Outcome of smoking cessation counselling of HIV-positive persons by HIV care physicians.

OBJECTIVES: Smoking is the most prevalent modifiable risk factor for cardiovascular diseases among HIV-positive persons. We assessed the effect on smoking cessation of training HIV care physicians in counselling. METHODS: The Swiss HIV Cohort Study (SHCS) is a multicentre prospective observational database. Our single-centre intervention at the Zurich centre included a half day of standardized training for physicians in counselling and in the pharmacotherapy of smokers, and a physicians' checklist for semi-annual documentation of their counselling. Smoking status was then compared between participants at the Zurich centre and other institutions. We used marginal logistic regression models with exchangeable correlation structure and robust standard errors to estimate the odds of smoking cessation and relapse. RESULTS: Between April 2000 and December 2010, 11 056 SHCS participants had 121 238 semi-annual visits and 64 118 person-years of follow-up. The prevalence of smoking decreased from 60 to 43%. During the intervention at the Zurich centre from November 2007 to December 2009, 1689 participants in this centre had 6068 cohort visits. These participants were more likely to stop smoking [odds ratio (OR) 1.23; 95% confidence interval (CI) 1.07-1.42; P=0.004] and had fewer relapses (OR 0.75; 95% CI 0.61-0.92; P=0.007) than participants at other SHCS institutions. The effect of the intervention was stronger than the calendar time effect (OR 1.19 vs. 1.04 per year, respectively). Middle-aged participants, injecting drug users, and participants with psychiatric problems or with higher alcohol consumption were less likely to stop smoking, whereas persons with a prior cardiovascular event were more likely to stop smoking. CONCLUSIONS: An institution-wide training programme for HIV care physicians in smoking cessation counselling led to increased smoking cessation and fewer relapses.

Regression of HIV-associated pulmonary arterial hypertension and long-term survival during antiretroviral therapy.

In a 37-year-old patient HIV infection was diagnosed in June 1986. Eight years later the patient complained of increasing shortness of breath and occasional syncopes on exertion. He developed peripheral oedema and ascites. Echocardiography revealed severe pulmonary hypertension. Right ventricular systolic pressure (RVSP) was 77 mm Hg. There was no evidence of left ventricular dysfunction, valvular heart disease, thromboembolic disease or obstructive or restrictive lung disease, nor were there other known causes or risk factors of pulmonary hypertension. HIV-associated pulmonary arterial hypertension was diagnosed. Oral anticoagulation and zidovudine were begun, but RVSP rose to 96 mm Hg. After the introduction of lamivudine, and later stavudine and nelfinavir, HIV-RNA copies decreased from 133 400 to below 50 copies per mL. Six years after the diagnosis of HIV-associated pulmonary arterial hypertension RVSP had continually fallen to 49 mm Hg and the grossly enlarged right heart dimensions had nearly normalised without vasodilator treatment. The patient remains in excellent health and his sole complaint is of mild dyspnoea on exertion.

Costs of treatment of Swiss patients with HIV on antiretroviral therapy in hospital-based and general practice-based care: a prospective cohort study.

Some ambulant people with HIV are cared for primarily by their general practitioner and some in an outpatient clinic. Costs and patterns of care in these settings were studied in 65 such patients based in Zürich, from a limited societal perspective (excluding patient costs) based on medical resource use. Antiretroviral therapy (ART), other medications and patient variables were collected prospectively, and non-medication resources (professional time and investigations) and treatment history data were collected from medical records and by record linkage to the Swiss HIV Cohort Study database. Cost differences between the settings were estimated using multiple regression, controlling for differences in case-mix. ART comprised 80% of the total cost, non-medication costs 15% and non-ART medications 5%. Total costs were higher in the outpatient clinic (estimated additional cost after controlling for case-mix = 3489 Swiss Francs per year at 1999 prices, 95% confidence interval 742 to 6236, p=0.017). The difference was accounted for by higher ART costs in the outpatient clinic, not through a tendency to use more expensive drugs or higher doses but rather through the use of more drugs concurrently. Differences in ART prescribing patterns between the doctors in the outpatient clinic and the general practitioners were considerable and appear worthy of further investigation.

[Hyperventilation and airway resistance. Bronchial spasms after hyperventilation]. / Hyperventilation und Atemwegwiderstände. Bronchialspasmen nach Hyperventilation.

Airway resistance, FEV1.0 and lung volume were measured by body plethysmography before and after voluntary hyperventilation. In normal subjects, resistance increased to 130--140% of the initial value measured before hyperventilation. The same increase was observed in silicosis patients without chronic obstructive bronchitis. Asthmatic patients in an asymptomatic phase showed a rise in airway resistance to an average of 255% of the nearly normal initial values, and also a reduction in FEV1.0. In normal subjects and asthmatic patients, the administration of bronchodilators inhibits the rise in airway resistance induced by hyperventilation. The hyperventilation test can be used to identify increased susceptibility to bronchoconstriction.

[Structures of co-operation between an HIV-outpatient clinic and private care physicians]. / Kooperationsstrukturen in der HIV-Betreuung zwischen einem spezialisierten HIV-Zentrum und niedergelassenen Arztinnen und Arzten.

OBJECTIVES OF THE STUDY: This qualitative study looks at structures of co-operation between the two major HIV-care settings in the region of Zurich (Switzerland), i.e. a HIV-specialised outpatient clinic at the University hospital and private practitioners. Hypothesizing that good co-operation between the institutions increases the quality and effectiveness of care for patients living with HIV and treated with highly active antiretroviral therapy (HAART), the structures of co-operation are investigated. METHODS: Qualitative data were collected by means of three focus-group discussions with physicians from both settings. By means of a structured interview guide, different aspects of co-operation were assessed (e. g. current status, deficits, degree of satisfaction). Contents analysis of the data revealed consensus versus dissonance pertaining to different areas of co-operation. RESULTS: Results show that co-operation has been implemented effectively on three different planes (case-related, knowledge-related, training-related) and generally has been perceived by the participants to function well. Institutions have different emphasis on care (specialists vs. generalists). They formulate different concepts of co-operation, which result in diverse degrees of satisfaction. CONCLUSIONS: On the basis of the results obtained, suggestions for improved co-operation as recommended by the participants are discussed, which could further increase the quality of HIV-related care.

Quality of generalist vs. specialty care for people with HIV on antiretroviral treatment: a prospective cohort study.

OBJECTIVES: To describe health-care use by persons with HIV in an urban area of Switzerland (Zurich). Further, to compare the different health-care settings. DESIGN: A 1-year prospective cohort study recruiting 60 patients at general practices and 60 patients at a specialized university outpatient clinic. METHODS: Patients and their treating physicians were interviewed or answered questionnaires, respectively, at baseline, month 6 and 12. RESULTS: During the study period, five patient groups were identified among the 106 enrolled patients, of whom (i) 42% saw a general practitioner exclusively, (ii) 31% were treated at the specialized outpatient clinic, (iii) 8% were in shared care, (iv) 10% changed health-care model, and (v) 9% were lost to follow-up. Baseline demographic, psychosocial and clinical data were similar among patient groups. At study end, the proportion of patients with HIV-1 RNA < 400 copies/mL was 72%, 74%, 88%, 55% among groups (i) to (iv), respectively (ns), and 22% at month 6 among those lost to follow-up. Indicators for quality of care were similarly good among all patient groups. CONCLUSIONS: A well-working system offers high-quality healthcare to persons living with HIV, where existing teams of specialty and primary health-care professionals efficiently and effectively co-operate.