane Library were consulted using the keywords ‘determinants’, ‘quality of life’, ‘HIV’ and ‘AIDS’. To be included, studies should have reported overall health and/or physical/mental health scores on a validated instrument and performed multivariable regression analyses to identify determinants that independently influence perceived HRQoL.ResultsIn total, 49 studies were included for further analysis and they used a variety of HRQoL instruments: Medical Outcomes Study Short Form-36 or variants, Medical Outcomes Study-HIV, HIV Cost and Services Utilization Study measure, Multidimensional Quality of Life Questionnaire, HIV targeted quality of life instrument, Functional Assessment of Human Immunodeficiency Virus Infection, HIV Overview of Problems Evaluation System, EuroQol, Fanning Quality of Life scale, Health Index and PROQOL-HIV. In this review, the discussed determinants were thematically divided into socio-demographic, clinical, psychological and behavioural factors. Employment, immunological status, presence of symptoms, depression, social support and adherence to antiretroviral therapy were most frequently and consistently reported to be associated with HRQoL among people living with HIV.ConclusionsHRQoL among people living with HIV is influenced by several determinants. These determinants independently, but simultaneously impact perceived HRQoL. Most HRQoL instruments do not capture all key determinants. We recommend that the choice for an instrument should depend on the purpose of the HRQoL assessment.Electronic supplementary materialThe online version of this article (doi:10.1186/2049-3258-72-40) contains supplementary material, which is available to authorized users.

Cost-Effectiveness of HIV Treatment as Prevention in Serodiscordant Couples

BackgroundThe cost-effectiveness of early antiretroviral therapy (ART) in persons infected with human immunodeficiency virus (HIV) in serodiscordant couples is not known. Using a computer simulation of the progression of HIV infection and data from the HIV Prevention Trials Network 052 study, we projected the cost-effectiveness of early ART for such persons.MethodsFor HIV-infected partners in serodiscordant couples in South Africa and India, we compared the early initiation of ART with delayed ART. Five-year and lifetime outcomes included cumulative HIV transmissions, life-years, costs, and cost-effectiveness. We classified early ART as very cost-effective if its incremental cost-effectiveness ratio was less than the annual per capita gross domestic product (GDP; $8,100 in South Africa and $1,500 in India), as cost-effective if the ratio was less than three times the GDP, and as cost-saving if it resulted in a decrease in total costs and an increase in life-years, as compared with delayed ART.ResultsIn South Africa, early ART prevented opportunistic diseases and was cost-saving over a 5-year period; over a lifetime, it was very cost-effective ($590 per life-year saved). In India, early ART was cost-effective ($1,800 per life-year saved) over a 5-year period and very cost-effective ($530 per life-year saved) over a lifetime. In both countries, early ART prevented HIV transmission over short periods, but longer survival attenuated this effect; the main driver of life-years saved was a clinical benefit for treated patients. Early ART remained very cost-effective over a lifetime under most modeled assumptions in the two countries.ConclusionsIn South Africa, early ART was cost-saving over a 5-year period. In both South Africa and India, early ART was projected to be very cost-effective over a lifetime. With individual, public health, and economic benefits, there is a compelling case for early ART for serodiscordant couples in resource-limited settings. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

A comparative analysis of outpatient costs in HIV treatment programs

To analyze the costs of human immunodeficiency virus (HIV) outpatient treatment for individuals with different CD4 cell counts in the Brazilian public health system, and to compare to costs in other national health systems. A retrospective survey was conducted in five public outpatient clinics of the Brazilian national HIV program in the city of São Paulo. Data on healthcare services provided for a period of one year of HIV outpatient treatment were gathered from randomly selected medical records. Prices of inputs used were obtained through market research and public sector databases. Information on costs of HIV outpatient treatment in other national health systems were gathered from the literature. Annual costs of HIV outpatient treatment from each country were converted into 2010 U.S. dollars. Annual cost of HIV outpatient treatment for the Brazilian national public program was US$ 2,572.92 in 2006 in São Paulo, ranging from US$ 1,726.19 for patients with CD4 cell count > 500 to US$ 3,693.28 for patients with 51 < CD4 cell count < 200. Antiretrovirals (ARVs) represented approximately 62.0% of annual HIV outpatient costs. Comparing among different health systems during the same period, HIV outpatient treatment presented higher costs in countries where HIV treatment is provided by the private sector. The main cost drivers of HIV outpatient treatment in different health systems were: ARVs, other medications, health professional services, and diagnostic exams. Nevertheless, the magnitude of cost drivers varied among HIV outpatient treatment programs due to health system efficiency. The data presented may be a valuable tool for public policy evaluation of HIV treatment programs worldwide.

Economic and health-related quality-of-life (HRQoL) comparison of lopinavir/ritonavir (LPV/r) and atazanavir plus ritonavir (ATV+RTV) based regimens for antiretroviral therapy (ART)-naïve and -experienced United Kingdom patients in 2011

Background:Using a United Kingdom (UK)-based National Health Services perspective for 2011 this study first estimated the cost-effectiveness and budget impact implications for lopinavir/ritonavir (LPV/r) vs atazanavir plus ritonavir (ATV+RTV) treatment of antiretroviral therapy (ART)-naïve patients and secondly examined the long-term health-related quality-of-life (HRQoL) and economic implications for LPV/r vs ATV+RTV treatment of ART-experienced patients.Methods:A previously published Markov model that integrates epidemiological data of human immunodeficiency virus (HIV) with predictors of coronary heart disease (CHD) was modified under a clearly specified set of assumptions to reflect viral load (VL) suppression profiles and other differences for these two regimens, applying results from the CASTLE study in ART-naïve patients and using data from BMS-045 in ART-experienced patients. ART costs were referenced to current (2011) pricing guidelines in the UK. Medical care costs reflected UK treatment patterns and relevant drug pricing. Costs and outcomes were discounted at 3.5% per year. Costs are expressed in British pounds (£) and life expectancy in quality-adjusted life years (QALYs).Results:In the ART-naïve subjects, the model predicted a marginal improved life expectancy of 0.031 QALYs (11 days) for the ATV+RTV regimen as a result of predicted CHD outcomes based on lower increases in cholesterol levels compared with the LPV/r regimen. The model demonstrated cost savings with the LPV/r regimen. The total lifetime cost savings was £4070 per patient for the LPV/r regimen. LPV/r saved £2133 and £3409 per patient at 5 and 10 years, respectively. Referenced to LPV/r, the incremental cost-effectiveness ratio (ICER) for ATV+RTV was £149,270/QALY. For ART-experienced patients VL suppression differences favored LPV/r, while CHD risk associated with elevated total cholesterol marginally favored ATV+RTV, resulting in a net improvement in life expectancy of 0.31 QALYs (106 days) for LPV/r. Five-year costs were £5538 per patient greater for ATV+RTV, with a discounted lifetime saving of £1445 per LPV/r patient. LPV/r was modestly dominant economically, producing better outcomes and cost savings.Limitations:The limitations of this study include uncertainty related to how well the model’s assumptions capture current practice, as well as the validity of the model parameters used. This study was limited to using aggregated data in the public domain from the two clinical trials. Thus, some of the model parameters may reflect limitations due to trial design and data aggregation bias. This study has attempted to illuminate the effect of these limitations by presenting the results of the comprehensive sensitivity analysis.Conclusions:Based on 2011 costs of HIV in the UK and the published efficacy data from the CASTLE and BMS-045 studies, ATV+RTV-based regimens are not expected to be a cost-effective use of resources for ART-naïve patients similar to patients in the CASTLE study, nor for ART-experienced patients based on the only published comparison of ATV+RTV and LPV/r.

The Cost-effectiveness of Pre-Exposure Prophylaxis for HIV Infection in South African Women

Recent trials report the short-term efficacy of tenofovir-based pre-exposure prophylaxis (PrEP) for prevention of human immunodeficiency virus (HIV) infection. PrEP's long-term impact on patient outcomes, population-level transmission, and cost-effectiveness remains unknown. We linked data from recent trials to a computer model of HIV acquisition, screening, and care to project lifetime HIV risk, life expectancy (LE), costs, and cost-effectiveness, using 2 PrEP-related strategies among heterosexual South African women: (1) women receiving no PrEP and (2) women not receiving PrEP (a tenofovir-based vaginal microbicide). We used a South African clinical cohort and published data to estimate population demographic characteristics, age-adjusted incidence of HIV infection, and HIV natural history and treatment parameters. Baseline PrEP efficacy (percentage reduction in HIV transmission) was 39% at a monthly cost of $5 per woman. Alternative parameter values were examined in sensitivity analyses. Among South African women, PrEP reduced mean lifetime HIV risk from 40% to 27% and increased population discounted (undiscounted) LE from 22.51 (41.66) to 23.48 (44.48) years. Lifetime costs of care increased from $7280 to $9890 per woman, resulting in an incremental cost-effectiveness ratio of $2700/year of life saved, and may, under optimistic assumptions, achieve cost savings. Under baseline HIV infection incidence assumptions, PrEP was not cost saving, even assuming an efficacy >60% and a cost <$1. At an HIV infection incidence of 9.1%/year, PrEP achieved cost savings at efficacies ≥50%. PrEP in South African women is very cost-effective by South African standards, conferring excellent value under virtually all plausible data scenarios. Although optimistic assumptions would be required to achieve cost savings, these represent important benchmarks for future PrEP study design.

Cost of HIV and determinants of health care costs in HIV-positive patients in Germany – Results of the DAGNÄ K3A Study

The rising prevalence of human immunodeficiency virus (HIV)-infection in Germany leads to an increasing health economic burden. However there is a lack of nation-wide data on the current medical and societal costs of HIV and AIDS. Objectives: The aims of this study were to estimate the medical expenditures for HIV-care in Germany and to identify variables associated with resource use. Methods: We performed an 18-months prospective multi-centre study in an HIV-specialized ambulatory care setting from 2006–2009. All health care costs were estimated following a bottom-up approach from two perspectives: 1) those incurred to society in general and 2) those incurred to statutory health insurance. Clinical and health economic data were obtained using questionnaires, patient interviews and physician clinical documentation. Several empirical models for identifying the relationship between health care costs and independent variables were developed. Results: 518 patients from 17 centres were included in this health economic analysis. Average annual health care costs were €23,298 per patient from the societal perspective and €19,103 from the statutory health insurance perspective. Most expenses were derived from drug expenditures (80% of the total and 89% of direct costs), while hospital costs represented 7% of total expenditures. A statistically significant association was found between health care costs and clinical variables with a higher CD4 count and female gender generating lower costs, while increased antiretroviral experience and injection drug use (IDU) as a mode of transmission led to higher expenditures (p<0.05). Health care expenditures for HIV-infection are mainly driven by drug costs. We identified several clinical variables influencing the cost of HIV-treatment. This information could assist policymakers in their decision-making processes when allocating limited health care resources to HIV care.

Voluntary Physician Switching by Human Immunodeficiency Virus-Infected Individuals

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients. We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region. Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52). Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Clinical and Economic Outcomes of Nonadherence to Highly Active Antiretroviral Therapy in Patients With Human Immunodeficiency Virus

Nonadherence with highly active antiretroviral therapy (HAART) is common in typical human immunodeficiency virus (HIV) patient care settings, but the consequences have not been well described. This study aimed to quantify the clinical and economic effects of nonadherence and estimate the cost-effectiveness of improving adherence in treatment-naive HIV patients. A Markov model was developed to project quality-adjusted life expectancy and direct medical costs for patients on an initial once-daily regimen of efavirenz, lamivudine, and stavudine XR. The model compared 2 adherence scenarios: "ideal" (based on clinical trials) and "typical" (based on observational studies in actual practice). Disease progression was a function of viral load, CD4 count, and adherence. Data on HIV natural history, treatment benefits, costs, and utilities were derived from the literature. With typical adherence, patients lose 1.2 quality-adjusted life years (QALYs) that could be gained with ideal adherence. Improving adherence to ideal levels is cost-effective at 29,400 US dollars/QALY gained. As much as 1,600 US dollars/y per patient could be spent on an intervention to improve adherence to ideal levels, and the incremental cost-effectiveness would remain less than 50,000 US dollars/QALY gained. A cost-effectiveness ratio of 50,000 US dollars/QALY is a commonly accepted minimum standard for cost-effective medical interventions in the United States, although many experts believe this standard has drifted upwards over time. Typical adherence with HAART reduces quality-adjusted life expectancy by 12% compared with ideal adherence. Interventions to improve adherence appear to be a highly cost-effective use of resources.

Bayesian Network Approaches to Health Services Research

To explore the feasibility of using the Bayesian network approach to study health outcomes and evaluate its predictive performance. Methods: The Human immuno-deficiency virus Cost and Services Utilization Study (HCSUS) baseline dataset consisting of 2,864 human immuno-deficiency virus positive adults was used. The Hugin Researcher 6.2TM was used to develop the Bayesian network and Na ve Bayes models. The SAS/STAT PROC LOGISTIC was used to develop the logistic regressions.Results: The area under the receiver operating characteristic curve of the Bayesian network model was statistically higher than that of the Na ve Bayes model, but no higher than that of the logistic regression model using the 8 variables from a previous study. In a second analysis using the 10 most influential predictors discovered by the Bayesian network approach, the Na ve Bayes and the logistic regression performance improved. Conclusion: The BN approaches contributed to the discovery of additional influential predictors that lead to an increase of the models' predictive performance. When attempting to discover unknown relationships that might be missed by traditional analysis methods alone, the use of the Bayesian network as complementary methods may add value.

Pain and Use of Complementary and Alternative Medicine in a National Sample of Persons Living with HIV

The current study investigated the relationship of pain to use of complementary and alternative medicine (CAM) in a U.S. nationally representative sample of 2466 persons with human immunodeficiency virus (HIV), using data from the HIV Cost and Services Utilization Study. Pain was conceptualized as a need characteristic within the context of predisposing, enabling, and need (PEN) characteristics following Andersen's Behavioral Model of Health Services Use. Multivariate analyses were used to examine the association of baseline PEN characteristics with CAM use by follow-up (approximately 6 months later), including use of five specific CAM domains. Change in pain from baseline to follow-up was also examined in relation to CAM use. Baseline pain was a strong predictor of CAM use, and increased pain over time was associated with use of unlicensed or underground drugs with potential for harm. These results highlight the importance of medical efforts to control pain in persons living with HIV.