ABSTRACT
BACKGROUND: The economic consequences of a missed opportunity for HIV testing at an earlier stage of infection within a healthcare setting are poorly described. METHODS: For all newly diagnosed HIV patients followed at the Southern Alberta HIV/AIDS Clinic (SAC), Calgary, Canada, between 1 April 2011 and 1 April 2016, all clinical encounters occurring < 3 years prior to diagnosis within the region were obtained. The direct costs of HIV care after diagnosis to 31 March 2019 were determined from a payers' perspective and reported as mean cost per patient per month (PPPM) in 2019 Canadian dollars (CDN$). Patients with no encounters for 3 years prior to diagnosis were compared with patients with encounters, with special attention to patients with HIV clinical indicator conditions (HCICs). RESULTS: Of 388 patients, 60% had one or more prior encounter without HIV testing; 14% had been treated for an HCIC. Females, older patients and heterosexuals were more likely to have prior encounters. At diagnosis, patients with previous encounters presented with lower CD4 counts and higher rates of AIDS. The mean PPPM costs for patients with any prior encounter or for an HCIC-based encounter were 16% and 33% higher, respectively, than for patients with no prior encounters. While mean PPPM costs for antiretroviral drugs and outpatient visits were slightly higher, in-patient costs were 10 times higher for people with HIV who had a previous HCIC encounter vs. those with no encounters (CDN$316 vs. $31, respectively). CONCLUSIONS: Any healthcare visit, especially for an HCIC, represents relatively easy opportunities for HIV testing. Not testing can result in poorer health and higher costs. Targeted clinical testing and novel interventions to correct overlooked testing opportunities within healthcare settings may be an easy way to implement cost savings.
Subject(s)
HIV Infections , Alberta , CD4 Lymphocyte Count , Delivery of Health Care , Female , HIV Infections/diagnosis , HIV Infections/drug therapy , Health Care Costs , HumansABSTRACT
OBJECTIVES: The aim of the study was to reappraise the precise costs of HIV care and cost drivers, to determine the optimal tools for modelling costs for HIV care, and to understand the implications of changing medical management of HIV-infected patients for both subsequent outcomes and health care budgets. METHODS: We obtained all drug, laboratory, out-patient and in-patient care costs for all HIV-infected patients followed between 1 January 2006 and 31 December 2017 (2017 Cdn$). Mean cost per patient per month (PPPM) was used as the standard comparator value. Patients were stratified based on CD4 count: (1) ≤ 75, (2) 76-200, (3) 201-500 and (4) > 500 cells/µL. We determined the cost for only HIV-related expenses. We compared current costs with costs previously reported for the same population. RESULTS: The number of HIV-infected patients in care doubled from 2006 to 2017; total costs increased from $12.4 to $30.1 million, with antiretroviral (ARV) drugs accounting for 78.8% of costs by 2017. Out-patient/laboratory costs declined from 12% to 8.5%, while in-patient costs exhibited more annual variation. Mean PPPM costs increased from $1316 in 2006 to $1712 in 2014, declining to $1446 in 2017. Higher PPPM costs were associated with CD4 counts < 200 cells/µL. Costs have shifted. While the cost of ARV drugs increased by 32%, the costs of out-patient and in-patient services decreased by 80% and 71%, respectively. Most of the decrease for in-patient costs was attributable to a substantial decrease in HIV-related hospitalizations. CONCLUSIONS: Although antiretroviral therapy (ART) provides immense benefits, it is not inexpensive. ARV drugs remain the largest cost driver. Hospital costs have remained low. Substantial costs of lifelong ART necessitate innovative, locally applicable strategies for ARV selection and use.
Subject(s)
Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , HIV Infections/economics , Patient Care/economics , Adult , Ambulatory Care/economics , Anti-HIV Agents/economics , Antiretroviral Therapy, Highly Active/economics , CD4 Lymphocyte Count , Cost-Benefit Analysis , Female , Health Care Costs/trends , Hospitalization/economics , Humans , Male , Middle Aged , Models, EconomicABSTRACT
OBJECTIVES: New HIV diagnoses in persons aged > 50 years (hereafter 'older persons') are becoming more common; the clinical features and outcomes of these older individuals are poorly described. METHODS: We conducted a retrospective cohort study of all new adult HIV diagnoses between October 1989 and December 2019 in southern Alberta, Canada. Differences in risk for HIV acquisition and screening, sociodemographic/clinical characteristics, and causes of death were compared between individuals younger and older than 50 years at the time of diagnosis. RESULTS: New HIV diagnoses in persons > 50 years old increased from 7% in 1990 to 18% in 2019. Risk for HIV acquisition and screening reasons differed by age. Heterosexual sex (29%) was the greatest risk factor among older persons, contrasting with male same sex activity in younger persons (51%) (P < 0.001). Illness was the most common indication for testing in older persons (47%), whereas younger persons were more likely to have requested testing (34%) (P < 0.001). Relationship status differed, with 33% of older persons being married to an opposite sex partner versus 12% in younger persons (P < 0.001). Although older persons had a lower mean nadir CD4 count (132 cells/µL) than younger persons (181 cells/µL) (P < 0.001), 80% of deaths between 2010 and 2019 in the older group were attributable to non-AIDS-related causes versus 47% in younger patients. Since 2000, AIDS-related deaths and potential years of life lost have declined for both age groups. CONCLUSION: The increase in new HIV diagnoses in persons aged > 50 years in southern Alberta suggests that older individuals require customized approaches for optimizing HIV diagnosis and treatment.
Subject(s)
HIV Infections/diagnosis , HIV Infections/mortality , Heterosexuality/statistics & numerical data , Adult , Age Factors , Aged , CD4 Lymphocyte Count , Canada , Female , Humans , Male , Middle Aged , Mortality , Population Surveillance , Retrospective Studies , Young AdultABSTRACT
Antibiotic-resistant Gram-negative bacteraemias (GNB) are increasing in incidence. We aimed to investigate the impact of empirical antibiotic therapy on clinical outcomes by carrying out an observational 6-year cohort study of patients at a teaching hospital with community-onset Escherichia coli bacteraemia (ECB), Klebsiella pneumoniae bacteraemia (KPB) and Pseudomonas aeruginosa bacteraemia (PsAB). Antibiotic therapy was considered concordant if the organism was sensitive in vitro and discordant if resistant. We estimated the association between concordant vs. discordant empirical antibiotic therapy on odds of in-hospital death and ICU admission for KPB and ECB. Of 1380 patients, 1103 (79.9%) had ECB, 189 (13.7%) KPB and 88 (6.4%) PsAB. Discordant therapy was not associated with increased odds of either outcome. For ECB, severe illness and non-urinary source were associated with increased odds of both outcomes (OR of in-hospital death for non-urinary source 3.21, 95% CI 1.73-5.97). For KPB, discordant therapy was associated with in-hospital death on univariable but not multivariable analysis. Illness severity was associated with increased odds of both outcomes. These findings suggest broadening of therapy for low-risk patients with community-onset GNB is not warranted. Future research should focus on the relationship between patient outcomes, clinical factors, infection focus and causative organism and resistance profile.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Gram-Negative Bacterial Infections/drug therapy , Hospitals, Teaching , Sepsis/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Gram-Negative Bacterial Infections/blood , Humans , Male , Middle Aged , Retrospective Studies , Sepsis/drug therapy , Treatment Outcome , Young AdultABSTRACT
OBJECTIVES: As more HIV-positive individuals receive antiretroviral therapy (ART), payers are seeking options for covering these increased and sustained drug costs. Strategic use of available generic antiretroviral (ARV) formulations may be feasible. De-simplifying a single-tablet co-formulation (STF) into two or more tablets using both brand and generic drugs has been proposed. We determine if voluntary de-simplification of one STF could be utilized as a cost-saving strategy. We report on the challenges, uptake, outcomes and cost savings of this initiative. METHODS: Patients stable on the most commonly used STF (Triumeq® ) were offered the option of remaining on Triumeq® or switching to generic abacavir/lamivudine and Tivicay® between 1 January 2015 and 1 January 2018; those starting ART consisting of abacavir/lamivudine/doulutegravir in the same period were offered the option of starting Triumeq® or generic abacavir/laminvudine and Tivicay® . No incentives were provided. We examined the acceptance/decline rates, patient satisfaction, health care outcomes and annual cost savings. RESULTS: Of 626 patients receiving Triumeq® , 321 were approached; 177 (55.1%) agreed to de-simplify. Of patients initiating ART, 62.7% chose the generic co-formulation. Patients switching to or starting on the generic co-formulation were more likely to be male, > 45 years old, Caucasian, men who have sex with men (MSM) and more HIV-experienced, and to have more comorbidities (all P < 0.05). Preference for STF was cited for declining de-simplification. No concern about generic ARVs was expressed. The rate of viral load > 500 HIV-1 RNA copies/mL after baseline was 2.7% in switched patients compared with 7.0% in those declining to switch. No de novo resistance occurred. A saving of Cdn$1 319 686 was achieved in the first year. CONCLUSIONS: Reliance on altruism, while respecting patient autonomy, achieved de-simplification in > 50% of patients approached, and generated immediate cost savings with no increased risk of adverse events, viral breakthrough or resistance.
Subject(s)
Anti-Retroviral Agents/economics , Dideoxynucleosides/economics , Drugs, Generic/economics , HIV Infections/drug therapy , Heterocyclic Compounds, 3-Ring/economics , Lamivudine/economics , Adult , Age Factors , Aged , Anti-Retroviral Agents/therapeutic use , Canada , Comorbidity , Cost Savings , Dideoxynucleosides/therapeutic use , Drug Combinations , Drugs, Generic/therapeutic use , Female , Heterocyclic Compounds, 3-Ring/therapeutic use , Homosexuality, Male/statistics & numerical data , Humans , Lamivudine/therapeutic use , Male , Middle Aged , Oxazines , Patient Acceptance of Health Care , Patient Satisfaction , Piperazines , Pyridones , Tablets , Treatment OutcomeABSTRACT
OBJECTIVES: The incremental costs of expanding antiretroviral (ARV) drug treatment to all HIV-infected patients are substantial, so cost-saving initiatives are important. Our objectives were to determine the acceptability and financial impact of de-simplifying (i.e. switching) more expensive single-tablet formulations (STFs) to less expensive generic-based multi-tablet components. We determined physician and patient perceptions and acceptance of STF de-simplification within the context of a publicly funded ARV budget. METHODS: Programme costs were calculated for patients on ARVs followed at the Southern Alberta Clinic, Canada during 2016 (Cdn$). We focused on patients receiving Triumeq® and determined the savings if patients de-simplified to eligible generic co-formulations. We surveyed all prescribing physicians and a convenience sample of patients taking Triumeq® to see if, for budgetary purposes, they felt that de-simplification would be acceptable. RESULTS: Of 1780 patients receiving ARVs, 62% (n = 1038) were on STF; 58% (n = 607) of patients on STF were on Triumeq®. The total annual cost of ARVs was $26 222 760. The cost for Triumeq® was $8 292 600. If every patient on Triumeq® switched to generic abacavir/lamivudine and Tivicay® (dolutegravir), total costs would decrease by $4 325 040. All physicians (n = 13) felt that de-simplifying could be safely achieved. Forty-eight per cent of 221 patients surveyed were agreeable to de-simplifying for altruistic reasons, 27% said no, and 25% said maybe. CONCLUSIONS: De-simplifying Triumeq® generates large cost savings. Additional savings could be achieved by de-simplifying other STFs. Both physicians and patients agreed that selective de-simplification was acceptable; however, it may not be acceptable to every patient. Monitoring the medical and cost impacts of de-simplification strategies seems warranted.
Subject(s)
Anti-Retroviral Agents/economics , Cost Savings , Dideoxynucleosides/economics , Drugs, Generic/economics , HIV Infections/drug therapy , Heterocyclic Compounds, 3-Ring/economics , Lamivudine/economics , Patient Compliance/psychology , Adult , Anti-Retroviral Agents/therapeutic use , Canada , Cohort Studies , Dideoxynucleosides/therapeutic use , Drug Combinations , Drug Therapy, Combination/economics , Drugs, Generic/therapeutic use , Female , HIV Infections/psychology , Heterocyclic Compounds, 3-Ring/therapeutic use , Humans , Lamivudine/therapeutic use , Male , Middle Aged , Oxazines , Piperazines , Practice Patterns, Physicians' , Pyridones , TabletsABSTRACT
OBJECTIVES: To investigate factors that predict speed of recovery and long-term CD4 cell count in HIV-1 seroconverters initiating combination antiretroviral therapy (cART), and to quantify the influence of very early treatment initiation. We make use of all pre-treatment CD4 counts, because analyses using only a single observation at initiation may be subject to biases. METHODS: We used data from the CASCADE (Concerted Action on SeroConversion to AIDS and Death in Europe) multinational cohort collaboration of HIV-1 seroconverters. We analysed pre- and post-treatment data of patients with seroconversion dates estimated January 2003-March 2014 (n = 7600 for primary analysis) using a statistical model in which the characteristics of recovery in CD4 counts are determined by multiple predictive factors. Secondary analyses were performed incorporating uncertainty in the exact timing of seroconversion to allow more precise estimation of the benefit of very early treatment initiation. RESULTS: 'True' CD4 count at cART initiation was the strongest predictor of CD4 count beyond 3 years on cART. Allowing for lack of complete certainty in the date of seroconversion, CD4 recovery was more rapid for patients in whom treatment was initiated within 4 months. For a given CD4 count, higher viral load (VL) at initiation was strongly associated with higher post-treatment CD4 recovery. For other patient and drug characteristics, associations with recovery were statistically significant but small in magnitude. CONCLUSIONS: CD4 count at cART initiation is the most important factor in predicting post-treatment recovery, but VL provides substantial additional information. If cART is initiated in the first 4 months following seroconversion, recovery of CD4 counts appears to be more rapid.
Subject(s)
Anti-HIV Agents/therapeutic use , HIV Infections/immunology , HIV-1/immunology , CD4 Lymphocyte Count , Female , HIV Infections/drug therapy , Humans , Male , Models, Statistical , Seroconversion , Treatment Outcome , Viral LoadABSTRACT
New federal regulations allow HIV-positive individuals to be live kidney donors; however, potential candidacy for donation is poorly understood given the increased risk of end-stage renal disease (ESRD) associated with HIV infection. To better understand this risk, we compared the incidence of ESRD among 41 968 HIV-positive participants of North America AIDS Cohort Collaboration on Research and Design followed for a median of 5 years with the incidence of ESRD among comparable HIV-negative participants of National Health and Nutrition Examination III followed for a median of 14 years. We used risk associations from multivariable Cox proportional hazards regression to derive cumulative incidence estimates for selected HIV-positive scenarios (no history of diabetes, hypertension, AIDS, or hepatitis C virus coinfection) and compared these estimates with those from similarly selected HIV-negative scenarios. For 40-year-old HIV-positive individuals with health characteristics that were similar to those of age-matched kidney donors, viral load <400 copies/mL, and CD4+ count ≥500 cells/µL, the 9-year cumulative incidence of ESRD was higher than that of their HIV-negative peers, yet still low: 2.5 versus 1.1 per 10 000 among white women, 3.0 versus 1.3 per 10 000 among white men, 13.2 versus 3.6 per 10 000 among black women, and 15.8 versus 4.4 per 10 000 among black men. HIV-positive individuals with no comorbidities and well-controlled disease may be considered low-risk kidney donor candidates.
Subject(s)
Graft Rejection/epidemiology , HIV Infections/complications , Kidney Failure, Chronic/epidemiology , Kidney Transplantation/adverse effects , Living Donors , Adult , Case-Control Studies , Female , Follow-Up Studies , Glomerular Filtration Rate , Graft Rejection/etiology , Graft Survival , HIV Infections/virology , HIV Seropositivity , HIV-1/physiology , Humans , Incidence , Kidney Failure, Chronic/etiology , Kidney Function Tests , Male , Middle Aged , Nephrectomy , North America/epidemiology , Prognosis , Risk Factors , Viral LoadABSTRACT
OBJECTIVES: Improved survival has shifted the HIV epidemic in the developed world towards more individuals >50 years of age. Older individuals, with new or longstanding HIV infection, are at greater risk for HIV-related and non-HIV-related conditions, compounding the burden and complexity of HIV management. The aim of the study was to examine the impact of age on the cost of HIV care in a well-defined HIV-infected population. METHODS: All HIV-infected individuals >16 years old receiving HIV care between 1 January 2000 and 1 January 2011 were included in the study. The costs of antiretroviral therapy (ART), HIV-related out-patient care and HIV-related in-patient care were collected using mean cost per person, per month (PPPM) as the comparator variable for the comparison between older (>50 years old) and younger (≤ 50 years old) patients. RESULTS: The proportion of older patients increased from 9.6% to 25.4% and proportional costs increased from 25% to 31% from 1999 to 2010. Older patients were more likely than younger patients to be on ART (89% vs. 69%, respectively; P<0.01) and to have AIDS (29% vs. 20%, respectively; P<0.05) but had similar median CD4 counts (404 vs. 396 cells/µL, respectively; not significant). They incurred higher costs for all aspects of HIV care throughout the entire 12 years. By 2010, the mean PPPM cost of HIV care for longstanding older patients was $1325 compared with $1075 for younger patients. More expensive ART as a consequence of more complex regimens, more comorbid interactions and greater adherence accounted for most of the cost difference. CONCLUSIONS: The aging of the HIV-infected population in care is leading to increased HIV care costs. Health care planners and funding agencies need to be aware of the impact of this important shift in HIV demographics on the overall costs of HIV care.
Subject(s)
Aging , Antiretroviral Therapy, Highly Active/economics , HIV Infections/drug therapy , Health Care Costs/statistics & numerical data , Adolescent , Adult , Canada/epidemiology , Female , Humans , Male , Middle Aged , Patient Acceptance of Health Care/statistics & numerical data , Young AdultABSTRACT
Rearing rats in environmental enrichment produces a protective effect when exposed to stimulants, as enriched rats display attenuated cocaine seeking during reinstatement. However, less is known about what changes in the brain are responsible for this protective effect. The current study investigated differences in Fos protein expression following reinstatement of cocaine seeking in differentially reared rats. Rats were reared in either enriched (EC) or impoverished (IC) conditions for 30 days, after which rats self-administered cocaine in 2-h sessions. Following self-administration, rats underwent extinction and cue-induced or cocaine-primed reinstatement of cocaine seeking, brains were extracted, and Fos immunohistochemistry was performed. IC rats sought cocaine significantly more than EC rats during cue-induced reinstatement, and cocaine seeking was positively correlated with Fos expression in the nucleus accumbens core and ventral pallidum. IC rats displayed greater Fos expression than EC rats in the accumbens and ventral pallidum, suggesting a role of these areas in the enrichment-induced protective effect.
ABSTRACT
OBJECTIVES: The aim of the study was to determine the risk factors predictive of symptomatic HIV-associated neurocognitive disorders (sHAND) among HIV-infected patients receiving active medical care. METHODS: Baseline demographic and clinical characteristics were analysed in patients with sHAND (HIV-associated dementia and minor neurocognitive disorder) in a population-based longitudinal cohort of HIV-infected patients with access to universal health care, including combination antiretroviral therapy (cART) from 1999 to 2008. Variables evaluated for their association with sHAND included age and ethnicity, survival duration with HIV-1 infection, vascular disease risk factors, and laboratory indices such as blood CD4 T-cell count at its nadir and at cART initiation, using both univariable and multivariable logistic regression models. RESULTS: A total of 1320 patients were investigated, including the patients diagnosed with sHAND (n = 90) during the study period. In univariable analyses, increased age, increased length of survival with HIV, low nadir CD4 and CD8 T-cell counts, high baseline viral load (> 1,000,000 HIV-1 RNA copies/mL), and African origin were predictive of a diagnosis of sHAND (P < 0.05). In multivariable analysis, increased age, increased length of survival, low nadir CD4 T-cell counts, and high baseline viral load remained predictive of sHAND (P < 0.05). Remarkably, CD4 T-cell counts at cART initiation, hepatitis C virus coinfection, and vascular disease risk factors failed to predict sHAND in both analyses. CONCLUSIONS: Increased age and survival duration, lower nadir CD4 T-cell counts, and higher baseline viral load were consistent predictors of the development of sHAND among persons with HIV/AIDS in universal health care, underscoring the importance of attention to these variables in clinical care.
Subject(s)
AIDS Dementia Complex/physiopathology , Acquired Immunodeficiency Syndrome/physiopathology , Cognition Disorders/physiopathology , HIV Seropositivity/physiopathology , AIDS Dementia Complex/epidemiology , AIDS Dementia Complex/etiology , Acquired Immunodeficiency Syndrome/complications , Acquired Immunodeficiency Syndrome/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Anti-HIV Agents/therapeutic use , CD4 Lymphocyte Count , Canada/epidemiology , Cognition Disorders/epidemiology , Cognition Disorders/etiology , Cohort Studies , Female , HIV Infections , HIV Seropositivity/complications , HIV Seropositivity/epidemiology , Hepatitis C , Humans , Logistic Models , Longitudinal Studies , Male , Middle Aged , Neuropsychological Tests , Predictive Value of Tests , Risk Factors , Viral LoadABSTRACT
OBJECTIVES: Intimate partner violence (IPV) is a risk factor for HIV infection. Little is known, however, about the prevalence, clinical associations, and impact of IPV among patients living with HIV. METHODS: HIV-infected gay and bisexual men in Southern Alberta, Canada were screened for IPV between May 2009 and December 2011. The associations with IPV of sociodemographic factors, psychological factors, clinical status, and HIV-related and HIV-unrelated hospitalizations, data for which were obtained from a regional database, were evaluated using Poisson regression. RESULTS: Of 687 gay and bisexual patients, 22.4% had experienced one or several types of IPV. Patients disclosing IPV were more likely to be Aboriginal [adjusted prevalence ratio (APR) = 2.48; 95% confidence interval (CI) 1.18-5.20], to be younger (APR/year = 0.97; 95% CI 0.95-0.99), to be victims of childhood abuse (APR = 4.27; 95% CI 2.84-6.41), to be smokers (APR = 2.53; 95% CI 1.59-4.00), to have had depression prior to HIV diagnosis (APR = 1.87; 95% CI 1.10-3.16), to use ongoing psychiatric resources (APR = 3.53; 95% CI 2.05-6.10), to have recently participated in unprotected sex (APR = 2.29; 95% CI 1.10-4.77), and to have poor or fair vs. very good or excellent health-related quality of life (APR = 2.91; 95% CI 1.57-5.39). IPV was also associated with a higher rate of clinically relevant interruptions in care (APR = 1.95; 95% CI 1.23-3.08), a higher incidence of AIDS among patients presenting early to care (CD4 count ≥ 200 cells/µL; APR = 2.06; 95% CI 1.15-3.69), and an increased rate of HIV-related hospitalizations [relative risk (RR) = 1.55; 95% CI 0.99-2.33], especially after HIV diagnosis was established (RR = 2.46; 95% CI 1.51-3.99). CONCLUSIONS: The prevalence of IPV is high among HIV-infected gay and bisexual men and is associated with poor social, psychiatric, and medical outcomes. IPV is an under-recognized social determinant of health in this community that may be amenable to meaningful clinical interventions.
Subject(s)
Bisexuality , Depression/epidemiology , HIV Seropositivity/epidemiology , Homosexuality, Male , Medication Adherence/statistics & numerical data , Spouse Abuse/statistics & numerical data , Substance-Related Disorders/epidemiology , Adult , Alberta/epidemiology , American Indian or Alaska Native/ethnology , Black People/ethnology , CD4 Lymphocyte Count , Canada , Depression/ethnology , Depression/psychology , HIV Seropositivity/ethnology , HIV Seropositivity/psychology , Hospitalization/statistics & numerical data , Humans , Incidence , Male , Medication Adherence/ethnology , Medication Adherence/psychology , Prevalence , Residence Characteristics , Risk Factors , Sexual Partners/psychology , Socioeconomic Factors , Spouse Abuse/ethnology , Spouse Abuse/prevention & control , Substance-Related Disorders/ethnology , Substance-Related Disorders/psychology , Unsafe Sex , White People/ethnologyABSTRACT
BACKGROUND: We examined whether determinants of disease progression and causes of death differ between injecting drug users (IDUs) and non-IDUs who initiate combination antiretroviral therapy (cART). METHODS: The ART Cohort Collaboration combines data from participating cohort studies on cART-naïve adults from cART initiation. We used Cox models to estimate hazard ratios for death and AIDS among IDUs and non-IDUs. The cumulative incidence of specific causes of death was calculated and compared using methods that allow for competing risks. RESULTS: Data on 6269 IDUs and 37 774 non-IDUs were analysed. Compared with non-IDUs, a lower proportion of IDUs initiated cART with a CD4 cell count <200 cells/µL or had a prior diagnosis of AIDS. Mortality rates were higher in IDUs than in non-IDUs (2.08 vs. 1.04 per 100 person-years, respectively; P<0.001). Lower baseline CD4 cell count, higher baseline HIV viral load, clinical AIDS at baseline, and later year of cART initiation were associated with disease progression in both groups. However, the inverse association of baseline CD4 cell count with AIDS and death appeared stronger in non-IDUs than in IDUs. The risk of death from each specific cause was higher in IDUs than non-IDUs, with particularly marked increases in risk for liver-related deaths, and those from violence and non-AIDS infection. CONCLUSION: While liver-related deaths and deaths from direct effects of substance abuse appear to explain much of the excess mortality in IDUs, they are at increased risk for many other causes of death, which may relate to suboptimal management of HIV disease in these individuals.
Subject(s)
Anti-HIV Agents/therapeutic use , Drug Users/statistics & numerical data , HIV Infections/drug therapy , HIV Infections/mortality , Substance Abuse, Intravenous/complications , Substance Abuse, Intravenous/mortality , AIDS-Related Opportunistic Infections/mortality , Adolescent , Adult , CD4 Lymphocyte Count , Cohort Studies , Disease Progression , Drug Therapy, Combination , Female , HIV Infections/etiology , HIV Infections/immunology , Humans , Male , Middle Aged , Odds Ratio , Proportional Hazards Models , RNA, Viral/blood , Risk Factors , Viral Load , Young AdultABSTRACT
BACKGROUND: Hospital antimicrobial stewardship (AMS) programmes are multidisciplinary initiatives to optimize antimicrobial use. Most hospitals depend on time-consuming manual audits to monitor clinicians' prescribing. But much of the information needed could be sourced from electronic health records (EHRs). OBJECTIVES: To develop an informatics methodology to analyse characteristics of hospital AMS practice using routine electronic prescribing and laboratory records. METHODS: Feasibility study using electronic prescribing, laboratory and clinical coding records from adult patients admitted to six specialities at Queen Elizabeth Hospital, Birmingham, UK (September 2017-August 2018). The study involved: (i) a review of AMS standards of care; (ii) their translation into concepts measurable from commonly available EHRs; and (iii) a pilot application in an EHR cohort study (n = 61679 admissions). RESULTS: We developed data modelling methods to characterize antimicrobial use (antimicrobial therapy episode linkage methods, therapy table, therapy changes). Prescriptions were linked into antimicrobial therapy episodes (mean 2.4 prescriptions/episode; mean length of therapy 5.8 days), enabling several actionable findings. For example, 22% of therapy episodes for low-severity community-acquired pneumonia were congruent with prescribing guidelines, with a tendency to use broader-spectrum antibiotics. Analysis of therapy changes revealed IV to oral therapy switching was delayed by an average 3.6 days (95% CI: 3.4-3.7). Microbial cultures were performed prior to treatment initiation in just 22% of antibacterial prescriptions. The proposed methods enabled fine-grained monitoring of AMS practice down to specialities, wards and individual clinical teams by case mix, enabling more meaningful peer comparison. CONCLUSIONS: It is feasible to use hospital EHRs to construct rapid, meaningful measures of prescribing quality with potential to support quality improvement interventions (audit/feedback to prescribers), engagement with front-line clinicians on optimizing prescribing, and AMS impact evaluation studies.
ABSTRACT
Ley determinant (Fuc alpha 1----2Gal beta 1----4[Fuc alpha 1----3]GlcNAc beta 1----R) defined by mAb BM-1 is highly expressed in human immunodeficiency virus (HIV)-infected T cell lines and in CD3+ peripheral mature T cells of patients with acquired immune deficiency syndrome (AIDS) or with AIDS-related complex (ARC). Ley expression increased greatly in the CD3+ population in the advanced stage of AIDS when the CD4+ population decreased greatly. Six other carbohydrate antigens tested by their respective mAbs were not detected in these same cells. None of the carbohydrate antigens tested by the seven mAbs used in this study were found in noninfected T cell lines and in normal peripheral blood lymphocytes.
Subject(s)
AIDS-Related Complex/immunology , Acquired Immunodeficiency Syndrome/immunology , Glycosphingolipids/analysis , HIV/immunology , T-Lymphocytes/immunology , Antibodies, Monoclonal/immunology , Antigen-Antibody Reactions , Cell Line , Humans , Lewis Blood Group Antigens/immunology , T-Lymphocytes/analysisABSTRACT
Abacavir is a nucleoside reverse transcriptase inhibitor (NRTI) that is used in combination antiretroviral therapy in HIV-infected patients. It is currently recommended as a preferred or an alternative NRTI in antiretroviral-naïve patients. The major toxicity of abacavir is a hypersensitivity reaction (HSR), which occurs in approximately 5% of treated patients. There is a strong association between the human leukocyte antigen (HLA)-B*5701 allele and abacavir HSR, which has allowed for rapid acceptance of genetic screening for HLA-B*5701 in clinical use. Canadian clinicians working in hospital centers with HLA typing capacity opted to launch a pilot project in 2006 to offer the screening test as standard of care to HIV-infected patients. Currently, more than 11,000 HLA-B*5701 tests have been performed, among which 6.3% are positive. Continued efforts have been made to ensure that testing is available to all HIV-infected patients to widen the patients' therapeutic options. HLA-B*5701 screening shows clinical use and preliminary data suggest cost-effectiveness.
Subject(s)
Anti-HIV Agents/adverse effects , Dideoxynucleosides/adverse effects , Drug Hypersensitivity/genetics , HIV Infections/genetics , HLA-B Antigens/genetics , Alleles , Anti-HIV Agents/therapeutic use , Canada , Cost-Benefit Analysis , Dideoxynucleosides/therapeutic use , Drug Hypersensitivity/immunology , Genetic Testing/economics , HIV Infections/drug therapy , HIV Infections/economics , HIV Infections/immunology , HLA-B Antigens/immunology , Humans , Randomized Controlled Trials as Topic , Reverse Transcriptase Inhibitors/adverse effects , Reverse Transcriptase Inhibitors/therapeutic useABSTRACT
OBJECTIVE: The aim of the study was to compare the performance of several bedside neuropsychological tools for detection of HIV-associated neurocognitive disorder (HAND) in antiretroviral drug-exposed persons. METHODS: We analysed the relative performance of the HIV Dementia Scale (HDS), International HIV Dementia Scale (IHDS) and the Mini-Mental Status Exam (MMSE) together with neuropsychological tests (Symbol-Digit, Grooved Pegboard and Trail Making) in HIV-1-seronegative subjects (HIV-; n=13) and in HIV-1-seropositive subjects with HAND (HIV+HAND; n=13) and other neurological disorders (HIV+OND; n=20). RESULTS: Established neuropsychological tests consistently showed significantly poorer performance by HIV+HAND subjects compared with the other two groups. Similarly, the mean HDS and IHDS scores were lower in the HIV+HAND group compared with the other two groups (P<0.005) while the mean MMSE score did not show significant differences between the HIV+HAND and HIV+OND groups. Receiver operator characteristics curves generated from these data using predefined cut-off scores revealed that the HDS, IHDS and MMSE displayed corresponding area under the curve values of 0.82, 0.74 and 0.48, respectively (P<0.006). CONCLUSIONS: The present findings indicate that the MMSE is a weak tool for diagnosing HAND in this group of patients but the HDS and IHDS demonstrate better efficiencies, although cut-off values for the HDS require reassessment in the era of effective antiretroviral therapy.
Subject(s)
AIDS Dementia Complex/diagnosis , Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , Mental Status Schedule , Neuropsychological Tests/standards , Antiretroviral Therapy, Highly Active , CD4 Lymphocyte Count , Female , HIV Infections/psychology , Humans , Male , Middle Aged , Sensitivity and SpecificityABSTRACT
High levels of geographic mobility in and out of HIV care centres (i.e. the churn effect) can disrupt the continuity of patient care, misalign prevention services, impact local prevalence data perturbing optimal allocation of resources, and contribute to logical challenges in repeated transfer of health records. We report on the clinical, demographic, and administrative impact of high population turnover within HIV populations.
Subject(s)
HIV Infections/epidemiology , Adult , CD4 Lymphocyte Count , Canada/epidemiology , Emigration and Immigration , Female , Humans , Male , Population DynamicsABSTRACT
OBJECTIVES: To report on the cost of medical care for HIV-infected patients stratified by CD4 cell count for a regional population over a 9-year period, and to examine the effect of reporting costs of HIV care only or only in antiretroviral therapy (ART)-experienced patients. METHODS: Retrospective costing analysis on all HIV-infected patients within the Southern Alberta Cohort from April 1997 to April 2006. Costs for all drugs (ART/non-ART), in-patient (HIV/non-HIV) and out-patient care were obtained from primary sources. Costs were aggregated by patient's CD4 cell count and ART exposure and presented as mean cost per patient per month (PPPM) in 2006 Canadian dollars. RESULTS: The number of patients and annual costs increased by 74% and 69%, respectively. Overall mean PPPM costs increased slightly from $1082 in 1997/1998 to $1159 in 2005/2006. PPPM costs for patients with CD4 counts < or =75 cells/microL increased from $1595 to $2687 while costs for CD4 counts >500, 201-500 and 76-200 cells/microL remained relatively stable at $979, $1057 and $1294, respectively. In-patient hospitalization costs account for most of the cost increases. Reporting costs using only ART-experienced patients would overestimate total costs by 2-9%. Costs for only HIV care were 10-24% lower than total care costs. CONCLUSIONS: Care costs have remained relatively stable for most HIV patients except those with CD4 counts < or =75 cells/microL. Expensive new antiretroviral drugs have had, at present, a minimal cost impact. Enhanced testing to achieve earlier diagnosis and initiation of highly active antiretroviral therapy could potentially reduce costs of late presentation and in-patient care.
Subject(s)
AIDS-Related Opportunistic Infections/economics , Antiretroviral Therapy, Highly Active/economics , HIV Infections/economics , HIV-1 , Hospitalization/economics , Adult , Alberta , CD4 Lymphocyte Count/economics , Cost-Benefit Analysis/economics , Female , HIV Infections/therapy , Health Care Costs , Humans , Male , Middle Aged , Practice Guidelines as Topic , Retrospective StudiesABSTRACT
BACKGROUND: False-reactivity in HIV-negative specimens has been detected in HIV fourth-generation antigen/antibody or 'combo' assays which are able to detect both anti-HIV-1/HIV-2 antibodies and HIV-1 antigen. OBJECTIVES: We sought to characterize these specimens and determine the effect of heterophilic interference. STUDY DESIGN: Specimens previously testing as false-reactive on the Abbott ARCHITECT HIV Ag/Ab combo assay and re-tested on a different (Siemens ADVIA Centaur HIV Ag/Ab) assay. A subset of these specimens were also pre-treated with heterophilic blocking agents and re-tested on the Abbott assay. RESULTS: Here we report that 95% (252/264) of clinical specimens that were repeatedly reactive on the Abbott ARCHITECT HIV Ag/Ab combo assay (S/Co range, 0.94-678) were negative when re-tested on a different fourth generation HIV combo assay (Siemens ADVIA Centaur HIV Ag/Ab). All 264 samples were subsequently confirmed to be HIV negative. On a small subset (57) of specimens with available volume, pre-treatment with two different reagents (HBT; Heterophilic Blocking Tube, NABT; Non-Specific Blocking Tube) designed to block heterophilic antibody interference either eliminated (HBT) or reduced (NABT) the false reactivity when re-tested on the ARCHITECT HIV Ag/Ab combo assay. CONCLUSIONS: Our results suggest that the Abbott ARCHITECT HIV Ag/Ab combo assay can be prone to heterophilic antibody interference.