A Mixed-Methods Exploration of the Needs of People Living with HIV (PLWH) Enrolled in Access to Care, a National HIV Linkage, Retention and Re-Engagement in Medical Care Program.

Competing needs pose barriers to engagement in HIV medical care. Mixed methods were used to explore and describe the needs of participants enrolled in Access to Care, a national HIV linkage, retention and re-engagement in care (LRC) program that served people living with HIV who knew their status but were not engaged in care. When asked to prioritize their most urgent needs, participants reported housing or shelter (31%), HIV medical services (24%), and employment (8%). When we assessed the HIV continuum of care by needs status, we found no significant differences in linkage, retention, or viral suppression between participants with and without basic needs. Qualitative interviews with program staff contextualized the barriers to HIV medical care faced by participants and explored the strategies used by LRC programs to address participant needs. Study findings will be of use to future programs and have implications for HIV policy, in particular the implementation of the National HIV/AIDS Strategy (2015-2020).

Apparent declines in the global HIV transmission rate.

Estimates of global and regional HIV incidence and prevalence are helpful for gauging the state of the epidemic. However, they do not contain as much information as the HIV transmission rate for judging the potential speed of HIV spread. The HIV transmission rate can be defined as follows: for every 100 persons living with HIV, the number of HIV infections transmitted to seronegative partners in one year. Here, we estimate the transmission rate for the global epidemic for the years 2001 and 2007, and for 10 major international regions for the year 2007. The transmission rate is calculated as incidence divided by prevalence, and the quotient then multiplied by 100. Previously published and publicly available, the Joint United Nations Programme on HIV/AIDS estimates of HIV incidence and prevalence at the global and regional levels were utilized. Between 2001 and 2007, the global HIV transmission rate dropped from 10.2 to 8.2, a decrease of 19.6% in six years time. The regional estimates for 2007 ranged from 3.7 in Western and Central Europe, to 10.5 in the Middle East and Northern Africa, to 17.6 in Oceania. The global transmission rate for 2007 of 8.2 indicates that 91.8% or more of persons living with HIV are not transmitting to other persons in a given year. The 19.6% decrease in HIV transmission rate between 2001 and 2007 appears to indicate some success in global HIV prevention efforts. The range of regional estimates helps to identify areas with the potential for rapidly growing epidemics, even if the raw numbers of new infections and prevalence are low. I believe the transmission rate to be a useful statistic and recommend its further adoption.

The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV.

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Cost-effectiveness of chemoprophylaxis after occupational exposure to HIV.

OBJECTIVES: To assess the economic efficiency of recent US Public Health Service recommendations for chemoprophylaxis with a combination of antiretroviral drugs following high-risk occupational exposure to human immunodeficiency virus (HIV). To provide a framework for evaluating the relative effectiveness and costs associated with candidate postexposure prophylaxis (PEP) regimens. METHODS: Standard techniques of cost-effectiveness and cost-utility analysis were used. The analysis compares the costs and consequences of a hypothetical, voluntary combination-drug PEP program consisting of counseling for all HIV-exposed health care workers, followed by chemoprophylaxis for those who elect it vs an alternative in which PEP is not offered. A societal perspective was adopted and a 5% discount rate was used. Hospital costs of recommended treatment regimens (zidovudine alone or in combination with lamivudine and indinavir) were used, following the dosing schedules recommended by the US Public Health Service. Estimates of lifetime treatment costs for HIV and acquired immunodeficiency syndrome were obtained from the literature. Because the effectiveness of combination PEP has not been established, the effectiveness of zidovudine PEP was used in the base-case analyses. MAIN OUTCOME MEASURES: Net PEP program costs, number of HIV infections averted, cost per HIV infection averted, and cost-utility ratio (net cost per discounted quality-adjusted life-year saved) for zidovudine, lamivudine, and indinavir combination PEP. Lower bounds on the effectiveness required for combination regimens to be considered incrementally cost saving, relative to zidovudine PEP alone, were calculated. Multiple sensitivity and threshold analyses were performed to assess the impact of uncertainty in key parameters. RESULTS: Under base-case assumptions, the net cost of a combination PEP program for a hypothetical cohort of 10,000 HIV-exposed health care workers is about $4.8 million. Nearly 18 HIV infections are prevented. The net cost per averted infection is just less than $400,000, which exceeds estimated lifetime HIV and acquired immunodeficiency syndrome treatment costs. Although combination PEP is not cost saving, the cost-utility ratio (about $37,000 per quality-adjusted life-year in the base case) is within the range conventionally considered cost-effective, provided that chemoprophylaxis is delivered in accordance with Public Health Service guidelines. Small incremental improvements in the effectiveness of PEP are associated with large overall societal savings. CONCLUSIONS: Under most reasonable assumptions, chemoprophylaxis with zidovudine, lamivudine, and indinavir following moderate- to high-risk occupational exposures is cost-effective for society. If combination PEP is minimally more effective than zidovudine PEP, then the added expense of including lamivudine and indinavir in the drug regimen is clearly justified.

Human immunodeficiency virus counseling, testing, referral, and partner notification services. A cost-benefit analysis.

BACKGROUND: The Centers for Disease Control and Prevention (Atlanta, Ga) annually provides more than +100 million in funding to states, territories, and cities for the provision of human immunodeficiency virus (HIV) counseling, testing, referral, and partner notification (CTRPN) services. Given the size of this expenditure, it is important to consider the net benefits of this program activity. We compared the economic costs and benefits of publicly funded HIV CTRPN services. METHODS: Standard methods for cost-benefit analysis were used. A societal perspective was employed. Major assumptions used in the base-case analysis included the following: (1) without public funding, the HIV CTRPN services would not be provided; (2) for every 100 HIV-seropositive persons identified and reached by CTRPN services, at least 20 new HIV infections are averted; and (3) for every +100 spent on direct and indirect costs of CTRPN services, approximately another +60 is spent on the ancillary costs of alerting people to HIV issues and CTRPN service availability. Sensitivity analyses were performed to explore the robustness of base-case results to these and other changes in model assumptions. RESULTS: Under base-case assumptions, the combined direct, indirect, and ancillary costs of the CTRPN program in 1990 dollars were +188,217,600. At a 6% discount rate, the estimated economic benefits of this expenditure are +3,781,918,000. The resultant benefit-cost ratio is 20.09. Sensitivity analyses showed that the benefit-cost ratio is greater than 1 for all considered cases. CONCLUSIONS: This cost-benefit analysis strongly suggests that publicly funded CTRPN services result in a net economic gain to society.

Consequences of HIV prevention interventions and programs: spectrum, selection, and quality of outcome measures.

The outcome measures employed in an HIV prevention intervention study should match the research and policy questions at hand. If the question is 'did the intervention work to prevent HIV infection?', then seroincidence data may be insufficient. However, if the question is 'why did the intervention work?', then more detailed behavioral data are necessary (and sometimes behavior change itself is the real goal of an intervention study). Given the wide range of questions asked by HIV prevention policy makers, funders and researchers, a spectrum of outcome measures is needed across HIV prevention intervention studies. These include measures of behavioral determinants, HIV-related risk behaviors, HIV incidence (and other biologic markers), morbidity, mortality, and cost-effectiveness factors (such as cost per quality-adjusted life year saved). In this paper, we review the range of outcome measures used and needed in these intervention studies. Particular attention is paid to the psychometric properties of self-reported behavior change measures of sexual behavior and substance use. Additional emphasis is placed on the role of cost-effectiveness measures in intervention studies. A general framework is proposed for conceptualizing the array of outcome measure possible for any given HIV prevention intervention study.

Cost-effectiveness of counseling and testing and partner notification: a decision analysis.

OBJECTIVE: Counseling and testing and partner notification are effective HIV prevention strategies, but they can be resource intensive. This paper evaluates the cost-effectiveness of partner notification and counseling and testing offered in HIV and sexually transmitted disease (STD) clinics in preventing future HIV infections in the United States of America. METHODS: Decision trees were developed from both societal and provider perspectives. The counseling and testing and partner notification models incorporate estimates of HIV prevalence, return rates for counseling, risk of HIV transmission within 1 year, and the effectiveness of counseling. Cost estimates for counseling and testing and partner notification programs and lifetime treatment cost of HIV for the United States of America were obtained from published literature. Extensive sensitivity analyses of model parameters were conducted. RESULTS: For a cohort of 10,000 individuals at a clinic with an HIV seroprevalence of 1.5%, we estimate that counseling and testing prevents eight HIV infections and saves society almost $1,000,000. We estimate that partner notification for the 113 infected persons identified by counseling and testing, prevents another 1.2 HIV infections and saves an additional $181,000. To the provider (HIV and STD clinics), this translates to a cost of $32,000 per case prevented by counseling and testing and an additional $28,000 for partner notification. Model results are most sensitive to assumptions of HIV prevalence, risk of transmission, and treatment cost of HIV. CONCLUSIONS: Counseling and testing and partner notification are cost effective in preventing HIV transmission in this setting. This model can be adapted to assess the cost-effectiveness of counseling and testing and partner notification in other settings.

Cost-effectiveness of post-exposure prophylaxis following sexual exposure to HIV.

OBJECTIVES: To assess the cost-effectiveness, relative to other health-related interventions in the U.S., of post-exposure prophylaxis (PEP) following potential HIV exposure through sexual contact with a partner who may or may not be infected, and to compare the relative cost-effectiveness of dual- and triple-combination PEP. METHODS: Standard techniques of cost-utility analysis were used to assess the cost-effectiveness of PEP with a four-week regimen of zidovudine and lamivudine, or zidovudine, lamivudine, and indinavir. Due to a lack of empirical data on the effectiveness of PEP with combination drug regimens, the analysis assumed that combination PEP was no more effective than PEP with zidovudine alone. The main outcome variable is the cost per quality-adjusted life year (QALY) saved by the program. RESULTS: Providing PEP to a cohort of 10,000 patients who report receptive anal intercourse with a partner of unknown HIV status (who is assumed to be infected with probability equal to 0.18) would prevent about 20 infections, at an average net cost of about US$ 70,000 per infection averted. The cost-utility ratio, US$ 6316 per QALY saved, indicates that PEP is highly cost-effective in this instance. Moreover, triple-combination PEP would need to be about 9% more effective than dual-combination PEP for the addition of indinavir to the regimen to be considered cost-effective. Prophylaxis following receptive vaginal exposure is cost-effective only when it is nearly certain that the partner is infected; PEP for insertive anal and vaginal intercourse does not appear to be cost-effective. CONCLUSIONS: From a purely economic standpoint, PEP should be restricted to partners of infected persons (e.g., serodiscordant couples), to patients reporting unprotected receptive anal intercourse (including condom breakage), and possibly to cases where there is a substantial likelihood that the partner is infected. Providing PEP to all who request it does not appear to be an economically efficient use of limited HIV prevention and treatment resources.

Cost-effectiveness of HIV-prevention skills training for men who have sex with men.

OBJECTIVE: A previous study empirically compared the effects of two HIV-prevention interventions for men who have sex with men: (i) a safer sex lecture, and (ii) the same lecture coupled with a 1.5 h skills-training group session. The skills-training intervention led to a significant increase in condom use at 12-month follow-up, compared with the lecture-only condition. The current study retrospectively assesses the incremental cost-effectiveness of skills training to determine whether it is worth the extra cost to add this component to an HIV-prevention intervention that would otherwise consist of a safer sex lecture only. DESIGN: Standard techniques of incremental cost-utility analysis were employed. METHODS: A societal perspective and a 5% discount rate were used. Cost categories assessed included: staff salary, fringe benefits, quality assurance, session materials, client transportation, client time valuation, and costs shared with other programs. A Bernoulli-process model of HIV transmission was used to estimate the number of HIV infections averted by the skills-training intervention component. For each infection averted, the discounted medical costs and quality-adjusted life years (QALY) saved were estimated. One- and multi-way sensitivity analyses were performed to assess the robustness of base-case results to changes in modeling assumptions. RESULTS: Under base-case assumptions, the incremental cost of the skills training was less than $13,000 (or about $40 per person). The discounted medical costs averted by incrementally preventing HIV infections were over $170,000; more than 21 discounted QALY were saved. The cost per QALY saved was negative, indicating cost-savings. These results are robust to changes in most modeling assumptions. However, the model is moderately sensitive to changes in the per-contact risk of HIV transmission. CONCLUSIONS: Under most reasonable assumptions, the incremental costs of the skills training were outweighed by the medical costs saved. Thus, not only is skills training effective in reducing risky behavior, it is also cost-saving.

Using cost-effectiveness league tables to compare interventions to prevent sexual transmission of HIV.

Cost-effectiveness information is needed to help public health decision makers choose between competing HIV prevention programs. One way to organize this information is in a 'league table' that lists cost-effectiveness ratios for different interventions and which facilitates comparisons across interventions. Herein we propose a common outcome measure for use in HIV prevention league tables and present a preliminary league table of interventions to reduce sexual transmission of HIV in the US. Fifteen studies encompassing 29 intervention for different population groups are included in the table. Approximately half of the interventions are cost-saving (i.e. save society money, in the long run), and three-quarters are cost-effective by conventional standards. We discuss the utility of such a table for informing the HIV prevention resource allocation process and delineate some of the difficulties associated with the league table approach, especially as applied to HIV prevention cost-effectiveness analysis.

Cost-threshold analyses of the National AIDS Demonstration Research HIV prevention interventions.

OBJECTIVE: The goal of the multisite National AIDS Demonstration Research (NADR) program was to reduce the sexual and drug injection-related HIV risks of out-of-treatment injection drug users and their sex partners. Previous analyses have established that the NADR interventions were effective at changing participants' risky behaviors. This study was to determine whether the NADR program also was cost-effective. METHODS: Data from eight NADR study sites were included in the analysis. A mathematical model was used to translate reported sexual and injection-related behavior changes into an estimate of the number of infections prevented by the NADR interventions and then to calculate the corresponding savings in averted HIV/AIDS medical care costs and quality-adjusted years of life, assuming United States values for these parameters. Because cost data were not collected in the original NADR evaluation, the savings in averted medical care costs were compared with the cost of implementing a similar intervention program for injection drug users. RESULTS: The eight NADR interventions prevented approximately 129 infections among 6629 participants and their partners. Overall, the NADR program would be cost saving (i.e. provide net economic savings) if it cost less than US$2107 per person and would be cost-effective if it cost less than US$10,264 per person. Both of these estimates are considerably larger than the US$273 per person cost of the comparison intervention. There was substantial cross-site variability. CONCLUSIONS: The results of this analysis strongly suggest that the NADR interventions were cost-saving overall and were, at the very least, cost-effective at all eight sites. In the United States and other developed counties, investments in HIV-prevention interventions such as these have the potential to save substantial economic resources by averting HIV-related medical care expenses among injection drug users.

Lifetime cost of care for children with human immunodeficiency virus infection.

BACKGROUND: Knowledge of the cost of care for children with HIV infection is necessary to analyze the economic impact of recommendations for universal counseling and voluntary HIV testing of pregnant women. OBJECTIVES: To estimate the total cost of care for children with HIV infection. METHODS: We performed a retrospective cohort study of all 88 children with (n = 29) or at risk for (n = 59) perinatally acquired HIV infection cared for at Children's Hospital of Wisconsin between February 2, 1987, and June 1, 1995. Review of medical records for all 29 children with perinatally acquired HIV infection or AIDS identified: date of HIV diagnosis; date of classification into Category N, A, B or C; date of AIDS diagnosis; and date of death or transfer of care. The time each subject remained in each CDC category was calculated and the Kaplan-Meier product-limit method was used to calculate survival time for all patients in each CDC category. Hospital-based inpatient and outpatient charges per patient per month in each CDC category (N, A, B, C and AIDS) were calculated with information from the hospital financial services database, and lifetime hospital-based inpatient and outpatient charges were estimated as the sum of the charges for each category. From that, total charges were calculated assuming that hospital-based charges were 83% of total charges. RESULTS: Based on a median survival time of 120 months, the mean lifetime charges for hospital-based care for children with HIV infection was $408307 (estimates ranged from $172217 to $498539). If hospital-based care represents 83% of the total charges for care of children with HIV infection, then mean total lifetime charges for care of children with HIV infection were $491936 ($207490 to $600649). CONCLUSIONS: The care of children with HIV infections is expensive. This information may be useful in planning for care programs and for analyzing the economic impact of recommendations for universal counseling and voluntary HIV testing of pregnant women.

Estimating the value of preventing a human immunodeficiency virus infection.

We estimated the medical cost savings for a case of human immunodeficiency virus (HIV) infection prevented. Using medical care cost estimates, assumptions concerning knowledge of serostatus, time spent in various stages of HIV disease, and a discount factor, we estimated the present value of future cost savings for a case of HIV prevented, which ranged from $56,000 to $80,000. Since this method excludes both indirect costs and direct costs other than medical care, these figures underestimate the true cost savings for a case of HIV prevented. However, the method may prove useful in assigning a systematic economic value to an HIV infection averted that can be used in cost-benefit analyses of HIV prevention interventions.

Influence of behavioral and social science on public health policymaking.

Public health policies are important guiding principles that serve to shape the well-being of individuals, groups, and society. Behavioral and social scientists can play key influential roles in public health policymaking. The actors and processes involved in setting public health policy are described, and several substantive examples of public health decision making are discussed, emphasizing HIV prevention policy experiences at the Centers for Disease Control and Prevention. The significant influence of behavioral and social science in each of these examples is identified and critiqued. Challenges to further integration of behavioral science and public health policy are identified, and potential solutions are proposed.

Threshold analysis and programs for prevention of HIV infection.

BACKGROUND: Measuring the economic effectiveness of HIV-infection prevention activities poses special challenges in terms of behavioral change and health outcomes assessment. METHODS: One way to address this difficulty is to employ threshold analysis to determine a level of cost per HIV infection averted above which society would seem unwilling to pay. The authors employ a cost-utility analytic framework to determine a monetary threshold for HIV prevention programs, subject base-case results to sensitivity analyses, and apply these results to the Centers for Disease Control and Prevention's fiscal year 1993 budget for extramural HIV prevention programs. RESULTS: The monetary threshold for cost per HIV infection averted was calculated to be $417,000 in 1993 dollars, and ranged from $185,000 to $648,000 depending upon the dollar amount society would be willing to pay per quality-adjusted life year gained. CONCLUSIONS: Economic evaluations of particular HIV-infection prevention activities at least can begin by determining whether their levels of effectiveness are above or below this derived monetary threshold, and refinements beyond this dichotomous evaluation can proceed as further data become available.

How HIV treatment advances affect the cost-effectiveness of prevention.

OBJECTIVE: The cost-effectiveness of an HIV prevention program depends, in part, on its potential to avert HIV-related medical care costs. Recent advances in antiretroviral therapy have made HIV/AIDS treatment both more effective and more costly, which might make HIV prevention either more or less cost-effective. The objective of the present study was to explicate the relationship between the effectiveness and costs of HIV treatment and the cost-effectiveness of HIV prevention programs. METHODS: A basic analytic framework was used to compare the cost-effectiveness of HIV prevention interventions with respect to different HIV/AIDS medical care scenarios. Algebra was used to calculate a cost-effectiveness threshold that distinguishes prevention programs that become more cost-effective when therapeutic advances simultaneously increase or decrease the cost and effectiveness of treatment from those that become less cost-effective. Recent estimates of the costs and consequences of combination antiretroviral therapy were used to illustrate the calculation method. RESULTS: The advent of combination antiretroviral therapies for HIV has increased the cost-effectiveness of some, but not all, HIV prevention interventions. CONCLUSIONS: Whether a particular prevention program becomes more or less cost-effective as a consequence of advancements in the medical treatment of HIV/AIDS depends upon the specific characteristics of both the program and the therapy.

Physicians' risk attitudes, laboratory usage, and referral decisions: the case of an academic family practice center.

Individual differences in physicians' laboratory use and referral rates are important aspects of practice variation that have real financial and health consequences. A way to explain these differences is needed. In this empirical study, physicians' risk attitudes (measured on a multidimensional scale) are shown to be good predictors of use rates for certain specific laboratory procedures, but not good predictors of physicians' referral rates. A 15-item survey form that measured risk-taking attitudes in the financial, health, social, and ethical domains was administered to all clinical faculty at an academic family practice center (n = 14). Each physician's utilization rates for the 17 most frequently ordered laboratory procedures were calculated for all patient visits for one calendar year. Overall referral rates were calculated for the same period. Physicians' risk attitudes (12 completed the survey) accounted for over 50% of the variance for several of the laboratory procedures. For example, the rank-order correlation between the complete blood count utilization rate and a Likert-scale item measuring physicians' propensity to take physical risks was 0.91 (p less than 0.001). The details of these findings help to explain an important component of practice variation.

Teaching clinical decision making in a family practice clerkship.

Limited health care resources and other social factors are making clinical decision making (CDM) a necessary subject of study for medical students. However, CDM material is technical and could be perceived by students as arcane. This study evaluated student attitudes toward a CDM module imbedded in a third-year medical student (MSIII) family medicine clerkship. A survey instrument was used for the evaluation and included a within-subject check for response consistency. The results show that MSIIIs feel that technical CDM material is within their grasp and that it is relevant to their day-to-day care of patients.