Community and patient values for preventing herpes zoster.

OBJECTIVES: The US Advisory Committee on Immunization Practices has recently recommended a new vaccine against herpes zoster (shingles) for routine use in adults aged > or =60 years. However, estimates of the cost effectiveness of this vaccine vary widely, in part because of gaps in the data on the value of preventing herpes zoster. Our aims were to (i) generate comprehensive information on the value of preventing a range of outcomes of herpes zoster; (ii) compare these values among community members and patients with shingles and post-herpetic neuralgia (PHN); and (iii) identify clinical and demographic characteristics that explain the variation in these values. METHODS: Community members drawn from a nationally representative survey research panel (n = 527) completed an Internet-based survey using time trade-off and willingness-to-pay questions to value a series of scenarios that described cases of herpes zoster with varying pain intensities (on a scale of 0 to 10, where 0 represents no pain and 10 represents the worst imaginable pain) and duration (30 days to 1 year). Patients with shingles (n = 382) or PHN (n = 137) [defined as having symptoms for > or =90 days] from two large healthcare systems completed telephone interviews with similar questions to the Internet-based survey and also answered questions about their current experience with herpes zoster. We constructed generalized linear mixed models to evaluate the associations between demographic and clinical characteristics, the length and intensity of the health states and time trade-off and willingness-to-pay values. RESULTS: In time trade-off questions, community members offered a mean of 89 (95% CI 24, 182) discounted days to avoid the least severe scenario (pain level of 3 for 1 month) and a mean of 162 (95% CI 88, 259) discounted days to avoid the most severe scenario (pain level of 8 for 12 months). Compared with patients with shingles, community members traded more days to avoid low-severity scenarios but similar numbers of days to avoid high-severity scenarios. Compared with patients with PHN, community members traded fewer days to avoid high-severity scenarios. In multivariate analyses, older age was the only characteristic significantly associated with higher time trade-off values. In willingness-to-pay questions, community members offered a mean of $US450 (95% CI 203, 893) to avoid pain of level 3 for 1 month and a mean of $US1384 (95% CI 873, 2050) [year 2005 values] to avoid pain of level 8 for 12 months. Community members traded less money than patients with either shingles or PHN to avoid both low- and high-severity scenarios (p-values <0.05 to <0.001). In multivariate models, male gender, higher income and having experienced shingles or PHN were associated with higher willingness to pay to avoid herpes zoster. When patients were asked to assign a value to avoiding their own case of herpes zoster, those with shingles assigned a mean of 67 days or $US2319, while those with PHN assigned a mean of 206 days or $US18 184. Both the time and monetary value traded were associated with the maximum intensity of the pain the individual had experienced, but neither was associated with the duration of the pain. CONCLUSIONS: We believe that this study provides the most comprehensive information to date on the value individuals place on preventing herpes zoster, and it includes the only such valuation from nationally representative community members as well as patients with herpes zoster. Community members would trade substantial amounts of time or money to avoid herpes zoster, even in the least severe scenarios. The time trade-off results in this study may differ from those in other studies because of important differences in methods of assessing health utilities. Consideration of both community and patient perspectives is crucial to help decision makers fully determine the implications of their policies now that a vaccine against herpes zoster is available.

Male sexual dysfunction associated with antiretroviral therapy.

To determine whether treatment with protease inhibitors (PIs) is associated with male sexual dysfunction, we conducted a retrospective, cohort study of 254 adult male PI recipients who received care from the staff-model division of a large managed care organization in New England between 1993 and 1998. After a median of 5.0 years of observation, 80 incident cases of sexual dysfunction were observed. Relative to unexposed individuals, the rate of sexual dysfunction adjusted for confounding was most elevated with use of ritonavir (hazard ratio [HR], 2.83; 95% confidence interval [CI], 1.34-5.97; p =.006) followed by indinavir (HR, 1.69; 95% CI, 0.84-3.37; p =.14), nelfinavir (HR, 1.53; 95% CI, 0.66-3.54; p =.32) and saquinavir (HR, 1.25; 95% CI, 0.53-2.96; p =.60). We conclude that PIs, especially ritonavir, appear to increase the risk of sexual dysfunction.