Stringent adherence to a cytomegalovirus-prevention protocol is associated with reduced overall costs in the first 6 months after kidney transplantation.

BACKGROUND: We previously documented that a stringent implementation of a preemptive cytomegalovirus (CMV) prevention protocol reduced the number of CMV disease episodes after kidney transplantation, when compared with a routine preemptive protocol. The impact on overall costs was assessed. METHODS: Cost comparisons were made for inpatient and outpatient costs and overall costs, using costs provided by the financial department. Variables were analyzed using the Wilcoxon rank-sum test. A multivariable global linear model evaluated the effect of all co-variables on cost differences. In Cohort 1 (n = 84), 74% were followed with a standard CMV preemptive protocol, and 26% received prophylaxis. In Cohort 2 (n = 74), an intensified CMV surveillance protocol was applied in 74% of patients, and 26% were given prophylaxis. RESULTS: Overall, Cohort 1 had significantly higher treatment costs as compared with Cohort 2 (mean Swiss francs [CHF] 104,548 and CHF 76,983, respectively, P = 0.0005). Excluding patients who received prophylaxis reduced these costs to CHF 89,318 in Cohort 1 and CHF 73,652 in Cohort 2. Outcome between Cohort 1 and 2 was comparable. CONCLUSION: A stringent adherence to the CMV prevention protocol was associated with a significant reduction in overall costs. Whether this benefit is because of the demonstrated reduction in the rate of CMV disease needs to be assessed in a randomized trial.

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.

Importance of mental health assessment in HIV-infected outpatients.

HIV infection, even when well controlled, may be associated with important mental health problems. We sought to investigate anxiety, depression, and health-related quality of life using screening measurements in patients with HIV infection and to examine their dependency on biosocial parameters relating to HIV. Prospective clinical, virologic, and immunologic data were obtained in a cross-sectional study within the Swiss HIV Cohort Study. Four self-reported questionnaires were used in 397 HIV-infected individuals. The scores for anxiety and depression were high as measured by the Hospital Anxiety and Depression Scale (HADS) and the State Trait Anxiety Inventory (STAI). Half the population scored <75 on a visual analog scale (VAS) Patients were also affected in their quality of life as measured by the HIV Medical Outcome Study (HIV-MOS). Almost all scores were significantly worse for intravenous drug users compared with other transmission groups. People who were employed, with a higher education or with higher CD4 count tended to score better, whereas those who had been hospitalized within the last 6 months, infected for a longer time, with higher viral load, or loss of weight scored significantly worse. A multivariate analysis showed higher education, being employed, low viral load, female gender, and shorter HIV disease duration to be associated with better scores. This study highlights the importance of mental health assessment regardless of HIV-disease parameters.

[HIV serological parameters in the prognosis and follow-up assessment of an HIV infection]. / HIV-Serologische Parameter zur Prognose und Verlaufsbeurteilung einer HIV-Infektion.

53 individuals negative for anti-HIV by screening test and 79 individuals positive for anti-HIV were prospectively surveyed for clinical progression and by quantitatively measuring anti-p24 (antibodies against an HIV core protein), anti-gp41 (antibodies against an HIV surface protein) and HIV-(p24) antigen. The patients were classified into four categories of HIV-markers: 1. Anti-p24 in high concentrations, HIV-Ag negative, 2. anti-p24 in high concentrations, HIV-Ag positive (most often transitory only), 3. anti-p24 absent/deficient, HIV-Ag negative and 4. anti-p24 absent/deficient and HIV-AG positive. Within a minimum of 18 months, 4 of the 53 (8%) initially anti-HIV negative individuals contracted HIV infection. 17 of the 79 (22%) initially anti-HIV positive individuals showed disease progression. 8 of the patients in category 4 already had AIDS when entering the study, and 3 of the 6 (5%) remaining patients of this category developed AIDS. Amongst the 19 patients in the third category 2 individuals (11%) developed AIDS and in a further 5 (26%) individuals the disease progressed but in no case to AIDS. None of the patients of the categories 1 and 2 developed AIDS but 2 of the 10 (20%) individuals in the second category and 3 of the 29 (10%) in the first category showed disease progression but not to AIDS. In conclusion, the quantitative measurement of anti-p24 and of HIV-Ag affords prognostic pointers for the clinical outcome of HIV infection.