Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre

Hospital and community care costs for people newly diagnosed of living with HIV in London, UK

This study of people newly diagnosed of living with HIV (ND-PLHIV) calculated the use, cost and outcome of HIV services at a London HIV centre. ND-PLHIV were followed July 2017-October 2018. Hospital data included inpatient days (IP), outpatient (OP), dayward (DW) visits, tests and procedures, and anti-retroviral drugs (ARVs). Community services were recorded in daily diaries. Mean per patient-year (MPPY) use was multiplied by unit costs. 13.6 MPPY (95%CI 12.4-14.9) OP visits, 0.4 MPPY (95%CI 0.1-0.7) IP days, 0.09 MPPY (95%CI 0.01-0.2) DW visits and 4.6 MPPY community services (95%CI 3.4-5.8). Total annual costs per patient-year (CPPY) was £11,483 (95%CI £10,369-12,597): ARVs comprised 63% and community services 2%. White participants used fewer hospital and more community services compared with minority ethnic community (MEC) participants. Costs for White ND-PLHIV was £10,778 CPPY (95%CI £9629-11,928); £13,214 (95%CI £10,656-15,772) for MEC ND-PLHIV (p < 0.06). Annual costs were inversely related to CD4 count at entry (r = -5.58, p = 0.02); mean CD4 count was 476 cells/mm³ (95%CI 422-531) versus 373 cells/mm³ (95%CI 320-425) for White and MEC participants respectively (p = 0.03). Annual costs for ND-PLHIV with CD4 ≤ 350 cells/mm³ was £2478 PPY higher compared with CD4 count >350 cells/mm³ (p = 0.04).

Costs and cost-effectiveness of HIV community services: quantity and quality of studies published 1986-2011

Community services comprise an important part of a country's HIV response. English language cost and cost-effectiveness studies of HIV community services published between 1986 and 2011 were reviewed but only 74 suitable studies were identified, 66% of which were performed in five countries. Mean study scores by continent varied from 42 to 69% of the maximum score, reflecting variation in topics covered and the quality of coverage: 38% of studies covered key and 11% other vulnerable populations - a country's response is most effective and efficient if these populations are identified given they are key to a successful response. Unit costs were estimated using different costing methods and outcomes. Community services will need to routinely collect and analyze information on their use, cost, outcome and impact using standardized costing methods and outcomes. Cost estimates need to be disaggregated into relevant cost items and stratified by severity and existing comorbidities. Expenditure tracking and costing of services are complementary aspects of the health sector 'resource cycle' that feed into a country's investment framework and the development and implementation of national strategic plans.

Rates and cost of hospitalization before and after initiation of antiretroviral therapy in urban and rural settings in South Africa

Few studies have compared hospitalizations before and after antiretroviral therapy (ART) initiation in the same patients. We analyzed the cost of hospitalizations among 3906 adult patients in 2 South African hospitals, 30% of whom initiated ART. Hospitalizations were 50% and 40% more frequent and 1.5 and 2.6 times more costly at a CD4 cell count, 100 cells/mm(3) when compared with 200–350 cells/mm(3) in the pre-ART and ART period, respectively. Mean inpatient cost per patient year was USD 117 (95%confidence interval, 85 to 158) for patients on ART and USD 72(95% confidence interval, 56 to 89) for pre-ART patients. Raising ART eligibility thresholds could avoid the high cost of hospitalization before and immediately after ART initiation.

Assessing user preferences for sexually transmitted infection testing services: a discrete choice experiment

OBJECTIVE

To assess user preferences for different aspects of sexually transmitted infection (STI) testing services.

DESIGN

A discrete choice experiment.

SETTING

14 centres offering tests for STIs in East Sussex, England.

PARTICIPANTS

People testing for STIs.

MAIN OUTCOME MEASURE

(Adjusted) ORs in relation to preferred service characteristics.

RESULTS

3358 questionnaires were returned; mean age 26 (SD 9.4) years. 70% (2366) were recruited from genitourinary medicine (GUM) clinics. The analysis suggested that the most important characteristics to users were whether 'staff had specialist STI knowledge' compared with 'staff without it' (OR 2.55; 95% CI 2.47 to 2.63) and whether 'tests for all STIs' were offered rather than 'some' (OR 2.19; 95% CI 2.12 to 2.25). They remained the most important two service characteristics despite stratifying the analysis by variables such as age and sex. Staff levels of expertise were viewed as particularly important by people attending CASH centres, women and non-men who have sex with men. A 'text or call to a mobile phone' and 'dropping in and waiting' were generally the preferred methods of results reporting and appointment system, respectively.

CONCLUSIONS

This study suggests that people testing for STIs place particular importance on testing for all infections rather than some and staff with specialist STI knowledge. Thus, targets based purely on waiting up to 48 h for an appointment are misguided from a user perspective.

Determinants of health care costs of HIV-positive patients in the Canary Islands, Spain

The aims of this study were to estimate medical expenditures on human immunodeficiency virus (HIV) treatment and to identify significant associated variables. We performed a retrospective multi-centre study in the Canary Islands using a sample of 569 patients recruited at outpatient visits. The study examined demographic and clinical variables, health-related quality of life (HRQOL), and health care resources. Clinical data was obtained from medical records and patient interviews. Several empirical models for identifying the relationship between health care costs and independent variables were developed. The greatest expense came from pharmaceutical expenditure (82.1% of direct costs), while hospital costs only represented 4.6% of total expenditure. The data showed a statistically significant association between health care costs and the CD4 count of the previous year. HRQOL was also a significant variable. Therefore, CD4 cell count can be used to predict health care costs in patients. Policymakers could use this information to help guide their decisions in allocating limited health care resources to HIV treatments.

The cost of HIV treatment and care. A global review

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

Cost effectiveness of expanded antenatal HIV testing in London

BACKGROUND

Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing).

OBJECTIVE

To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy.

DESIGN

Incremental cost-effectiveness analysis.

METHODS

Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies.

RESULTS

Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40.

CONCLUSION

Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.