Hospital and outpatient health services utilization among HIV-infected patients in care in 1999

Hospitalization Rates and Outcomes Among Persons Living With Human Immunodeficiency Virus in the Southeastern United States, 1996-2016

BACKGROUND

Antiretroviral therapy (ART) advances, aging, and comorbidities impact hospitalizations in human immunodeficiency virus (HIV)-positive populations. We examined temporal trends and patient characteristics associated with hospitalization rates and outcomes.

METHODS

Among patients in the University of North Carolina Center for AIDS Research HIV Clinical Cohort receiving care during 1996-2016, we estimated annual hospitalization rates, time to inpatient mortality or live discharge, and 30-day readmission risk using bivariable Poisson, Fine-Gray, and log-binomial regression models.

RESULTS

The 4323 included patients (29% women, 60% African American) contributed 30 007 person-years. Overall, the hospitalization rate per 100 person-years was 34.3 (95% confidence interval [CI], 32.4-36.4) with a mean annual change of -3% (95% CI, -4% to -2%). Patients who were black (vs white), older, had HIV RNA >400 copies/mL, or had CD4 count <200 cells/μL had higher hospitalization rates (all P < .05). Thirty-day readmission risk was 18.9% (95% CI, 17.7%-20.2%), stable over time (P > .05 for both 2010-2016 and 2003-2009 vs 1996-2002), and higher among black patients, those with detectable HIV RNA, and those with lower CD4 cell counts (all P < .05). Higher inpatient mortality was associated with older age and lower CD4 cell count (both P < .05).

CONCLUSIONS

Hospitalization rates decreased from 1996 to 2016, but high readmissions persisted. Older patients, those of minority race/ethnicity, and those with uncontrolled HIV experienced higher rates and worse hospitalization outcomes. These findings underscore the importance of early ART and care engagement, particularly at hospital discharge.

The cost of hospital care for HIV patients in Colombia: an insurer's perspective

The aim of this study was to evaluate the cost derived from the hospitalization of people living with HIV (PLHIV) in Colombia between 2011 and 2015. This is an analysis of the direct cost of PLHIV hospitalization from the perspective of an insurer of the Colombian General Social Security System. The costs were calculated in Colombian pesos and corrected for inflation on the basis of the 2017 Consumer Price Index of the Bank of the Republic of Colombia. It was converted to US dollars at the Market Representative Exchange Rate of the same year. We analyzed 1129 hospitalizations in 612 PLHIV, of which 12% started with a diagnosis of HIV during the same hospitalization, with the majority in the AIDS stage (63%). The median overall cost of hospitalizations was US$1509 (25th and 75th percentiles: US$711-US$3254), being even higher in patients with AIDS and as the CD4 T lymphocyte count decreased. The cost derived from the medical care of PLHIV increases as the clinical control of the disease worsens, and it is a key indicator of the impact of the strategies implemented for the timely identification of the infection and subsequent management of the disease.

Model-Based Methods to Translate Adolescent Medicine Trials Network for HIV/AIDS Interventions Findings Into Policy Recommendations: Rationale and Protocol for a Modeling Core (ATN 161)

Background

The United States Centers for Disease Control and Prevention estimates that approximately 60,000 US youth are living with HIV. US youth living with HIV (YLWH) have poorer outcomes compared with adults, including lower rates of diagnosis, engagement, retention, and virologic suppression. With Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) support, new trials of youth-centered interventions to improve retention in care and medication adherence among YLWH are underway.

Objective

This study aimed to use a computer simulation model, the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-Adolescent Model, to evaluate selected ongoing and forthcoming ATN interventions to improve viral load suppression among YLWH and to define the benchmarks for uptake, effectiveness, durability of effect, and cost that will make these interventions clinically beneficial and cost-effective.

Methods

This protocol, ATN 161, establishes the ATN Modeling Core. The Modeling Core leverages extensive data—already collected by successfully completed National Institutes of Health–supported studies—to develop novel approaches for modeling critical components of HIV disease and care in YLWH. As new data emerge from ongoing ATN trials during the award period about the effectiveness of novel interventions, the CEPAC-Adolescent simulation model will serve as a flexible tool to project their long-term clinical impact and cost-effectiveness. The Modeling Core will derive model input parameters and create a model structure that reflects key aspects of HIV acquisition, progression, and treatment in YLWH. The ATN Modeling Core Steering Committee, with guidance from ATN leadership and scientific experts, will select and prioritize specific model-based analyses as well as provide feedback on derivation of model input parameters and model assumptions. Project-specific teams will help frame research questions for model-based analyses as well as provide feedback regarding project-specific inputs, results, sensitivity analyses, and policy conclusions.

Results

This project was funded as of September 2017.

Conclusions

The ATN Modeling Core will provide critical information to guide the scale-up of ATN interventions and the translation of ATN data into policy recommendations for YLWH in the United States.

Early HIV Diagnosis Leads to Significantly Decreased Costs in the First 2 Years of HIV Care in an Urban Charity Hospital in New Orleans

We undertook a retrospective cohort study of patients with a positive HIV test in the emergency department who were then linked to care. Inpatient, outpatient, and emergency costs were collected for the first 2 years after HIV diagnosis. Fifty-six patients met the inclusion criteria; they were predominantly uninsured (73%) and African American (89%). The median total cost for a newly diagnosed patient over the first 2 years was US$36 808, driven predominantly by outpatient costs of US$17 512. Median inpatient and total costs were significantly different between the lowest (<200 cells/mm³) and highest (>499 cells/mm³) CD4 count categories (US$21 878 vs US$6607, P <.05; US$61 378 vs US$18 837, P <.05, respectively). Total costs were significantly different between viral load categories <100 000 HIV-RNA copies/mL and ≥100 000 HIV-RNA copies/mL (US$28 219 vs US$49 482, P <.05). Costs were significantly lower among patients diagnosed earlier in their disease. Decreased cost is another factor supporting early diagnosis and linkage to care for patients with HIV.

Closing the Gap in Antiretroviral Initiation and Viral Suppression: Time Trends and Racial Disparities

BACKGROUND

In the current antiretroviral (ART) era, the evolution of HIV guidelines and emergence of new ART agents might be expected to impact the times to ART initiation and HIV virologic suppression. We sought to determine if times to AI and virologic suppression decreased and if disparities exist by age, race/ethnicity, and HIV risk.

METHODS

We performed a retrospective cohort study of data from 12 sites of the HIV Research Network, a consortium of US clinics caring for HIV-infected patients. HIV-infected adults (≥18 year old) newly presenting for care between 2003 and 2013 were included in this study. Times to AI and virologic suppression were defined as time from enrollment to AI and HIV RNA <400 copies per milliliter, respectively. We conducted time-to-event analyses using competing risk regression in the HIV Research Network cohort from 2003 to 2012 in 2-year intervals, with follow-up through 2013.

RESULTS

Among 15,272 participants, 76.9% were male, 48.4% black, and 10.9% were injection drug use with median age of 38 years (interquartile range: 29-46 years). The adjusted subdistribution hazards ratios (SHRs) for AI and virologic suppression each increased for years 2007-2008 [SHR 1.23 (1.16-1.30), and SHR 1.25 (1.17-1.34), respectively], 2009-2010 [1.55 (1.46-1.64), and 1.54 (1.43-1.65), respectively], and 2011-2012 [1.94 (1.83-2.07), and 1.73 (1.61-1.86), respectively] compared with 2003-2004. Blacks had a lower probability of AI than whites and Hispanics.

CONCLUSIONS

Since 2007, times from enrollment to AI and virologic suppression have decreased significantly compared with 2003-2004, but persisting disparities should be addressed.

Cost-effectiveness of CYP2B6 genotyping to optimize efavirenz dosing in HIV clinical practice

AIMS

To assess the cost-effectiveness of CYP2B6 genotyping to guide efavirenz dosing for initial HIV therapy in the USA.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) microsimulation model to project quality-adjusted life expectancy and lifetime costs (2014 US dollars) for efavirenz-based HIV therapy with or without CYP2B6 genotyping. We assumed that with genotyping 60% of patients would be eligible to receive lower doses.

RESULTS

Current care without CYP2B6 genotyping has an incremental cost-effectiveness ratio >$100,000/QALY compared with genotype-guided dosing, even if lower dosing reduces efficacy. When we assumed generic efavirenz availability, conclusions were similar unless lower dosing reduces efficacy by 6% or more.

CONCLUSION

CYP2B6 genotyping can inform efavirenz dosing and decrease HIV therapy cost.

The lifetime medical cost savings from preventing HIV in the United States

OBJECTIVE

Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States.

METHODS

We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD).

RESULTS

The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided.

CONCLUSIONS

The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment.

Comparable sustained virologic suppression between community- and academic-based HIV care settings

PURPOSE

The human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome epidemic in the United States is evolving because of factors such as aging and geographic diffusion. Provider shortages are also driving the restructuring of HIV care delivery away from specialized settings, and family medicine providers may play a larger role in the future. We attempted to compare the effectiveness of HIV treatment delivered at community versus hospital care settings.

METHODS

The outcome of interest was sustained virologic suppression defined as 2 consecutive HIV-1 RNA measurements ≤400 copies/mL within 1 year after antiretroviral initiation. We used data from the multistate HIV Research Network cohort to compare sustained virologic suppression outcomes among 15,047 HIV-infected adults followed from 2000 to 2008 at 5 community- and 8 academic hospital-based ambulatory care sites. Community-based sites were mostly staffed by family medicine and general internal medicine physicians with HIV expertise, whereas hospital sites were primarily staffed by infectious disease subspecialists. Multivariate mixed effects logistic regression controlling for potential confounding variables was applied to account for clustering effects of study sites.

RESULTS

In an unadjusted analysis the rate of sustained virologic suppression was significantly higher among subjects treated in community-based care settings: 1,646 of 2,314 (71.1%) versus 8,416 of 12,733 (66.1%) (P < .01). In the adjusted multivariate model with potential confounding variables, the rate was higher, although not statistically significant, in the community-based settings (adjusted odds ratio, 1.26; 95% confidence interval, 0.73-2.16).

CONCLUSION

Antiretroviral therapy can be delivered effectively through community-based treatment settings. This finding is potentially important for new program development, shifting HIV care into community-based settings as the landscape of accountable care, health reform, and HIV funding and resources evolves.

Increase in CD4 count among new enrollees in HIV care in the modern antiretroviral therapy era

BACKGROUND

Earlier HIV diagnosis and engagement in care improve outcomes and is cost effective, as a result, in 2006, the Centers for Disease Control and Prevention (CDC) revised the HIV-screening guidelines. We sought to determine whether the CD4 count (CD4) at presentation, a surrogate for time to presentation, increased during the study period. Our a priori hypothesis was that the CD4 at presentation increased during the study period, particularly after the CDC guideline revision.

METHODS

We performed a retrospective cohort study and analyzed data from the HIV Research Network, a consortium of 18 US clinics caring for HIV-infected patients. HIV-infected adults (≥18 years old) newly presenting for care between 2003 and 2011 were included in this study. Multivariable linear regression examined associations with CD4 at enrollment. Calendar year was modeled as a linear spline with a change in slope at 2008, allowing determination of the mean change in CD4 per year during 2003-2007 and 2008-2011.

RESULTS

Over 13,543 newly presenting subjects enrolled from 2003 to 2011. Median CD4 at enrollment rose from 285 to 317 cells per cubic millimeter between 2003-2007 and 2008-2011 (P < 0.001). After adjusting for age, race/ethnicity, gender, HIV risk factor, and clinic site, the mean increase in the CD4 count at presentation per year was 13.3 cells per cubic millimeter per year (95% confidence interval 6.4 to 20.1 cells per cubic millimeter per year) greater during 2008-2011 than during 2003-2007.

CONCLUSIONS

We demonstrate a small, but statistically significant, increase in CD4 at presentation after the CDC guideline revision. More efforts are needed to decrease time to presentation to HIV care.

Impact of hepatitis coinfection on hospitalization rates and causes in a multicenter cohort of persons living with HIV

BACKGROUND

Chronic viral hepatitis is a potentially important determinant of health care utilization among persons living with HIV. We describe hospitalization rates and reasons for hospitalization among persons living with HIV stratified by coinfection with hepatitis B virus (HBV) and/or hepatitis C virus (HCV).

METHODS

Laboratory, demographic, and hospitalization data were obtained for all patients receiving longitudinal HIV care during 2010 at 9 geographically diverse sites. Hepatitis serostatus was assessed by hepatitis B surface antigen and/or hepatitis C antibody. ICD-9 codes were used to assign hospitalizations into diagnostic categories. Negative binomial regression was used to assess factors associated with all-cause and diagnostic category-specific hospitalizations.

RESULTS

A total of 2793 hospitalizations were observed among 12,819 patients. Of these patients, 49.3% had HIV monoinfection, 4.1% HIV/HBV, 15.4% HIV/HCV, 2.5% HIV/HBV/HCV, and 28.7% unknown hepatitis serostatus. Compared with HIV monoinfection, the risk of all-cause hospitalization was increased with HIV/HBV [adjusted incidence rate ratio 1.55 (1.17 to 2.06)], HIV/HCV [1.45 (1.21 to 1.74)], and HIV/HBV/HCV [1.52 (1.04 to 2.22)]. Risk of hospitalization for non-AIDS-defining infection was also higher among patients with HIV/HBV [2.07 (1.38 to 3.11)], HIV/HCV [1.81 (1.36 to 2.40)], and HIV/HBV/HCV [1.96 (1.11 to 3.46)]. HIV/HBV was associated with hospitalization for gastrointestinal/liver disease [2.55 (1.30 to 5.01)]. HIV/HCV was associated with hospitalization for psychiatric illness [1.89 (1.11 to 3.26)].

CONCLUSIONS

HBV and HCV coinfection are associated with increased risk of all-cause hospitalization and hospitalization for non-AIDS-defining infections, as compared with HIV monoinfection. Policy-makers and third-party payers should be aware of the heightened risk of hospitalization associated with coinfection when allocating health care resources and considering models of health care delivery.

Thirty-day hospital readmission rate among adults living with HIV

OBJECTIVE

Thirty-day hospital readmission rate is receiving increasing attention as a quality-of-care indicator. The objective of this study was to determine readmission rates and to identify factors associated with readmission among persons living with HIV.

DESIGN

Prospective multicenter observational cohort.

SETTING

Nine US HIV clinics affiliated through the HIV Research Network.

PARTICIPANTS

Patients engaged in HIV care during 2005-2010.

MAIN OUTCOME MEASURE(S)

Readmission rate was defined as the proportion of hospitalizations followed by a readmission within 30 days. Factors in multivariate analyses included diagnostic categories, patient demographic and clinical characteristics, and having an outpatient follow-up visit.

RESULTS

Among 11,651 total index hospitalizations, the 30-day readmission rate was 19.3%. AIDS-defining illnesses (ADIs, 9.6% of index hospitalizations) and non-AIDS-defining infections (26.4% of index hospitalizations) had readmission rates of 26.2 and 16.6%, respectively. Factors independently associated with readmission included lower CD4 cell count [adjusted odds ratio 1.80 (1.53-2.11) for CD4 cell count <50 vs. ≥351 cells/μl], longer length of stay [1.77 (1.53-2.04) for ≥9 days vs. 1-3 days], and several diagnostic categories including ADI. Having an outpatient follow-up clinic visit was not associated with lower readmission risk [adjusted hazard ratio 0.98 (0.88-1.08)].

CONCLUSION

The 19.3% readmission rate exceeds the 13.3% rate reported for the general population of 18-64-year-olds. HIV providers may use the 19.3% rate as a basis of comparison. Policymakers may consider the impact of HIV when estimating expected readmissions for a hospital or region. Preventing or recovering from severe immune dysfunction may be the most important factor to reducing readmissions.

A brief review of the estimated economic burden of sexually transmitted diseases in the United States: inflation-adjusted updates of previously published cost studies

We conducted a literature review of studies of the economic burden of sexually transmitted diseases in the United States. The annual direct medical cost of sexually transmitted diseases (including human immunodeficiency virus) has been estimated to be $16.9 billion (range: $13.9-$23.0 billion) in 2010 US dollars.

Trends in reasons for hospitalization in a multisite United States cohort of persons living with HIV, 2001-2008

INTRODUCTION

Hospitalization rates for comorbid conditions among persons living with HIV in the current highly active antiretroviral therapy era are unknown.

METHODS

Hospitalization data from 2001 to 2008 were obtained on 11,645 adults receiving longitudinal HIV care at 4 geographically diverse US HIV clinics within the HIV Research Network. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis was performed with repeated measures negative binomial regression.

RESULTS

During 2001 to 2008, the rate of AIDS-defining illness (ADI) hospitalizations declined from 6.7 to 2.7 per 100 person-years, incidence rate ratio per year, 0.89 (0.87, 0.91). Among the other diagnostic categories with average rates >2 per 100 person-years, cardiovascular hospitalizations increased over time [1.07 (1.03, 1.11)], whereas non-AIDS-defining infection [0.98 (0.96, 1.00)], psychiatric [0.96 (0.93, 1.00)], and gastrointestinal/liver [0.96 (0.92, 1.00)] were slightly decreasing or stable. Although less frequent overall, renal and pulmonary admissions also increased over time in univariate and multivariate analyses. Of all diagnostic categories, ADI admissions had the longest mean length of stay, 10.5 days.

DISCUSSION

ADI hospitalizations have continued to decline in recent years but are still relatively frequent and potentially costly given long lengths of stay. Increases or stability in the rates of chronic end-organ disease admissions imply a need for broader medical knowledge among individual clinicians and/or teams who care for persons living with HIV and a need for long-term access to medications for these conditions.

Clostridium difficile infection in HIV-seropositive individuals and transplant recipients

Immunocompromise is a commonly cited risk factor for Clostridium difficile infection (CDI). We reviewed the experimental and epidemiological literature on CDI in three immunocompromised groups, HIV-seropositive individuals, haematopoietic stem cell or bone marrow transplant recipients and solid organ transplant recipients. All three groups have varying degrees of impairment of humoral immunity, a major factor influencing the outcome of CDI. Soluble HIV proteins such as nef and immunosuppressive agents such as cyclosporin, azathioprine and mycophenalate mofetil modify signalling from the key cellular pathways triggered by C. difficile toxin A, although there is a paucity of data on how these factors may interact with pathways activated by toxin B. Despite this, there has been little direct investigation into the effect of immunosuppression on the pathogenesis of CDI. Epidemiological studies consistently show increased rates of CDI in these populations, which are higher in those with greater degrees of immunocompromise such as individuals with advanced AIDS not receiving combination antiretroviral therapy or allogeneic haematopoietic stem cell transplant recipients. Less consistently data suggests immunocompromise in each group also impacts rates of severe, recurrent or complicated CDI. However all these conditions are characterised by high levels of antibiotic use and prolonged hospital stay, both powerful drivers of CDI risk.

Is inadequate human immunodeficiency virus care associated with increased ED and hospital utilization? A prospective study in human immunodeficiency virus-positive ED patients

BACKGROUND

There is a lack of data on the effect(s) of suboptimal human immunodeficiency virus (HIV) care on subsequent health care utilization among emergency department (ED) patients with HIV. Findings on their ED and inpatient care utilization patterns will provide information on service provision for those who have suboptimal access to HIV-related care.

METHODS

A pilot prospective study was conducted on HIV-positive patients in an ED. At enrollment, participants were interviewed regarding health care utilization. Participants were followed up for 1 year, during which time data on ED visits and hospitalizations were obtained from their patient records. Inadequate HIV care (IHC) was defined according to Infectious Diseases Society of America recommendations as less than 3 scheduled clinic visits for HIV care in the year before enrollment. Cox regression models were used to evaluate whether IHC was associated with increased hazard of health care utilization.

RESULTS

Of 107 subjects, 36% were found to have IHC. Inadequate HIV care did not predict more frequent ED visits but was significantly associated with fewer hospitalizations (adjusted incidence rate ratio, 0.61 [95% CI: 0.43-0.86]). Inadequate HIV care did not significantly increase the hazard for earlier ED visit or hospitalization. However, further stratification analysis found that IHC increased the hazard of hospitalization for subjects without comorbid diseases (adjusted hazard ratio, 2.50 [95% CI: 1.10-5.68]).

CONCLUSIONS

In our setting, IHC does not appear to be associated with earlier or more frequent ED visits but may lead to earlier hospitalization, particularly among those without other chronic diseases.

Contemporary costs of HIV healthcare in the HAART era

BACKGROUND

The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.

METHODS

We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.

RESULTS

Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.

CONCLUSION

HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Comparing total health care costs and treatment patterns of HIV patients in a managed care setting

The objective of this study was to investigate total health care costs and time to occurrence of hospitalization in HIV-infected patients treated according to the 1998 DHHS guidelines in a managed care setting. The study also investigated which patients do not receive guideline treatment. We used a retrospective cross-sectional study design using medical and pharmacy claims data. Data from 1,791 HIV-infected patients using antiretroviral agents between 1 February 1998 and 31 July 1999, including demographic characteristics, medication guideline use, medication adherence and cost of care, were examined. Factors associated with total health care costs and time-to-inpatient admission (as a proxy for patient outcomes) were assessed. Patients receiving guideline (HAART) therapy (55%) had higher prescription and total health care costs but lower medical costs. Patients not receiving treatment according to guidelines were more likely to be female, older, have comorbidities, lower medication adherence and no AIDS-defining illness. Treatment with HAART guidelines was associated with longer time-to-inpatient admission controlling for other factors. In a short-term cross-sectional analysis, patients treated with HAART guidelines had better outcomes based on time-to-inpatient admission but higher prescription and total health care costs. Some patients are at risk for not receiving care according to national treatment guidelines and may be targeted for intervention programmes.

Standard of care: promoting antiretroviral adherence in clinical care

Although there has long been demand for programs and procedures that support or enhance adherence to antiretroviral therapy (ART) among HIV+ patients, there is scant evidence about the extent to which medical clinics have been able to incorporate adherence interventions into their standard care. A survey of clinical care settings in New York and Connecticut indicated that the current standard of care is to provide only minimal levels of adherence services, with ad hoc adherence support being offered on an as-needed basis, often by overburdened primary care staff. These results suggest a strong need for the development of ART adherence interventions that are not only easily translatable to real-life clinical settings, but also offer an organized compendium of resources for HIV+ patients, from initiation to maintenance.

Hospitalizations in a cohort of HIV patients in Australia, 1999-2007

OBJECTIVES

To describe hospitalization rates, risk factors and associated diagnoses in people with HIV in Australia between 1999 and 2007.

DESIGN

Retrospective cohort study of people with HIV (n = 842) using data linkage between the Australian HIV Observational Database and administrative hospital morbidity data collections.

METHODS

Incidence rate ratios with 95% confidence intervals were estimated using Poisson regression models to assess risk factors for hospitalization. Predictors of length of stay were assessed using generalized mixed models. The association between hospitalization and mortality was assessed using Cox regression.

RESULTS

In 4519 person-years of observation, there were 2667 hospital admissions; incidence rate of 59 per 100 person-years. Hospitalization rates were 50-300% higher in this cohort than comparable age and sex strata in the general population. Older age (incidence rate ratio 1.46, 95% confidence interval 1.28-1.65 per 10-year increase) and prior AIDS (incidence rate ratio 1.71, 95% confidence interval 1.24-2.35) were significantly associated with hospitalization. Other predictors of hospitalization included lower CD4 cell counts, higher HIV RNA, longer duration of HIV infection and experience with more drug classes. Lower CD4 cell counts, older age and hepatitis C virus antibody positivity were independently associated with longer hospital stay. Non-AIDS diseases were the principle reason for admission in the majority of cases. Mortality was associated with more frequent hospitalization during the study period.

CONCLUSION

Hospitalization rates are higher in people with HIV than the general population in Australia and are associated with markers of advanced HIV disease despite the widespread use of combination antiretroviral therapy.

Inpatient health services utilization among HIV-infected adult patients in care 2002-2007

OBJECTIVE

This study examines the frequency of inpatient hospitalization, the number of inpatient days, and factors associated with inpatient utilization in a multistate HIV cohort between 2002 and 2007.

DESIGN

A prospective cohort study of HIV-infected adults in care at 11 US HIV primary and specialty care sites located in different geographic regions.

METHODS

Demographic, clinical, and resource utilization data were collected from medical records for the years 2002-2007. Rates of resource use were calculated for number of hospital admissions, total inpatient days, and mean length of stay per admission.

RESULTS

Annual inpatient hospitalization rates significantly decreased from 35 to 27 per 100 persons from 2002 to 2007. The number of inpatient days per year significantly decreased over time, whereas mean length of stay per admission was stable. Women, patients 50 years or older, blacks, injection drug users, and patients without private insurance had higher hospitalization rates than their counterparts. Admission rates were lower for patients with high CD4 counts and low HIV-1 RNA levels.

CONCLUSIONS

Inpatient hospitalization rates and number of inpatient days decreased for HIV patients in this multistate cohort between 2002 and 2007. Sociodemographic disparities in inpatient utilization persist.

The impact of disease stage on direct medical costs of HIV management: a review of the international literature

The global prevalence of HIV infection continues to grow, as a result of increasing incidence in some countries and improved survival where highly active antiretroviral therapy (HAART) is available. Growing healthcare expenditure and shifts in the types of medical resources used have created a greater need for accurate information on the costs of treatment. The objectives of this review were to compare published estimates of direct medical costs for treating HIV and to determine the impact of disease stage on such costs, based on CD4 cell count and plasma viral load. A literature review was conducted to identify studies meeting prespecified criteria for information content, including an original estimate of the direct medical costs of treating an HIV-infected individual, stratified based on markers of disease progression. Three unpublished cost-of-care studies were also included, which were applied in the economic analyses published in this supplement. A two-step procedure was used to convert costs into a common price year (2004) using country-specific health expenditure inflators and, to account for differences in currency, using health-specific purchasing power parities to express all cost estimates in US dollars. In all nine studies meeting the eligibility criteria, infected individuals were followed longitudinally and a 'bottom-up' approach was used to estimate costs. The same patterns were observed in all studies: the lowest CD4 categories had the highest cost; there was a sharp decrease in costs as CD4 cell counts rose towards 100 cells/mm³; and there was a more gradual decline in costs as CD4 cell counts rose above 100 cells/mm³. In the single study reporting cost according to viral load, it was shown that higher plasma viral load level (> 100,000 HIV-RNA copies/mL) was associated with higher costs of care. The results demonstrate that the cost of treating HIV disease increases with disease progression, particularly at CD4 cell counts below 100 cells/mm³. The suggestion that costs increase as the plasma viral load rises needs independent verification. This review of the literature further suggests that publicly available information on the cost of HAART by disease stage is inadequate. To address the information gap, multiple stakeholders (governments, pharmaceutical industry, private insurers and non-governmental organizations) have begun to establish and support an independent, high quality and standardized multicountry data collection for evaluating the cost of HIV management. An accurate, representative and relevant cost-estimate data resource would provide a valuable asset to healthcare planners that may lead to improved policy and decision-making in managing the HIV epidemic.

Do reduced inpatient costs associated with highly active antiretroviral therapy (HAART) balance the overall cost for HIV treatment?

In this article we analyse how the costs of treating patients with HIV infection in the US have changed over time, with an emphasis on the relationship between inpatient hospitalization costs and the costs of highly active antiretroviral therapy (HAART). We examine how HIV treatment modes have evolved by comparing the pre-HAART treatment period before 1996-7 with the subsequent use of HAART. We describe the sources of data on HIV healthcare service utilization, the costs of those services, and the differences between the annual costs of treating all patients with different stages of HIV and the lifetime costs of treating a person with HIV from the time of infection. The major question in estimating HIV treatment costs and their components is how to incorporate a complete set of services utilized from all providers of HIV treatment for a representative sample of patients with HIV. The literature reviewed varies significantly on both of these factors. Although the hospitalization of patients with HIV has been declining over the past 2 decades, this rate of decrease accelerated after the introduction of HAART. Initially, the declines in hospitalization and its associated costs were greater than the increases in drug therapy costs, so the annual total costs of treating patients with HIV decreased. However, subsequent studies failed to show decreases in overall annual treatment costs, given rising drug costs and increases in hospitalizations due to complications from, or resistance to, HAART and due to other diseases impacting HIV-infected patients. Although the lifetime costs of treating a person with HIV have also increased, this treatment has resulted in substantial gains in the length and quality of life for those living with HIV.

Patterns of engagement in care by HIV-infected adults: South Carolina, 2004-2006

OBJECTIVE

Identify factors associated with HIV care utilization in South Carolina.

DESIGN

Cross-sectional analysis of South Carolina nonpregnant HIV-infected individuals (N = 13,042) for the period 1 January 2004 to 31 December 2006.

METHODS

Reporting of HIV laboratory markers is legally mandated in South Carolina. Individuals with reported viral load tests or CD4 cell counts during a calendar year were defined as 'in HIV-medical care' that year. Care utilization categories were in care, care all 3 years; not-in-care (NIC), no care received; and transitional care, during some but not all years. Multinomial logistic regression using generalized logits was used to estimate relationships between care utilization and predictor variables.

RESULTS

Five thousand, two hundred and seventeen (40.0%) of South Carolina HIV-infected adults were NIC and 3300 (25.3%) were in transitional care during 2004-2006. Although a larger number of black than white HIV-infected adults were NIC, adjusted odds for NIC status were lower among blacks than whites [adjusted odds ratio (AOR), 0.82; 95% confidence interval 0.74, 0.92)]. Women had lower odds of being NIC than men (AOR, 0.66; 95% confidence interval 0.58, 0.74). Compared with individuals 55 years or older, individuals who were 25-34 years old were most likely to demonstrate both the NIC (AOR, 1.85; 95% confidence interval 1.29, 2.65) and transitional (AOR, 1.85; 95% confidence interval 1.31, 2.62) care patterns.

CONCLUSION

Large proportions of the South Carolina HIV-infected adult population are not consistently accessing HIV-medical care. Targeted programs are needed to improve engagement for HIV-infected adults most likely to transition or not be in care.

Trends in hospitalizations for AIDS-associated Pneumocystis jirovecii Pneumonia in the United States (1986 to 2005)

BACKGROUND

Although hospitalizations for AIDS-associated Pneumocystis jirovecii pneumonia (PCP) in the United States have decreased since the introduction of chemoprophylaxis and potent combination antiretroviral therapy (ART), PCP remains an important cause of illness and death among AIDS patients.

METHODS

We analyzed trends in AIDS-associated PCP hospital discharges using the National Hospital Discharge Surveys between 1986 and 2005.

RESULTS

An estimated 539 million patients were discharged from hospitals between 1986 and 2005, of whom an estimated 312,411 had AIDS-associated PCP. The proportion of patients discharged from the hospital with AIDS-associated PCP decreased from 31% before the introduction of chemoprophylaxis (1986 to 1989) to 17% with chemoprophylaxis (1990 to 1995) and subsequently to 9% after the introduction of ART in 1996 (p < 0.001). Mortality from AIDS-associated PCP decreased from 21 to 16% and subsequently to 7% between these three time periods (p < 0.001). Among those who received mechanical ventilation, mortality decreased from 79% in the prechemoprophylaxis era to 31% in the ART era (p < 0.001) alongside an increase (from 5 to 11%) in the use of mechanical ventilation. We also observed a shift in the population at-risk for PCP over time: a greater proportion of black people, women, and people from Southern states were affected (all p < 0.001).

CONCLUSIONS

While there have been significant reductions in hospitalizations and hospital mortality for AIDS-associated PCP over the last 20 years, these reductions have not been homogenous across demographic subpopulations and geographic regions and point to new at-risk populations. Furthermore, mortality in severe cases of PCP that require mechanical ventilation has improved substantially.

Inpatient charges among HIV/AIDS patients in Rhode Island from 2000-2004

BACKGROUND

Inpatient HIV/AIDS charges decreased from 1996-2000. This decrease was mainly attributable to treatment of HIV/AIDS patients with Highly Active Antiretroviral Therapy (HAART). This study aims to evaluate the trend in inpatient charges from 2000-2004.

METHODS

Rhode Island Hospital Discharge Data (HDD) from 2000 to 2004 was used. International Classification of Disease (ICD-9) diagnosis code 042-044 was used to identify HIV/AIDS admissions. The final study population included 1927 HIV/AIDS discharges. We used a multivariable linear regression model to examine the factors associated with inflation adjusted inpatient charges.

RESULTS

We found a significant increase in inpatient charges from 2000-2004 after adjusting for length of stay (LOS), gender, age, race and point of entry for hospitalization. In addition to calendar year, LOS, gender and race were also associated with inpatient charges.

CONCLUSION

HIV/AIDS inpatient charges increased after adjusting for inflation despite earlier studies that showed a decline. Our results have implications for uninsured, as well as insured HIV/AIDS patients who do not have a medical plan that covers their charges sufficiently. Future research should investigate what factors are contributing to rising inpatient charges among HIV/AIDS patients.

The impact of HIV-associated lipodystrophy on healthcare utilization and costs

Background

HIV disease itself is associated with increased healthcare utilization and healthcare expenditures. HIV-infected persons with lipodystrophy have been shown to have poor self-perceptions of health. We evaluated whether lipodystrophy in the HIV-infected population was associated with increased utilization of healthcare services and increased healthcare costs.

Objective

To examine utilization of healthcare services and associated costs with respect to presence of lipodystrophy among HIV-infected patients.

Methods

Healthcare utilization and cost of healthcare services were collected from computerized accounting records for participants in a body image study among HIV-infected patients treated at a tertiary care medical center. Lipodystrophy was assessed by physical examination, and effects of lipodystrophy were assessed via body image surveys. Demographic and clinical characteristics were also ascertained. Analysis of healthcare utilization and cost outcomes was performed via between-group analyses. Multivariate modeling was used to determine predictors of healthcare utilization and associated costs.

Results

Of the 181 HIV-infected participants evaluated in the study, 92 (51%) had clinical evidence of HIV-associated lipodystrophy according to physician examination. Total healthcare utilization, as measured by the number of medical center visits over the study period, was notably increased among HIV-infected subjects with lipodystrophy as compared to HIV-infected subjects without lipodystrophy. Similarly, total healthcare expenditures over the study period were $1,718 more for HIV-infected subjects with lipodystrophy than for HIV-infected subjects without lipodystrophy. Multivariate modeling demonstrated strong associations between healthcare utilization and associated costs, and lipodystrophy score as assessed by a clinician. Healthcare utilization and associated costs were not related to body image survey scores among HIV-infected patients with lipodystrophy.

Conclusion

Patients with HIV-associated lipodystrophy demonstrate an increased utilization of healthcare services with associated increased healthcare costs as compared to HIV-infected patients without lipodystrophy. The economic and healthcare service burdens of HIV-associated lipodystrophy are significant and yet remain inadequately addressed by the medical community.

Use of complementary and alternative medicines among a multistate, multisite cohort of people living with HIV/AIDS

OBJECTIVE

The aim of the study was to assess the prevalence of and factors associated with use of complementary or alternative medicine (CAM) in a multistate, multisite cohort of HIV-infected patients.

METHODS

During 2003, 951 adult patients from 14 sites participated in face-to-face interviews. Patients were asked if they received treatment from any alternative therapist or practitioner in the previous 6 months. Logistic regression was performed to examine associations between demographic and clinical variables and CAM use.

RESULTS

The majority of the participants were male (68%) and African American (52%) with a median age of 45 years (range 20-85 years). Sixteen per cent used any CAM in the 6 months prior to the interview. Factors associated with use of CAM were the HIV risk factor injecting drug use [adjusted odds ratio (AOR) 0.51] compared with men who have sex with men (MSM), former drug use (AOR=2.12) compared with never having used drugs, having a college education (AOR=2.43), and visiting a mental health provider (AOR=2.76).

CONCLUSIONS

This study demonstrated similar rates of CAM use in the current highly active antiretroviral therapy (HAART) era compared with the pre-HAART era. Factors associated with CAM - such as education, use of mental health services, and MSM risk factor - suggest that CAM use may be associated with heightened awareness regarding the availability of such therapies. Given the potential detrimental interactions of certain types of CAM and HAART, all HIV-infected patients should be screened for use of CAM.

Assessment of a medical outreach program to improve access to HIV care among marginalized individuals

Marginalized populations are disproportionately affected by HIV, yet they have poor access to health services. Outreach programs focus on improving access, but few are evaluated. We assessed a medical outreach program targeting unstably housed, HIV-infected individuals. We extracted data from 2003-2005 to examine whether keeping medical appointments was associated with patient and program characteristics. Patients kept appointments more frequently when they were walk-in or same-day appointments (compared with future appointments; adjusted odds ratio [AOR]=1.69; 95% confidence interval [CI] = 1.38, 2.08), when they were at a community-based organization's drop-in center (compared with single-room occupancy hotels; AOR=2.50; 95% CI=1.54, 4.17), or when made by nonmedical providers (compared with medical providers; future appointments: AOR = 1.38; 95% CI = 1.05, 1.80; same-day appointments: AOR = 1.70; 95% CI = 1.03, 2.81). These findings demonstrate the importance of program-related characteristics in health services delivery to marginalized populations.

Longitudinal assessment (1995-2003) of hospitalizations of HIV-infected patients within a geographical population in Canada

OBJECTIVES

To determine the frequency of and reasons for hospitalization of adult HIV-infected patients compared with the general population.

METHODS

Length of stay, primary/secondary diagnoses and discharge status were reviewed for all HIV-infected patients admitted to Calgary-area hospitals between 1995 and 2003. Admissions were classified as HIV- or non-HIV-related using International Classification of Diseases, 9th and 10th revisions (ICD-9/10) codes and confirmed by chart review. Summary comparative data on admissions for the general population were obtained from the regional administrative database.

RESULTS

HIV-infected adults were hospitalized more than twice as frequently, experienced longer stays (median length 5 vs 3 days, respectively) and had higher in-hospital mortality rates (9.1 vs 1.3 per 100 admissions, respectively) than the general population (P < 0.01). Hospitalizations of HIV-infected patients declined by 58% from 1995 to 2003. Patients newly diagnosed with HIV infection accounted for 15% of all HIV-related hospitalizations. HIV-related admissions for known HIV-infected patients decreased from 12 per 100 patient-years-followed in 1995 to 3 per 100 patient-years-followed in 2003. Low CD4 counts, AIDS, and no current use of highly active antiretroviral therapy (HAART) were strongly correlated with hospitalizations (P < 0.01). Non-HIV-related hospitalizations for HIV-infected patients increased by 42% and were associated with comorbidities (e.g. substance use and psychological disorders).

CONCLUSION

Despite the reduction in HIV-related hospitalizations following the introduction of HAART, all-cause hospitalization rates have increased and have started to erode this benefit.

Healthcare utilization of patients accessing an African national treatment program

Background

The roll-out of antiretroviral therapy (ART) in Africa will have significant resource implications arising from its impact on demand for healthcare services. Existing studies of healthcare utilization on HAART have been conducted in the developed world, where HAART is commenced when HIV illness is less advanced.

Methods

This paper describes healthcare utilization from program entry by treatment-naïve patients in a peri-urban settlement in South Africa. Treatment criteria included a CD4 cell count <200 cells/μl or an AIDS-defining illness. Data on health service utilization were collected retrospectively from the primary-care clinic and secondary and tertiary referral hospitals. Hospital visits were reviewed to determine the clinical reason for each visit.

Results

212 patients were followed for a median of 490 days. Outpatient visits per 100 patient years of observation (PYO), excluding scheduled primary-care follow-up, fell from 596 immediately prior to ART to 334 in the first 48 weeks on therapy and 245 thereafter. Total inpatient time fell from 2,549 days per 100 PYO pre-ART to 476 in the first 48 weeks on therapy and 73 thereafter. This fall in healthcare utilization occurred at every level of care. The greatest causes of utilization were tuberculosis, cryptococcal meningitis, HIV-related neoplasms and adverse reactions to stavudine. After 48 weeks on ART demand reverted to primarily non-HIV-related causes.

Conclusion

Utilization of both inpatient and outpatient hospital services fell significantly after commencement of ART for South African patients in the public sector, with inpatient demand falling fastest. Earlier initiation might reduce early on-ART utilization rates.

Utilization of health care services in hard-to-reach marginalized HIV-infected individuals

To benefit from HIV treatment advances individuals must utilize ambulatory primary care services. Few studies focus on marginalized populations, which tend to have poor health care utilization patterns. This study examined factors associated with health care utilization in hard-to-reach marginalized HIV-infected individuals. As part of a multisite initiative evaluating outreach programs that target underserved HIV-infected individuals, 610 participants were interviewed about their HIV disease, health services utilization, substance use, mental health, and case management. Primary outcomes included ambulatory, emergency department, and inpatient visits. Generalized estimating equations were used in logistic regression analyses. On regression analyses ambulatory visits were associated with having insurance (adjusted odds ratio [AOR] = 2.46), mental health medications (AOR = 7.46), and case management (AOR = 4.81). Emergency department visits were associated with having insurance (AOR = 1.74), homelessness (AOR = 2.23), poor health status (AOR = 2.02), length of HIV infection (AOR = 2.02), mental health care (AOR = 1.47), mental health medications (AOR = 1.59), and heavy alcohol intake (AOR = 1.46). Hospitalizations were associated with high school education (AOR = 1.57), having insurance (AOR = 10.45), homelessness (AOR = 2.18), poor health status (AOR = 2.64), length of HIV infection (AOR = 2.03), and mental health medications (AOR = 1.87). In hard-to-reach marginalized HIV-infected individuals, having insurance, case management and mental health care were associated with increased ambulatory visits. These findings support HIV multidisciplinary care with marginalized populations. Understanding factors associated with health care utilization is essential for outreach programs to facilitate engagement in HIV care.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Hospitalization trends among children and youths with perinatal human immunodeficiency virus infection, 1990-2002

BACKGROUND

Major improvements in disease progression among HIV-infected children have followed the adoption of combination antiretroviral therapy.

METHODS

We examined trends in hospitalization rates between 1990-2002 among 3,927 children/youths with perinatal HIV infection, ranging in age from newborn to 21 years. We used Poisson regression to test for trends in hospitalization rates by age and year; binomial regression to test for trends in intensive care unit (ICU) admissions and hospitalization at least once and more than once, by age and year; and multivariate logistic regression to examine factors associated with hospitalization, ICU admission, and hospitalization longer than 10 days.

RESULTS

Statistically significant downward trends in hospitalization rates and multiple hospitalizations were observed in all age groups from 1990-2002. The proportion of HIV-infected children/youths who were hospitalized at least once declined from 30.4% in 1990 to 12.9% in 2002, with a steady decline occurring after 1996, when the U.S. Public Health Service issued guidelines recommending triple-drug antiretroviral therapy (triple therapy) for HIV-infected children. ICU admissions declined significantly in all age groups except among children younger than 2 years. Logistic regression results indicated that black and Hispanic children/youths were significantly more likely to be hospitalized than white children/youths and that children/youths receiving triple therapy were significantly more likely to be hospitalized than therapy-naive children; the latter association was not observed among children monitored from 1997-2002.

CONCLUSIONS

Substantial reductions in rates of hospitalization, multiple hospitalizations, and ICU admission have occurred among HIV-infected children/youths from 1990-2002, particularly after 1996, with increased use of triple therapy.

Updated estimates of healthcare utilization and costs among perinatally HIV-infected children

OBJECTIVES

This study examined changes in healthcare use among perinatally HIV-infected children and developed new estimates of expected lifetime treatment costs.

METHODS

The study analyzed longitudinal medical record data from the Pediatric Spectrum of Disease study on perinatally HIV-infected children enrolled in 6 US sites during 1995 and 2001 for enrollee characteristics including healthcare utilization. For the year 2001, costs were assigned to hospitalization, HIV-related drug usage, and laboratory testing. To estimate lifetime treatment costs based on those categories, median survival times of 9, 15, and 25 years were assumed and average annual healthcare utilization costs were applied to each year of survival.

RESULTS

From 1995 to 2001, hospitalization rates fell from 0.67 per child-year to 0.23 per child-year (P < 0.05). In 2001, the average cost of healthcare utilization per child was $12,663, including $2164 for hospitalization, $9505 for HIV-related drugs, and $994 for laboratory tests. The discounted lifetime treatment cost, based on those 3 cost categories, was $113,476 for 9 years of survival, $151,849 for 15 years, and $228,155 for 25 years.

CONCLUSIONS

Hospitalizations among perinatally HIV-infected children decreased significantly from 1995 to 2001. Compared with previously published estimates, lifetime treatment costs for children perinatally infected with HIV have remained relatively stable. However, as years of survival increase for this population, lifetime costs also are likely to increase.

The direct costs of HIV/AIDS care

We reviewed published studies reporting the direct medical costs of treating HIV-infected people in countries using highly active antiretroviral therapy (HAART). Of 543 potentially relevant studies, only nine provided adequate data to make a meaningful statement about costs. Within studies, people with more advanced disease incurred higher total costs. Valid comparisons of total direct medical costs between studies were not possible because of differences in the specific components included, the heterogeneous nature of study populations in terms of disease stage, the sources and methods used to estimate unit costs, and the level of aggregation at which results were reported. The advent of HAART has major implications for the cost of treating HIV-infected individuals. Although this information is important for planning purposes, only a small number of published studies provide useful estimates of the direct cost. A useful method of estimating resource use and costs is computer simulation.

Distribution of health care expenditures for HIV-infected patients

BACKGROUND

Health care expenditures for persons infected with human immunodeficiency virus (HIV) in the United State determined on the basis of actual health care use have not been reported in the era of highly active antiretroviral therapy.

METHODS

Patients receiving primary care at the University of Alabama at Birmingham HIV clinic were included in the study. All encounters (except emergency room visits) that occurred within the University of Alabama at Birmingham Hospital System from 1 March 2000 to 1 March 2001 were analyzed. Medication expenditures were determined on the basis of 2001 average wholesale price. Hospitalization expenditures were determined on the basis of 2001 Medicare diagnostic related group reimbursement rates. Clinic expenditures were determined on the basis of 2001 Medicare current procedural terminology reimbursement rates.

RESULTS

Among the 635 patients, total annual expenditures for patients with CD4+ cell counts <50 cells/microL (36,533 dollars per patient) were 2.6-times greater than total annual expenditures for patients with CD4+ cell counts > or =350 cells/microL (13,885 dollars per patient), primarily because of increased expenditures for nonantiretroviral medication and hospitalization. Expenditures for highly active antiretroviral therapy were relatively constant at approximately 10,500 dollars per patient per year across CD4+ cell count strata. Outpatient expenditures were 1558 dollars per patient per year; however, the clinic and physician component of these expenditures represented only 359 dollars per patient per year, or 2% of annual expenses. Health care expenditures for patients with HIV infection increased substantially for those with more-advanced disease and were driven predominantly by medication costs (which accounted for 71%-84% of annual expenses).

CONCLUSIONS

Physician reimbursements, even with 100% billing and collections, are inadequate to support the activities of most clinics providing HIV care. These findings have important implications for the continued support of HIV treatment programs in the United States.

Economic models of antiretroviral therapy: searching for the optimal strategy

The diffusion of protease inhibitors and non-nucleoside reverse transcriptase inhibitors in the US in 1996 and 1997 reduced the number of deaths attributable to HIV disease and changed the way we think about the illness. Today, HIV disease may be deemed a fairly expensive chronic condition rather than an intolerably expensive fatal illness. Although most studies have found that patients receiving new drug therapies are hospitalised less frequently than patients who received early drug therapies, it is unclear whether the diffusion of new drug therapies has increased or decreased the annual cost of care. However, it is evident that the diffusion of new drug therapies has increased the lifetime cost of care. Analysts rely on models to simulate the course and cost of HIV disease. This study reviews the evolution of these models, paying particular attention to how these models estimate the cost of care. The primary findings of this review are that the economic data used in these models are often too imprecise to accurately identify the cost of each disease stage and are almost always outdated. Moreover, it was found that estimates of drug costs in these models may not accurately reflect actual expenditures.

Hospitalizations for Metabolic Conditions, Opportunistic Infections, and Injection Drug Use Among HIV Patients

BACKGROUND

Rapid changes in HIV epidemiology and highly active antiretroviral therapy (HAART) may have resulted in recent changes in patterns of inpatient utilization.

OBJECTIVE

To examine trends in inpatient diagnoses and mortality in HIV patients.

DESIGN/SETTING/PATIENTS

Serial cross-sectional analyses of HIV patients hospitalized in 1996, 1998, and 2000, using hospital discharge data from the Healthcare Costs and Utilization Project for 12 states. Each hospitalization was classified as an opportunistic illness, complication of injection drug use (IDU), liver-related complication, ischemic heart disease, cerebrovascular disease, non-Pneumocystis carinii pneumonia (PCP), diabetes, or chronic hepatitis C virus (HCV).

MAIN OUTCOME MEASURES

Number of hospital admissions, inpatient mortality.

RESULTS

We evaluated 316,963 admissions that occurred between 1996 and 2000, with an overall mortality of 7%. Hospitalizations for opportunistic infections significantly decreased from 40% to 27% of all HIV-related admissions. The overall proportion of IDU complications remained relatively stable (6%) each year. Hospitalizations increased for liver-related complications from 8% to 13% and for chronic HCV from 1% to 5% in this period. The number of hospitalizations for cerebrovascular disease and for ischemic heart disease was relatively negligible in all years. Overall, inpatient mortality decreased between 1996 and 2000. Relatively higher mortality was observed among African Americans, Hispanics, those with Medicaid, those with Medicare, and the uninsured, however. Opportunistic infections and liver-related complications were associated with greater inpatient mortality.

CONCLUSION

Results do not show a significant recent rise in HIV-related inpatient utilization. Admissions to treat opportunistic infections have declined precipitously, consistent with the effects of HAART. Although not dramatic, liver-related disease is an increasing cause of hospitalization in HIV+ patients.

Temporary employment, absence of stable partnership, and risk of hospitalization or death during the course of HIV infection

OBJECTIVE

To estimate the independent association between socioeconomic conditions and the risk of all-cause hospitalization or death during the course of HIV disease in the highly active antiretroviral therapy (HAART) era.

METHODS

Patients in the French PRIMO multicenter prospective cohort of 319 individuals were enrolled during primary HIV-1 infection between 1996 and 2002. Associations between social characteristics (ie, employment status, stable partnership) and the risk of hospitalization or death were assessed using generalized estimating equations.

RESULTS

During a median follow-up of 2.5 years, 109 hospitalizations among 84 patients (26.3%) and 3 deaths occurred. Even after adjustment for classic determinants of HIV-infected patients' health status, social characteristics were independently associated with the risk of hospitalization or death, with a significantly increased risk for patients with temporary employment compared with those with stable employment (adjusted odds ratio [OR] = 2.5, 95% confidence interval: 1.1 to 5.6) and for patients without a stable partnership compared with those with a stable partnership (OR = 1.6, 95% confidence interval: 1.0 to 2.7).

CONCLUSIONS

In the era of HAART, adverse social conditions constitute independent risk factors of hospitalization or death during the course of HIV disease.

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002

BACKGROUND

Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization.

OBJECTIVE

The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV.

DESIGN

Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002.

SETTING

This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions.

PATIENTS

In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002.

MAIN OUTCOME MEASURES

Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits.

RESULTS

Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002.

CONCLUSION

Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001

BACKGROUND

Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. We examined the diagnoses for hospitalizations of patients with HIV in 2001.

METHODS

Demographic and healthcare data were collected for 8376 patients from 6 U.S. HIV care sites in 2001. We categorized diagnoses into 18 disease groups and used Poisson regression to analyze the number of admissions for each of the 4 most common groups. We also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses.

RESULTS

Twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions.

CONCLUSIONS

Five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates.

Health care access and utilization patterns in unstably housed HIV-infected individuals in New York City

As part of a multisite initiative to evaluate outreach targeting underserved HIV-infected individuals, we describe baseline characteristics of unstably housed HIV-infected individuals from New York City, and their health care access and utilization patterns. Interviews with 150 HIV-infected single room occupancy (SRO) hotel residents on health care access and utilization, barriers to accessing health care, demographic characteristics, history of incarceration, severity of HIV disease, depressive symptoms, substance use, and exposure to violence were conducted. Most participants were 40 years of age or older, male, black or Latino, had public insurance, a history of substance use, depressive symptoms, and a CD4(+) count above 200 cells/mm(3). Access to and utilization of care was high with 91% reporting having a regular provider, 95% identifying a non-emergency department (ED) clinic or office as their usual location of care, 89% reporting at least one ambulatory visit, and 82% reporting optimal (>/=2) ambulatory visits during the previous 6 months. Additionally, 45% reported at least one ED visit, and 30% at least one hospitalization within the previous 6 months. Among black and Latino marginalized SRO hotel residents in New York City, this study found surprisingly high measures of access to and utilization of ambulatory care services, along with high use of acute care services. Understanding HIV-related health services access and utilization patterns among marginalized populations is essential to improve their HIV care. These patterns of high levels of access to and utilization of health care services contradict clinical experiences and other studies, and require further exploration.

Hospital and Outpatient Health Services Utilization Among HIV-Infected Children in Care 2000–2001

BACKGROUND

The aging of the pediatric HIV cohort and advances in antiretroviral therapy for children may have resulted in recent changes in patterns of healthcare utilization.

OBJECTIVES

The objectives of this study were to examine inpatient and outpatient HIV-related health service utilization in a multistate sample of HIV-infected children, and to assess sociodemographic and clinical correlates of utilization.

DESIGN

Cohort study of pediatric patients with HIV. Demographic, clinical, and resource utilization data were collected from medical records for 2000 and 2001.

SETTING

This study was conducted at 4 U.S. HIV primary pediatric and specialty care sites in different geographic regions.

PATIENTS

Three hundred three HIV-positive children with at least one outpatient visit or CD4 test in either 2000 or 2001 were studied.

MAIN OUTCOME MEASURES

Mean outcome measures were number of hospital admissions, mean length of hospital stay, and number of outpatient clinic/office visits.

RESULTS

Hospitalization rates decreased significantly from 39.2 (95% confidence interval [CI], 28.4-50.1) to 25.3 (95% CI, 16.4-34.3) admissions per 100 patients between 2000 and 2001. Hospitalizations were higher among patients with greater immunosuppression, those 2 years and under, and those with AIDS, but were not significantly related to receipt of highly active antiretroviral therapy. Mean outpatient visits did not change significantly between 2000 and 2001 from 9.09 (95% CI, 8.3-9.9) to 9.06 (95% CI, 8.4-9.7) visits per child per year. Children 2 years and under, those on highly active antiretroviral therapy, those with AIDS, and those with Medicaid had significantly higher outpatient utilization. Those with higher HIV-1 RNA had higher outpatient utilization than those with less advanced disease.

CONCLUSION

Inpatient utilization significantly decreased between 2000 and 2001, but outpatient utilization did not change over time. Compared with prior studies, utilization rates appear to be declining over time. Unlike adults, racial/ethnic or gender disparities in healthcare utilization are less pronounced for HIV-infected children.

Review: use of health care services among persons living with HIV infection: state of the science and future directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

Patient characteristics and costs associated with dyslipidaemia and related conditions in HIV-infected patients: a retrospective cohort study

BACKGROUND

Metabolic abnormalities are common in HIV-infected individuals and, although multifactorial in origin, have been strongly associated with antiretroviral therapy.

METHODS

Using automated claims and clinical databases, combined with medical record data, we evaluated the burden of dyslipidaemia (DYS) and associated metabolic abnormalities among a cohort of 900 HIV-infected patients aged 18 years and older who received their care from a large multispecialty medical group between 1 January 1996 and 30 June 2002. A Cox proportional hazards model for DYS was developed. Resource use was compiled and subsequently costed with stratification to account for variable length of follow-up.

RESULTS

Mean follow-up time was 3.3 years. DYS was present in 54% of the cohort and 3.4% experienced a cardiovascular (CV) event. Both unadjusted and adjusted results found patients with dyslipidaemia and cardiovascular events significantly more likely to have received protease inhibitor (PI) treatment for longer periods of time. In the Cox proportional hazards model the following factors were significantly associated with an increased risk for DYS: older age, white race, PI use and male sex. Diagnoses of hypertension, hepatitis C virus infection, depression or opportunistic infections were all negatively associated with a DYS diagnosis. When controlled for length of follow up, patients with DYS (and no CV-related events) incurred greater median and mean total average costs than patients without DYS or CV-related events. For patients with more than 2 years of follow up, these total cost differences were statistically significant (P<0.05).

CONCLUSIONS

These findings indicate that DYS is common among patients with HIV infection and is associated with increased use of medical resources.

Strategies for initiating combination antiretroviral therapy

Numerous potent antiretroviral regimens have proven successful as initial therapy in treatment-naive HIV-infected patients. As the development of new agents makes possible new treatment regimens, providers are faced with increasingly complex questions of when to initiate treatment and which regimen to select for individual patients. Clinical trial data provide a foundation for choosing an initial regimen and play a key role in the formation of treatment guidelines issued by the United States Public Health Service and other organizations. This paper reviews the results of recent clinical trials focusing on initial therapy and addresses important considerations when beginning antiretroviral therapy (ART) in treatment-naive individuals.

Attitudes toward HIV Health Care Providers scale: development and validation

Patient attitudes toward their health care providers can play an important role in determining health behavior change. The frequency of contact with health care professionals and disease stigma makes assessing patients' perception of this relationship of particular interest in an HIV medical population. While past general satisfaction and attitude tools have been used to assess this construct, there is a need for an assessment tool specific to patient attitudes in an HIV setting. This study was designed to validate the Attitudes toward HIV Health Care Provider scale (AHHCP) in an HIV medical population. Principal components analysis of the AHHCP yielded a two-factor structure accounting for 53.3% of the total variance in attitudes toward health care providers. The two factors represented items concerning Professionalism and Emotional Support. The AHHCP was found to have good internal consistency (0.92) and convergent validity with a measure of patient satisfaction (r = 0.59). The results of the present study suggest that the AHHCP is a reliable and valid instrument for use in assessing patient attitudes toward their health care providers.

Provider barriers to prescribing HAART to medically-eligible HIV-infected drug users

We aimed to identify factors associated with a medical provider's resistance to prescribing HAART to medically-eligible HIV-infected illicit drug users. In four US cities, a mailed, self-administered survey queried 420 HIV care providers about patients' characteristics and barriers to care. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated using logistic regression. Providers identified as resistant to prescribing HAART to medically-eligible HIV-infected illicit drug users were more likely to be non-physicians (AOR=1.89, 95% CI: 1.04-3.46), to work in populations with a high prevalence of both mental illness (AOR=2.42; 95% CI: 1.11-5.26) and injection drug use (AOR=1.82 95% CI: 1.02-3.25) and were deterred from prescribing HAART by patients' limited ability to keep appointments, (AOR=3.19; 95% CI: 1.39-7.37), alcoholism (AOR=1.92; 95% CI: 1.04-3.55) and homelessness (AOR=1.81; 95% CI: 1.07-3.06). Providers working in populations with a high injection drug use prevalence commonly reported higher prevalence of non-injection drug use, alcohol problems and mental illness, and higher antiretroviral therapy refusal rates within their patient populations. Our findings underscore the challenges to providers who treat HIV-infected drug users and suggest that their care and treatment would benefit from on-site drug treatment, mental health and social services.