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Characteristics and short- and long-term direct medical costs among adults with timely and delayed presentation for HIV care in the Netherlands. PLoS One 2023; 18:e0280877. [PMID: 36753495 PMCID: PMC9907815 DOI: 10.1371/journal.pone.0280877] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/11/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION In Europe, half of people living with HIV (PLWH) present late to care, with associated higher morbidity and mortality. This study aims to assess short- and long-term costs of HIV-care based on time of presentation and identify other factors contributing to higher costs in the first and fifth year after antiretroviral therapy (ART) initiation. MATERIAL AND METHODS We included ATHENA cohort data which prospectively includes 98% of PLWH in the Netherlands. PLWH who initiated ART in 2013 were included and followed over five years. PLWH were divided in three categories based on CD4 cell-count at time of ART initiation: timely presentation (CD4>350cells/μL), late presentation (CD4 200-350cells/μL or >350cells/μL with AIDS-defining illness) and very late presentation (CD4<200cells/μL). The total HIV-care cost was calculated distinguishing ART medication and non-ART medication costs (hospitalization, outpatient clinic visits, co-medications, and HIV-laboratory tests). RESULTS From 1,296 PLWH, 273 (21%) presented late and 179 (14%) very late. Nearly half of those who entered HIV-care in a very late stage were of non-Dutch origin, with 21% originating from sub-Saharan Africa. The mean cost per patient in the first year was €12,902 (SD€11,098), of which about two-thirds due to ART (€8,250 (SD€3,142)). ART costs in the first and fifth year were comparable regardless of time of presentation. During the first year on treatment, non-ART medication costs were substantially higher among those with late presentation (€4,749 (SD€8,009)) and very late presentation (€15,886 (SD€ 21,834)), compared with timely presentation (€2,407(SD€4,511)). Higher non-ART costs were attributable to hospitalization and co-medication. The total non-ART costs incurred across five years on treatment were 56% and 246% higher for late and very late presentation respectively as compared to timely presentation. CONCLUSION Very late presentation is associated with substantial costs, with non-ART costs nearly seven times higher than for those presenting timely. Hospitalization and co-medication costs are likely to continue to drive higher costs for individuals with late presentation into the future. Programs that identify individuals earlier will therefore likely provide significant short- and long-term health cost savings.
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Abstract
From a process evaluation, participants in San Francisco's syringe exchange program (SEP) are described. Three groups, primary, secondary, and nonexchangers, were interviewed for a total of 244 study participants recruited from eight needle exchange sessions. Fifty percent of all primary exchangers exchanged for one or more injecting drug user(s) (IDUs). Three general routes of syringe distribution were identified between primary and secondary exchangers: between close friends and lovers; for people who lived in close proximity to them; and with customers who bought drugs from them. Focusing on why some go to SEPs and why some rely on others to go for them, findings are summarized primarily as the barriers for not attending SEPs, including exposure, legal status, illness, drug lifestyle, and conflicts with service provision. The secondary exchangers had similar risk reduction profiles to the SEP users that overall were better than the nonexchangers. For example, they shared syringes and cookers significantly fewer times than nonexchangers. The results demonstrate that these client-provided exchanges enable the SEP to overcome injection drug users' obstacles to program attendance, thereby reaching even hard to access members of IDU populations. We found the effects of these client-provided services to be positive for the larger IDU population.
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Enns EA, Zaric GS, Strike CJ, Jairam JA, Kolla G, Bayoumi AM. Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada. Addiction 2016; 111:475-89. [PMID: 26616368 DOI: 10.1111/add.13195] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 06/15/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. DESIGN Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. SETTING Toronto and Ottawa, Canada. PARTICIPANTS Simulated population of each city. INTERVENTIONS Zero to five supervised injection facilities. MEASUREMENTS Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. FINDINGS In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. CONCLUSIONS Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.
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Affiliation(s)
- Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Gregory S Zaric
- Ivey Business School, Western University, London, ON, Canada
| | - Carol J Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Center for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Jennifer A Jairam
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Gillian Kolla
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ahmed M Bayoumi
- Centre for Research on Inner City Health, Li KaShing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, St Michael's Hospital, Toronto, ON, Canada
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Cepeda JA, Niccolai LM, Lyubimova A, Kershaw T, Levina O, Heimer R. High-risk behaviors after release from incarceration among people who inject drugs in St. Petersburg, Russia. Drug Alcohol Depend 2015; 147:196-202. [PMID: 25496706 PMCID: PMC4297682 DOI: 10.1016/j.drugalcdep.2014.11.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 11/16/2014] [Accepted: 11/20/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Injection drug use, infectious disease, and incarceration are inextricably linked in Russia. We aimed to identify factors associated with time to relapse (first opioid injection after release from prison) and using a non-sterile, previously used syringe at relapse in a sample of people who inject drugs in St. Petersburg. METHODS We collected data on time from release to relapse among individuals with a history of incarceration, a subsample of a larger study among people who inject drugs. Proportional hazards and logistic regression were used to identify factors associated with time to relapse and injection with a non-sterile previously used syringe at relapse, respectively. RESULTS The median time to relapse after release was 30 days. Factors that were independently associated with relapsing sooner were being a native of St. Petersburg compared to not being native (AHR: 1.64; 95% CI 1.15-2.33), unemployed at relapse compared to employed (AHR: 4.49; 95% CI 2.96-6.82) and receiving a previous diagnosis of HBV and HCV compared to no previous diagnosis (AHR: 1.49; 95% CI 1.03-2.14). Unemployment at relapse was also significant in modeling injection with a non-sterile, previously used syringe at relapse compared to those who were employed (AOR: 6.80; 95% CI 1.96-23.59). CONCLUSIONS Unemployment was an important correlate for both resuming opioid injection after release and using a non-sterile previously used syringe at relapse. Linkage to medical, harm reduction, and employment services should be developed for incarcerated Russian people who inject drugs prior to release.
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Affiliation(s)
- Javier A. Cepeda
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT, USA,Center for Interdisciplinary Research on AIDS, 135 College Street, New Haven, CT, USA,corresponding author. Address: 60 College Street, New Haven, CT 06511, Phone: (203) 764-4333,
| | - Linda M. Niccolai
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT, USA,Center for Interdisciplinary Research on AIDS, 135 College Street, New Haven, CT, USA
| | | | - Trace Kershaw
- Center for Interdisciplinary Research on AIDS, 135 College Street, New Haven, CT, USA,Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, New Haven, CT, USA
| | - Olga Levina
- NGO Stellit, 3 Mira Street, St. Petersburg, Russia
| | - Robert Heimer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, 60 College Street, New Haven, CT, USA,Center for Interdisciplinary Research on AIDS, 135 College Street, New Haven, CT, USA
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Beaulieu M, Adrien A, Potvin L, Dassa C. Stigmatizing attitudes towards people living with HIV/AIDS: validation of a measurement scale. BMC Public Health 2014; 14:1246. [PMID: 25476441 PMCID: PMC4289343 DOI: 10.1186/1471-2458-14-1246] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 11/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although stigmatization has long been recognized as a major obstacle to HIV prevention. The lack of a valid and reliable measurement tool for stigmatization is a major gap in the research. This study aimed to: 1) develop a scale of stigmatizing attitudes towards people living with HIV (SAT-PLWHA-S) and 2) demonstrate its reliability and validity. METHODS French and English-speaking experts (n = 21) from different professional communities (academics, practitioners) assessed the clarity and relevance of the proposed items. The psychometric properties of the SAT-PLWHA-S were assessed with a random digit dial population based telephone survey (n = 1,500) of respondents in Quebec, Canada. Analyses included exploratory and confirmatory factor analyses, correlations, multiple linear regressions, t-tests, hypothesis testing of factorial structure invariance, and Cronbach's alpha. RESULTS Confirmatory factor analysis (CFA) supported a 27-item structure with seven factors: 1) concerns about occasional encounters; 2) avoidance of personal contact; 3) responsibility and blame, 4) liberalism, 5) non-discrimination, 6) confidentiality of seropositive status, and 7) criminalization of HIV transmission. Cronbach's alphas indicate satisfactory internal consistency. An assessment of concurrent validity using Pearson's correlation and multiple linear regression shows that homophobia and HIV transmission knowledge are significant determinants of stigmatizing attitudes toward PLHIV. Discriminant validity (t-test) results suggest that the SAT-PLWHA-S can differentiate attitudes between different groups and indicates invariant factor structure across language. CONCLUSIONS The results of this study suggest that the SAT-PLWHA-S is a reliable and valid tool for measuring stigmatizing attitudes toward PLHIV and that it can contribute to a deeper understanding of HIV stigma.
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Affiliation(s)
- Marianne Beaulieu
- Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada.
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Zakher B, Blazina I, Chou R. Association between knowledge of HIV-positive status or use of antiretroviral therapy and high-risk transmission behaviors: systematic review. AIDS Care 2013; 26:514-21. [PMID: 24007512 DOI: 10.1080/09540121.2013.832723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To systematically review the evidence on the association between knowledge of HIV-positive status or use of antiretroviral therapy (ART) and high-risk transmission behaviors, we searched Ovid MEDLINE from 2004 to February 2012 and the Cochrane Library Database through the first quarter of 2012. Four observational studies meeting inclusion criteria addressed HIV-positive status and seven addressed the use of ART and effects on behavior. Studies including both average and high-risk populations were conducted in developed countries and were rated at least fair quality. Overall, knowledge of HIV-positive status was associated with less engagement in high-risk transmission behaviors, and the use of ART was not found to increase participation in high-risk transmission behaviors by HIV-positive individuals.
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Affiliation(s)
- Bernadette Zakher
- a Department of Medical Informatics and Clinical Epidemiology , Oregon Health and Science University , Portland , OR , USA
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Cipriano LE, Zaric GS, Holodniy M, Bendavid E, Owens DK, Brandeau ML. Cost effectiveness of screening strategies for early identification of HIV and HCV infection in injection drug users. PLoS One 2012; 7:e45176. [PMID: 23028828 PMCID: PMC3445468 DOI: 10.1371/journal.pone.0045176] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/17/2012] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT). DESIGN Dynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59). METHODS We considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). RESULTS Adding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior. DISCUSSION Although annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.
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Affiliation(s)
- Lauren E Cipriano
- Department of Management Science and Engineering, Stanford University, Stanford, California, USA.
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Bruneau J, Daniel M, Kestens Y, Abrahamowicz M, Zang G. Availability of body art facilities and body art piercing do not predict hepatitis C acquisition among injection drug users in Montreal, Canada: Results from a cohort study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:477-84. [DOI: 10.1016/j.drugpo.2010.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 05/11/2010] [Accepted: 05/12/2010] [Indexed: 10/19/2022]
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Moreno S, Mocroft A, Monforte AD. Medical and societal consequences of late presentation. Antivir Ther 2010; 15 Suppl 1:9-15. [PMID: 20442456 DOI: 10.3851/imp1523] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients presenting late with HIV infection are at a higher risk of clinical events, are difficult to treat and have a higher mortality compared with those who present earlier. Indeed, being diagnosed too late for effective treatment has been shown to be a common scenario leading to death. The increased risk for opportunistic diseases and increased mortality are associated with low CD4(+) T-cell counts. In addition to the detrimental effect on the health of the individual, late presentation also creates a significant societal burden because it is associated with increased risk of HIV transmission and increased resource use. All of these factors highlight the benefit of earlier testing, diagnosis and treatment of HIV.
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Affiliation(s)
- Santiago Moreno
- Servicio de Enfermedadas Infecciosas, Hospital Ramon y Cajal, Madrid, Spain.
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Adler A, Mounier-Jack S, Coker R. Late diagnosis of HIV in Europe: definitional and public health challenges. AIDS Care 2009; 21:284-93. [DOI: 10.1080/09540120802183537] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A. Adler
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - S. Mounier-Jack
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - R.J. Coker
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
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Palmateer N, Anderson N, Wadd S, Hutchinson S, Taylor A, Goldberg D. Exploring associations between perceived HCV status and injecting risk behaviors among recent initiates to injecting drug use in Glasgow. Subst Use Misuse 2008; 43:375-88. [PMID: 18365938 DOI: 10.1080/10826080701202908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The aim of this study was to explore the influence of testing for hepatitis C virus (HCV) and perceived HCV status on injecting risk behavior. A cross-sectional, community-wide survey was undertaken at multiple sites throughout Greater Glasgow during 2001-2002. Four hundred ninety-seven injecting drug users (IDUs) consented to participate and were interviewed using a structured questionnaire to ascertain HCV test history and injecting risk behavior. The average age of participants was 27 years and the majority of the sample were male (70.4%). Participants had been injecting for an average duration of 2.5 years. Logistic regression analysis revealed no significant associations between having been tested and injecting risk behavior. After adjustment for potential confounding variables, HCV-negatives were significantly less likely to borrow needles/syringes and spoons or filters as compared with unawares and were significantly less likely to borrow spoons or filters as compared with HCV-positives. Due to the cross-sectional design of the study, it is uncertain whether this reduction in risk behavior could be attributed to perception of HCV status. Further research is recommended to consolidate the evidence for this relationship.
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Affiliation(s)
- Norah Palmateer
- Health Protection Scotland, Clifton House, Clifton Place, Glasgow, Scotland.
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Correlates of Lending Needles/Syringes Among HIV-Seropositive Injection Drug Users. J Acquir Immune Defic Syndr 2007; 46 Suppl 2:S72-9. [DOI: 10.1097/qai.0b013e3181576818] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bruneau J, Brogly SB, Tyndall MW, Lamothe F, Franco EL. Intensity of drug injection as a determinant of sustained injection cessation among chronic drug users: the interface with social factors and service utilization. Addiction 2004; 99:727-37. [PMID: 15139871 DOI: 10.1111/j.1360-0443.2004.00713.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS The objective of this study was to identify factors associated with sustained injection cessation and to examine further the relationship between the occurrence of sustained injection cessation of injection drug users (IDUs) and prior injection frequency. DESIGN AND SETTING IDUs in the Montreal St Luc Cohort who had at least three consecutive interviews between 1995 and 1999 were included. Sustained injection cessation was defined as a period of at least 7 consecutive months without injection. All IDUs completed interview-administered questionnaires on socio-demographic characteristics, drug and sexual behaviours and health-related issues. Logistic regression was used for analyses. FINDINGS A total of 186/1004 (18.5%) IDUs reported a period of sustained injection cessation during the study period. In multivariate analysis, HIV-positive status, 'booting' and cumulative time spent in prison were negatively associated with injection cessation, while injection initiation after 35 years of age and frequent crack use were positively associated with injection cessation. We found a negative association between the occurrence of injection cessation and the frequency of injection; the odds ratios (OR) for cessation were 0.49 [95% confidence interval (CI): 0.03, 0.78] for IDUs who injected 30-100 times and 0.21 (95% CI: 0.10, 0.46) for IDUs who injected more than 100 times in the previous month. Attending needle exchange programmes (NEPs) or pharmacies appeared to be a modifier of the relation between cessation and prior injection frequency. The OR was 0.68 (95% CI: 0.42, 1.12) for IDUs who injected 30-100 times prior to injection and attended NEPs or pharmacies and was 0.07 (0.01, 0.30) for IDUs who did not use these services. CONCLUSIONS Overall, a fifth of IDUs experienced at least one episode of injection cessation of 7 months or more during a period of 4.5 years. Our data suggest that NEPs and pharmacies may have played a role in inducing injection cessation episodes in a subgroup of IDUs. Research is needed to better identify the characteristics of IDUs who could benefit from an injection cessation intervention strategy. This information is important for social and health policy planning.
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Affiliation(s)
- Julie Bruneau
- Departments of Psychiatry and Family Medicine, University of Montreal, Canada.
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