Reduced economic burden of AIDS-defining illnesses associated with adherence to antiretroviral therapy.

OBJECTIVES: We assessed the economic burden of AIDS-defining illnesses (ADIs), which was further stratified by adherence to antiretroviral therapy (ART). METHODS AND MATERIALS: A nationwide longitudinal cohort of 18,234 incident cases with HIV followed for 11years was utilized. Adherence to ART was measured by medication possession ratio (MPR). Generalized estimating equations modeling was used to estimate the cost impact of ADIs. RESULTS: Having opportunistic infections increased the annual cost by 9% (varicella-zoster virus infection) to 98% (cytomegalovirus disease), while the annual costs increased by 26% (Kaposi's sarcoma) to 95% (non-Hodgkin's lymphoma) in the year when AIDS-related cancer occurred. ADIs occurred more frequently in the years with low adherence for ART compared to the high-adherence years (e.g., 0.1≤MPR<0.8 vs. MPR≥0.8, event rate of cytomegalovirus disease 4.03% vs. 0.51%). The annual baseline costs in the years with MPR<0.1, 0.1≤MPR<0.8, and MPR≥0.8 were $250, $4,752, and $8,990 (in 2018 USD), respectively. The economic impact of ADIs in the years with low adherence (MPR<0.1) was larger than that in the high-adherence years (MPR≥0.8) (e.g., MPR<0.1 vs. MPR≥0.8, annual cost increased by 244% vs. 9% when candidiasis occurred). CONCLUSIONS: Adherence to ART may increase the baseline medical costs but mitigate the incidence and economic burden of ADIs.

Cost-effectiveness of CRAG-LFA screening for cryptococcal meningitis among people living with HIV in Uganda.

BACKGROUND: Cryptococcal meningitis (CM) constitutes a significant source of mortality in resource-limited regions. Cryptococcal antigen (CRAG) can be detected in the blood before onset of meningitis. We sought to determine the cost-effectiveness of implementing CRAG screening using the recently developed CRAG lateral flow assay in Uganda compared to current practice without screening. METHODS: A decision-analytic model was constructed to compare two strategies for cryptococcal prevention among people living with HIV with CD4 < 100 in Uganda: No cryptococcal screening vs. CRAG screening with WHO-recommended preemptive treatment for CRAG-positive patients. The model was constructed to reflect primary HIV clinics in Uganda, with a cohort of HIV-infected patients with CD4 < 100 cells/uL. Primary outcomes were expected costs, DALYs, and incremental cost-effectiveness ratios (ICERs). We evaluated varying levels of programmatic implementation in secondary analysis. RESULTS: CRAG screening was considered highly cost-effective and was associated with an ICER of $6.14 per DALY averted compared to no screening (95% uncertainty range: $-20.32 to $36.47). Overall, implementation of CRAG screening was projected to cost $1.52 more per person, and was projected to result in a 40% relative reduction in cryptococcal-associated mortality. In probabilistic sensitivity analysis, CRAG screening was cost-effective in 100% of scenarios and cost saving (ie cheaper and more effective than no screening) in 30% of scenarios. Secondary analysis projected a total cost of $651,454 for 100% implementation of screening nationally, while averting 1228 deaths compared to no screening. CONCLUSION: CRAG screening for PLWH with low CD4 represents excellent value for money with the potential to prevent cryptococcal morbidity and mortality in Uganda.

[Evaluation of the benefit of different complementary exams in the search for a TB diagnosis algorithm for HIV patients put on ART in Niamey, Niger]. / Évaluation du bénéfice apporté par des examens complémentaires pour le diagnostic de la tuberculose chez des patients infectés par le VIH mis sous ARV à Niamey, Niger.

In Niger, the tuberculosis (TB) screening among people living with human immunodeficiency virus (HIV) (PLHIV) is nonsystematic and the use of additional tests is very often limited. The objective of this research is to evaluate the performance and the cost-effectiveness of various paraclinical testing strategies of TB among adult patients with HIV, using available tests in routine for patients cared in Niamey. This is a multicentric prospective intervention study performed in Niamey between 2010 and 2013. TB screening has been sought in newly diagnosed PLHIV, before ART treatment, performing consistently: a sputum examination by MZN (Ziehl-Nielsen staining) and microscopy fluorescence (MIF), chest radiography (CR), and abdominal ultrasound. The performance of these different tests was calculated using sputum culture as a gold standard. The various examinations were then combined in different algorithms. The cost-effectiveness of different algorithms was assessed by calculating the money needed to prevent a patient, put on ART, dying of TB. Between November 2010 and November 2012, 509 PLHIV were included. TB was diagnosed in 78 patients (15.3%), including 35 pulmonary forms, 24 ganglion, and 19 multifocal. The sensitivity of the evaluated algorithms varied between 0.35 and 0.85. The specificity ranged from 0.85 to 0.97. The most costeffective algorithm was the one involving MIF and CR. We recommend implementing a systematic and free direct examination of sputum by MIF and a CR for the detection of TB among newly diagnosed PLHIV in Niger.

Cryptococcal Meningitis Treatment Strategies Affected by the Explosive Cost of Flucytosine in the United States: A Cost-effectiveness Analysis.

BACKGROUND: In the United States, cryptococcal meningitis causes approximately 3400 hospitalizations and approximately 330 deaths annually. The US guidelines recommend treatment with amphotericin B plus flucytosine for at least 2 weeks, followed by fluconazole for a minimum of 8 weeks. Due to generic drug manufacturer monopolization, flucytosine currently costs approximately $2000 per day in the United States, with a 2-week flucytosine treatment course costing approximately $28 000. The daily flucytosine treatment cost in the United Kingdom is approximately $22. Cost-effectiveness analysis was performed to determine the value of flucytosine relative to alternative regimens. METHODS: We estimated the incremental cost-effectiveness ratio (ICER) of 3 cryptococcal induction regimens: (1) amphotericin B deoxycholate for 4 weeks; (2) amphotericin and flucytosine (100 mg/kg/day) for 2 weeks; and (3) amphotericin and fluconazole (800 mg/day) for 2 weeks. Costs of care were calculated using 2015 US prices and the medication costs. Survival estimates were derived from a randomized trial and scaled relative to published US survival data. RESULTS: Cost estimates were $83 227 for amphotericin monotherapy, $75 121 for amphotericin plus flucytosine, and $44 605 for amphotericin plus fluconazole. The ICER of amphotericin plus flucytosine was $23 842 per quality-adjusted life-year. CONCLUSIONS: Flucytosine is currently cost-effective in the United States despite a dramatic increase in price in recent years. Combination therapy with amphotericin and flucytosine is the most attractive treatment strategy for cryptococcal meningitis, though the rising price may be creating access issues that will exacerbate if the trend of profiteering continues.

TB screening among people living with HIV/AIDS in resource-limited settings.

Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among people living with HIV (PLHIV), making improved prevention and treatment of HIV-associated TB critical to ensuring long-term survival of PLHIV. TB screening among PLHIV is central to implementation of the World Health Organization's 3 I's interventions for reducing the impact of the TB and HIV syndemics. Effective TB screening will result in the identification of PLHIV with presumptive TB disease (ie, those with a positive symptom screen who require appropriate evaluation, including the use of diagnostic tools such as the Xpert MTB/RIF assay) and those eligible for isoniazid preventive therapy (ie, those who have a negative clinical symptom screen or who have a positive screen but are found not to have TB disease). Identification of PLHIV with presumptive TB also facilitates implementation of basic administrative measures for TB infection control, including fast tracking of coughing patients and separation from noncoughing PLHIV to reduce TB transmission. By contributing to the early diagnosis of TB disease among PLHIV, TB screening is also critical to facilitate early initiation of antiretroviral treatment among PLHIV diagnosed with TB disease who might not otherwise be eligible for antiretroviral treatment based on CD4 count or clinical staging. TB screening thus serves as a gateway for multiple TB/HIV interventions and is an integral part of routine clinical services for PLHIV at each clinic visit.

Cost effectiveness of cryptococcal antigen screening as a strategy to prevent HIV-associated cryptococcal meningitis in South Africa.

OBJECTIVES: Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM. DESIGN: Cost-effectiveness analysis. METHODS: Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART. RESULTS: The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51 per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495). CONCLUSIONS: CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.

Prevalence of cryptococcal antigenemia and cost-effectiveness of a cryptococcal antigen screening program--Vietnam.

BACKGROUND: An estimated 120,000 HIV-associated cryptococcal meningitis (CM) cases occur each year in South and Southeast Asia; early treatment may improve outcomes. The World Health Organization (WHO) recently recommended screening HIV-infected adults with CD4<100 cells/mm(3) for serum cryptococcal antigen (CrAg), a marker of early cryptococcal infection, in areas of high CrAg prevalence. We evaluated CrAg prevalence and cost-effectiveness of this screening strategy in HIV-infected adults in northern and southern Vietnam. METHODS: Serum samples were collected and stored during 2009-2012 in Hanoi and Ho Chi Minh City, Vietnam, from HIV-infected, ART-naïve patients presenting to care in 12 clinics. All specimens from patients with CD4<100 cells/mm(3) were tested using the CrAg lateral flow assay. We obtained cost estimates from laboratory staff, clinicians and hospital administrators in Vietnam, and evaluated cost-effectiveness using WHO guidelines. RESULTS: Sera from 226 patients [104 (46%) from North Vietnam and 122 (54%) from the South] with CD4<100 cells/mm(3) were available for CrAg testing. Median CD4 count was 40 (range 0-99) cells/mm(3). Nine (4%; 95% CI 2-7%) specimens were CrAg-positive. CrAg prevalence was higher in South Vietnam (6%; 95% CI 3-11%) than in North Vietnam (2%; 95% CI 0-6%) (p = 0.18). Cost per life-year gained under a screening scenario was $190, $137, and $119 at CrAg prevalences of 2%, 4% and 6%, respectively. CONCLUSION: CrAg prevalence was higher in southern compared with northern Vietnam; however, CrAg screening would be considered cost-effective by WHO criteria in both regions. Public health officials in Vietnam should consider adding cryptococcal screening to existing national guidelines for HIV/AIDS care.

[Assessment of the impact of the new health legislation on illegal immigrants in Spain: the case of human immunodeficiency virus infection]. / Evaluación del impacto del nuevo marco legal sanitario sobre los inmigrantes en situación irregular en España: el caso de la infección por el virus de la inmunodeficiencia humana.

The immigrant population in Spain, whether legal or not, has been entitled to healthcare under the same conditions as the Spanish population since the year 2000. The entry into vigour of the Royal Decree-Law 12/2012 of 20 April has significantly restricted this right, so that unauthorized or non-resident foreigners may now only receive emergency care, if they are under 18 or pregnant women. Out of an estimated 459,909 illegal immigrants in our country, 2,700 to 4,600 are probably infected with HIV; 1,800 to 3,220 know that they are infected, and 80% of the latter could receive antiretroviral treatment. The Royal Decree-Law is likely to cause many undesirable consequences in this population infected with HIV: increasing mortality, promoting the emergence of opportunistic diseases, increasing hospital admissions, increasing infections in the population (by HIV and other pathogens), or contributing to mother to child transmission of HIV. The expected increase in morbidity and mortality will be a greater cost in patient care, a cost which will be significantly higher in the more immunosuppressed patients. Therefore, the enforcement of the Royal Decree-Law will be much less cost-effective in the short term than was expected, and will negatively affect our country's public health, especially for those patients infected with HIV who will not be covered, thus increasing healthcare medium to long term costs, and moving away from the international health goals that were established.

Prevalence and factors associated with cryptococcal antigenemia among severely immunosuppressed HIV-infected adults in Uganda: a cross-sectional study.

BACKGROUND: Cryptococcal infection is a common opportunistic infection among severely immunosuppressed HIV patients and is associated with high mortality. Positive cryptococcal antigenemia is an independent predictor of cryptococcal meningitis and death in patients with severe immunosuppression. We evaluated the prevalence and factors associated with cryptococcal antigenemia among patients with CD4 counts of 100 cells/mm(3) or less in Mulago Hospital, Kampala, Uganda. Screening of a targeted group of HIV patients may enable early detection of cryptococcal infection and intervention before initiating antiretroviral therapy. Factors associated with cryptococcal antigenemia may be used subsequently in resource-limited settings in screening for cryptococcal infection, and this data may also inform policy for HIV care. METHODS: In this cross-sectional study, HIV-infected patients aged 18 years and older with CD4 counts of up to 100 cells/mm(3) were enrolled between December 2009 and March 2010. Data on socio-demographics, physical examinations and laboratory tests were collected. Factors associated with cryptococcal antigenemia were analyzed using multiple logistic regression. RESULTS: We enrolled 367 participants and the median CD4 count was 23 (IQR 9-51) cells/mm(3). Sixty-nine (19%) of the 367 participants had cryptococcal antigenemia. Twenty-four patients (6.5%) had cryptococcal meningitis on cerebrospinal fluid analysis and three had isolated cryptococcal antigenemia. Factors associated with cryptococcal antigenemia included: low body mass index of 15.4 kg/m2 or less (adjusted odds ratio, AOR = 0.5; 95% CI 0.3-1.0), a CD4(+) T cell count of less than 50 cells/mm(3) (AOR = 2.7; 95% CI1.2-6.1), neck pain (AOR = 2.3; 95% CI 1.2-4.6), recent diagnosis of HIV infection (AOR = 1.9; 95% CI 1.1-3.6), and meningeal signs (AOR = 7.9; 95% CI 2.9-22.1). However, at sub-analysis of asymptomatic patients, absence of neck pain (AOR = 0.5), photophobia (AOR = 0.5) and meningeal signs (AOR = 0.1) were protective against cryptococcal infection. CONCLUSIONS: Cryptococcal antigenemia is common among severely immunosuppressed HIV patients in Mulago Hospital, Kampala, Uganda. Independent predictors of positive serum cryptococcal antigenemia were CD4(+) T cell counts of less than 50 cells/mm, low body mass index, neck pain, signs of meningeal irritation, and a recent diagnosis of HIV infection. Routine screening of this category of patients may detect cryptococcosis, and hence provide an opportunity for early intervention. Absence of neck pain, photophobia and meningeal signs were protective against cryptococcal infection compared with symptomatic patients.

Effectiveness of antiretroviral treatment in patients from Pereira and Manizales / Efectividad del tratamiento antirretroviral en pacientes de Pereira y Manizales

Objective Evaluating the effectiveness of antiretroviral therapy in a sample of Colombian patients diagnosed as having HIV/AIDS and being treated by the Colombian Health Social Security System (CHSSS) Methods A descriptive study was conducted among 134 HIV/AIDS patients of any age or gender who had received antiretroviral therapy in the cities of Pereira and Manizales between July 1st 2008 and June 30th 2009. The following factors were assessed from the clinical history of the patients seen in three health insurance companies: viral load, CD4 count, antiretroviral treatment regimens, prescribed daily doses of medications, length of disease evolution, duration of therapy, history of opportunistic diseases, and drug costs. Results There was male predominance (91 men cf 43 women), mean age beingf 39 years, and an average of 59 months since diagnosis. All treatment regimens were defined by each drug's defined daily dose (DDD). The therapy was effective in 74.5 percent of patients. Effectiveness was defined as being viral load < 400 copies/ml. About 79.1 percent of patients had had their viral load measured during the last 6 months. Non-adherence to treatment and a history of having acquired 2 other sexually- transmitted infections were associated with an increased risk of uncontrolled HIV infection. The average value of drugs per year per patient was $4,077.2 ± 3,043.8 U.S. dollars/year. Conclusions Non-adherence to treatment remains one of the most important issues regarding antiretroviral therapy effectiveness, so programmes intended to control HIV/AIDS must address this problem.

Objetivo Evaluar la efectividad del tratamiento antirretroviral en una muestra de pacientes con diagnóstico de VIH/SIDA en dos ciudades colombianas. Métodos Estudio descriptivo en 134 pacientes en tratamiento para VIH/SIDA de cualquier edad y género en Pereira y Manizales entre 1 de julio de 2008 y 30 de junio de 2009. Se evaluó: carga viral, conteo de linfocitos CD4, esquemas antirretrovirales, dosis diaria prescrita, tiempo evolución de enfermedad, duración de terapia, antecedentes de enfermedades oportunistas, costos de medicamentos. Resultados Predominio masculino (91 hombres vs 43 mujeres), promedio de edad: 39 años y 59 meses de evolución de la enfermedad. Todos recibían esquemas a Dosis Diarias Definidas recomendadas. La terapia era efectiva en 73,6 por ciento de los pacientes (carga viral <400 copias/ml). Se pudo establecer que la falta de adherencia al tratamiento y el antecedente de haber tenido otras 2 infecciones de transmisión sexual se asociaban con mayor riesgo de no controlar la infección por VIH. El valor promedio de los medicamentos por año por paciente fue de US$ 4 077.2 ± 3 043.8 dólares. Conclusiones La falta de adherencia al tratamiento sigue siendo uno de los problemas más importantes para garantizar efectividad, por lo cual los programas de control del VIH/SIDA deben asegurarla.

Early antiretroviral therapy for patients with acute aids-related opportunistic infections: a cost-effectiveness analysis of ACTG A5164.

PURPOSE: ACTG A5164 demonstrated that early antiretroviral therapy (ART) in HIV-infected patients with acute opportunistic infections (OIs) reduced death and AIDS progression compared to ART initiation 1 month later. We project the life expectancies, costs, and incremental cost-effectiveness ratios (ICERs) of these strategies. METHOD: using an HIV simulation model, we compared 2 strategies for patients with acute OIs: (1) an intervention to deliver early ART, and (2) deferred ART. Parameters from ACTG A5164 included initial mean CD4 count (47/microL), linkage to outpatient care (87%), and immune reconstitution inflammatory syndrome 1 month after ART initiation (7%). The estimated intervention cost was $1,650/patient. RESULTS: early ART lowered projected 1-year mortality from 10.4% to 8.2% and increased life expectancy from 10.07 to 10.39 quality-adjusted life-years (QALYs). Lifetime costs increased from $385,220 with deferred ART to $397,500 with early ART, primarily because life expectancy increased, producing an ICER of $38,600/QALY. Results were most sensitive to increased intervention cost and decreased virologic efficacy in the early ART strategy. CONCLUSIONS: an intervention to initiate ART early in patients with acute OIs improves survival and meets US cost-effectiveness thresholds. Programs should be developed to implement this strategy at sites where HIV-infected patients present with OIs.

Cost-effectiveness analysis comparing chemotherapy regimens in the treatment of AIDS-related Kaposi's sarcoma in Brazil.

BACKGROUND: Economic analyses of agents used in the treatment of AIDS and opportunistic diseases are particularly important in developing countries. PURPOSE: To analyze the cost-effectiveness of AIDS-related Kaposi's sarcoma (AIDS-KS) chemotherapy regimens in Brazil. METHOD: A decision-analysis model was developed, and effectiveness data were derived from randomized phase III trials evaluating pegylated liposomal doxorubicin (PLD), liposomal daunorubicin (DNX), and the ABV regimen (doxorubicin, bleomycin, and vincristine). Resource data on direct medical costs were obtained from local sources. RESULTS: The cost-effectiveness estimates (defined as average costs per patient who responds completely or partially) favored PLD (US $10,272/responder) in comparison to DNX (US $16,263/responder). Regarding cost-effectiveness, the ABV regimen that is widely used in developing countries had better results when compared to both PLD (US $1,268 vs. US $10,271) and DNX (US $1,268 vs. US $16,260). The incremental cost per additional responder of using PLD instead of ABV was US $20,990. Sensitivity analyses suggest that these results hold over a wide range of assumptions. CONCLUSION: ABV seems to be the most reasonable treatment option for AIDS-KS patients in resource-limited countries like Brazil.

The value of screening for sexually transmitted diseases in an HIV clinic.

Because bacterial sexually transmitted diseases (STDs) facilitate HIV transmission, screening for and treatment of STDs among HIV-infected persons should prevent HIV spread to partners. Before screening programs for gonorrhea and Chlamydia infection should be widely established in HIV clinics, it is useful to know the prevalence of these infections. This study analyzed the results of a urine-based screening program for gonorrhea and Chlamydia in a New Orleans HIV clinic and compared the positivity rates to the prevalence in the local community. Among persons screened in the HIV clinic, 1.7% (46/2629) had gonorrhea and 2.1% (56/2629) had Chlamydia infection. Among persons aged 18-29 years, the test positivity for gonorrhea was similar in the HIV clinic to that of persons in sociodemographically similar community samples (3.1 versus 2.4%, adjusted odds ratio 1.6, P = 0.11) and the test positivity for Chlamydia infection was lower (5.4% versus 10.5%, adjusted odds ratio 0.6, P < 0.01). Based on a previously published mathematical model, it was estimated that treatment of all 46 gonorrhea and 56 Chlamydia infections in the HIV clinic may have averted 9 HIV infections among sex partners and saved far more in future medical costs than the cost of the screening. Routine screening for gonorrhea and Chlamydia infection should be considered in HIV clinics.

Prevention of human immunodeficiency virus-related opportunistic infections in France: a cost-effectiveness analysis.

A simulation model of human immunodeficiency virus (HIV) disease, which incorporated French data on the progression of HIV disease in the absence of antiretroviral therapy and on cost, was used to determine the clinical impact and cost-effectiveness of different strategies for the prevention of opportunistic infections in French patients who receive highly active antiretroviral therapy (HAART). Compared with use of no prophylaxis, use of trimethoprim-sulfamethoxazole (TMP-SMZ) increased per-person lifetime costs from euro 185,600 to euro 187,900 and quality-adjusted life expectancy from 112.2 to 113.7 months, for an incremental cost-effectiveness ratio of euro 18,700 per quality-adjusted life-year (euro/QALY) gained. Compared with use of TMP-SMZ alone, use of TMP-SMZ plus azithromycin cost euro 23,900/QALY gained; adding fluconazole cost an additional euro 54,500/QALY gained. All strategies that included oral ganciclovir had cost-effectiveness ratios that exceeded euro 100,000/QALY gained. In the era of HAART, on the basis of French data, prophylaxis against Pneumocystis carinii pneumonia, toxoplasmic encephalitis, and Mycobacterium avium complex bacteremia is cost-effective. Prophylaxis against fungal and cytomegalovirus infections is less cost-effective than are other therapeutic options for HIV disease and should remain of lower priority.

Cost effectiveness of human papillomavirus testing to augment cervical cancer screening in women infected with the human immunodeficiency virus.

PURPOSE: To determine the cost effectiveness of incorporating molecular testing for high-risk types of human papillomavirus into a cervical cancer screening program for women infected with the human immunodeficiency virus (HIV). SUBJECTS AND METHODS: We developed a Markov model to simulate the natural history of cervical cancer precursor lesions in HIV-infected women. Probabilities of progression and regression of cervical lesions were conditional on transient or persistent infection with human papillomavirus, as well as stage of HIV and effectiveness of antiretroviral therapy. Incorporating data from prospective cohort studies, national databases, and published literature, the model was used to calculate quality-adjusted life expectancy, life expectancy, lifetime costs, and incremental cost-effectiveness ratios for two main strategies: targeted screening-human papillomavirus testing is added to the initial two cervical cytology smears obtained after an HIV diagnosis and subsequent screening intervals are modified based on the test results; and universal screening-no testing for human papillomavirus is performed, and a single cytology screening interval is applied to all women. RESULTS: In HIV-infected women on anti-retroviral therapy, a targeted screening strategy in which cervical cytology screening was conducted every 6 months for women with detected human papillomavirus DNA, and annually for all others, cost $10,000 to $14,000 per quality-adjusted life year gained compared with no screening. A universal screening strategy consisting of annual cervical cytology for all women was 15% less effective and had a less attractive cost-effectiveness ratio. Targeted screening remained economically attractive in multiple sensitivity analyses, although when the overall incidence of cervical cancer precursor lesions was lowered by 75%, the screening interval for women with detected human papillomavirus DNA could be widened to 1 year. CONCLUSIONS: Adding human papillomavirus testing to the two cervical cytology smears obtained in the year after an HIV diagnosis, and modifying subsequent cytology screening intervals based on the results, appears to be an effective and cost-effective modification to current recommendations for annual cytology screening in HIV-infected women.

Tuberculosis screening of immigrants to low-prevalence countries. A cost-effectiveness analysis.

All adult immigrant applicants to Canada undergo chest radiographic screening for tuberculosis (TB). Tuberculin skin testing could reduce the number of chest X-rays, and identify more candidates for prophylaxis. We modeled the cost-effectiveness of chest radiography and tuberculin skin testing for TB prevention over a 20-yr time frame, among three simulated cohorts of 20-yr-old immigrants. Compared with no screening, radiographic screening prevented 4.3% of expected active TB cases in the highest risk cohort (50% TB-infected, 10% human immunodeficiency virus [HIV] seroprevalence), and 8.0% in the lowest risk cohort (5% TB-infected, 1% HIV seroprevalence). Tuberculin skin testing further reduced the expected incidence 8.0% and 4.0%, respectively. Compared with no screening, radiographic screening cost $3,943 Canadian per active TB case prevented in the highest risk cohort, and $236,496 per case prevented in the lowest risk group. Compared with radiographic screening, mass tuberculin skin testing cost $32,601 per additional case prevented in the highest risk group, and $68,799 per additional case prevented in the lowest risk group. Chest radiographic screening of young immigrants from countries with a high prevalence of TB is a relatively inexpensive means of TB prevention. Tuberculin skin testing is considerably less cost-effective. For immigrants from low-prevalence countries, both interventions are extremely costly with negligible impact. The cost-effectiveness of either strategy would be greatly enhanced by increased adherence to chemoprophylaxis recommendations. Radiographic screening of groups with a high prevalence of tuberculous infection will then likely save money.

Ocular lesions associated with HIV infection in India: a series of 100 consecutive patients evaluated at a referral center.

PURPOSE: To document the ocular disorders seen in patients known to be infected with human immunodeficiency (HIV) virus at a referral eye clinic in India. METHODS: The first 100 individuals known to be HIV-positive at a referral eye clinic between 1993 and 1998 were enrolled in a prospective study. They underwent complete ocular and systemic evaluation. RESULTS: Most of the patients (76%) were in the 20-to 40-year age group. Heterosexual exposure to commercial sex workers was the most common risk factor (70%) for HIV infection. Cytomegalovirus (CMV) retinitis (17%) and HIV retinopathy (15%) were the most common HIV-associated ophthalmic lesions. Pulmonary tuberculosis (67%) and oropharyngeal candidiasis (66%) were the most commonly associated systemic infections. Ocular involvement was most common in children who contracted the disease through perinatal transmission (66.7%) and in homosexual patients (60%). Ocular involvement was comparatively less common in patients who contracted the disease through blood transfusions (33%) or exposure to commercial sex workers (24.3%). CONCLUSIONS: This study shows that the spectrum of ocular lesions associated with HIV infection in India is different from that seen elsewhere in the world. The prevalence of CMV retinitis and HIV retinopathy is lower in India, and there have been no cases of ocular Kaposi sarcoma. Adnexal infections, albeit rare, were seen in our series. The nonavailability and cost of therapy influenced the visual prognosis in these patients.

Tuberculosis prevention in methadone maintenance clinics. Effectiveness and cost-effectiveness.

To determine the effectiveness and cost-effectiveness of a program to provide screening for tuberculosis infection and directly observed preventive therapy (DOPT) in methadone maintenance clinics, we determined completion rates of screening for tuberculosis infection, medical evaluation, and preventive therapy, as well as the number of active tuberculosis cases and tuberculosis-related deaths prevented, in five clinics in San Francisco, California. Between 1990 and 1995, a total of 2,689 clients (of whom 18% were HIV-seropositive) were screened at least once. Of eligible clients, 99% received tuberculin skin tests, 96% received a medical examination, 91% began isoniazid preventive therapy, and 82% completed preventive therapy. Program effectiveness was enhanced by close collaboration between public health and methadone maintenance programs and the use of incentives and enablers. Over a 3-yr follow-up period, only one verified case of tuberculosis was reported among clients with a positive tuberculin skin test, thereby preventing as much as 95% of expected tuberculosis cases. Over 10 yr, we estimate the program would prevent 30.0 (52%) of 57.7 expected cases of tuberculosis, and 7.6 (57%) of 13.4 expected tuberculosis-related deaths. The program cost $771,569, but averted an estimated $876,229, for a net savings of $104,660 (average of $3, 724 per case prevented). Our study demonstrates that when effectively implemented, screening for tuberculosis infection and DOPT in methadone maintenance clinics is a highly cost-effective approach to prevent tuberculosis.

[Stereotactic brain biopsy in AIDS patients: a necessary patient-oriented and cost-effective diagnostic measure?]. / Die stereotaktische Hirnbiopsie bei AIDS-Patienten: eine notwendige, patientenorientierte und kosteneffektive diagnostische Massnahme?

Neurological complications occur in 40% of "human immunodeficiency virus type 1" (HIV-1)-infected patients. Aim of the study was to evaluate the diagnostic yield of stereotactic brain biopsy and non invasive diagnostic procedures (CT, antitoxoplasma antibodies) and to calculate the benefit of the brain biopsy for the patient and the costs of both methods. From October 1989 through September 1995 we biopsied 44 of 2749 (2%) HIV-1-infected patients after non invasive diagnostic procedures had been performed. In 93% of the patients an unambiguous diagnosis was possible based on the biopsy and lead in 73% of the patients to a change of therapy. No complications occurred after biopsy. 40 CTs and 15 MRIs were done. The radiological appearance of toxoplasmosis and non Hodgkin lymphoma (NHL) differed from that of progressive multifocal leucencephalopathy (PML) in respect to enhancement (PML). CT showed a sensitivity of 55% (toxoplasmosis, NHL) and 78% (PML) and a specificity of 83% (PML), 84% (NHL) and 96% (toxoplasmosis), respectively. Antitoxoplasma antibodies showed a sensitivity of 45%, only. The stereotactic brain biopsy was more expensive (20.166,- ATS) than CT, MRI and antitoxoplasma antibodies (4109,- ATS up to 6959,- ATS). We conclude that stereotactic brain biopsy is an efficient and safe and for the patients important diagnostic procedure. In selected patients even expensive investigations should be undertaken considering specific therapy and cost effective homecare.