Food provision to support improved nutrition and well-being of people experiencing disadvantage - perspectives of service providers.

OBJECTIVE: Diet quality is significantly impacted by social and environmental factors. People experiencing socio-economic disadvantage face inequitable barriers to accessing nutritious foods and health services, resulting in significant health disparities. This study aimed to explore the barriers faced by organisations that provide food support to people experiencing disadvantage as well as to identify potential strategies to enhance this support for improved well-being of clients. DESIGN: Semi-structured interviews using an exploratory approach and inductive thematic analysis. SETTING: Australia. PARTICIPANTS: Individuals from organisations involved in the provision of food support for people experiencing disadvantage aged ≥16 years. RESULTS: Two major themes were identified from thirteen interviews. 'Dignity and respect for clients' serves as a guiding principle for food-related services across all organisations, while 'food' was a point of connection and a potential gateway to additional support pathways. Five additional subthemes included 'food as a platform to reduce social isolation, foster connection and promote participation', challenges with 'servicing clients with diverse experiences and needs', 'dependence on staff and volunteers with varying knowledge and skillsets', ensuring 'adequate access to services, resources and facilities' and 'necessity of community collaboration'. CONCLUSIONS: This study highlights the unique position of organisations involved in food support to identify client-specific needs and implement broader holistic health support. Future interventions should prioritise dignity, respect and social connection in design. Organisations require an adequately trained, sustainable workforce, with shared or enhanced services, resources and facilities, and greater community coordination with other services to maximise effectiveness.

Hospital and community care costs for people newly diagnosed of living with HIV in London, UK.

This study of people newly diagnosed of living with HIV (ND-PLHIV) calculated the use, cost and outcome of HIV services at a London HIV centre. ND-PLHIV were followed July 2017-October 2018. Hospital data included inpatient days (IP), outpatient (OP), dayward (DW) visits, tests and procedures, and anti-retroviral drugs (ARVs). Community services were recorded in daily diaries. Mean per patient-year (MPPY) use was multiplied by unit costs. 13.6 MPPY (95%CI 12.4-14.9) OP visits, 0.4 MPPY (95%CI 0.1-0.7) IP days, 0.09 MPPY (95%CI 0.01-0.2) DW visits and 4.6 MPPY community services (95%CI 3.4-5.8). Total annual costs per patient-year (CPPY) was £11,483 (95%CI £10,369-12,597): ARVs comprised 63% and community services 2%. White participants used fewer hospital and more community services compared with minority ethnic community (MEC) participants. Costs for White ND-PLHIV was £10,778 CPPY (95%CI £9629-11,928); £13,214 (95%CI £10,656-15,772) for MEC ND-PLHIV (p < 0.06). Annual costs were inversely related to CD4 count at entry (r = -5.58, p = 0.02); mean CD4 count was 476 cells/mm3 (95%CI 422-531) versus 373 cells/mm3 (95%CI 320-425) for White and MEC participants respectively (p = 0.03). Annual costs for ND-PLHIV with CD4 ≤ 350 cells/mm3 was £2478 PPY higher compared with CD4 count >350 cells/mm3 (p = 0.04).

The efficiency of the EmERGE pathway of care for people living with HIV in England.

This study estimated the efficiency of implementing the EmERGE Pathway of Care for people living with medically stable HIV in Brighton, UK; an App enables individuals to communicate with caregivers via their smart-phone. Individual data on the use of HIV outpatient services were collected one-year pre- and post-implementation of EmERGE. Unit costs of HIV outpatient services were calculated and linked with mean use of services per patient year. Primary outcomes were CD4 count and viral load; patient activation and quality-of-life measures were secondary outcomes. 565 participants were followed up April 2017 - October 2018: 93% men, mean age at recruitment 47.0 years (95%CI:46.2-47.8). Outpatient visits decreased by 9% from 5.6 (95%CI:5.4-5.8) to 5.1 (95%CI:4.9-5.3). Face-to-face visits decreased and virtual visits increased. Annual costs decreased by 9% from £751 (95%CI: £722-£780) to £678 (95%CI: £653-£705). Including anti-retroviral drugs, total annual cost decreased from £7,343 (95%CI: £7,314-7,372) to £7,270 (95%CI: £7,245-7,297): ARVs costs comprised 90%. EmERGE was a cost-saving intervention, patients remained engaged and clinically stable. Annual costs were reduced, but ARVs continue to dominate costs. Extension of EmERGE to other people with chronic conditions, could produce greater efficiencies but these needs to be evaluated and monitored over time.

The Theory of Planned Behaviour and dietary patterns: A systematic review and meta-analysis.

OBJECTIVE: Promoting adherence to healthy dietary patterns is a critical public health issue. Models of behaviour, such as the Theory of Planned Behaviour (TPB) allow programme designers to identify antecedents of dietary patterns and design effective interventions. The primary aim of this study was to examine the association between TPB variables and dietary patterns. METHODS: A systematic literature search was conducted to identify relevant studies. Random-effects meta-analysis was used to calculate average correlations. Meta-regression was used to test the impact of moderator variables. RESULTS: In total, 22 reports met the inclusion criteria. Attitudes had the strongest association with intention (r+=0.61) followed by perceived behavioural control (PBC, r+=0.46) and subjective norm (r+=0.35). The association between intention and behaviour was r+=0.47, and between PBC and behaviour r+=0.32. Moderator analyses revealed that younger participants had stronger PBC-behaviour associations than older participants had, and studies recording participants' perceptions of behaviour reported significantly higher intention-behaviour associations than did those using less subjective measures. CONCLUSIONS: TPB variables were found to have medium to large associations with both intention and behaviour that were robust to the influence of key moderators. Recommendations for future research include further examination of the moderation of TPB variables by age and gender and the use of more valid measures of eating behaviour.

Work-based assessment: qualitative perspectives of novice nutrition and dietetics educators.

BACKGROUND: The assessment of competence for health professionals including nutrition and dietetics professionals in work-based settings is challenging. The present study aimed to explore the experiences of educators involved in the assessment of nutrition and dietetics students in the practice setting and to identify barriers and enablers to effective assessment. METHODS: A qualitative research approach using in-depth interviews was employed with a convenience sample of inexperienced dietitian assessors. Interviews explored assessment practices and challenges. Data were analysed using a thematic approach within a phenomenological framework. Twelve relatively inexperienced practice educators were purposefully sampled to take part in the present study. RESULTS: Three themes emerged from these data. (i) Student learning and thus assessment is hindered by a number of barriers, including workload demands and case-mix. Some workplaces are challenged to provide appropriate learning opportunities and environment. Adequate support for placement educators from the university, managers and their peers and planning are enablers to effective assessment. (ii) The role of the assessor and their relationship with students impacts on competence assessment. (iii) There is a lack of clarity in the tasks and responsibilities of competency-based assessment. CONCLUSIONS: The present study provides perspectives on barriers and enablers to effective assessment. It highlights the importance of reflective practice and feedback in assessment practices that are synonymous with evidence from other disciplines, which can be used to better support a work-based competency assessment of student performance.

Efficiency of the EmERGE Pathway to provide continuity of care for Spanish people living with medically stable HIV.

OBJECTIVE: Calculate the efficiency of the EmERGE Pathway of Care for medically stable people living with HIV at the Hospital Clínic-IDIBAPS, Barcelona, Spain. METHODS: 546 study participants were followed between 1st July 2016 and 30th October 2019 across three HIV outpatient clinics, but the virtual clinic was closed during the second year. Unit costs were calculated, linked to mean use outpatient services per patient year, one-year before and after the implementation of EmERGE. Costs were combined with primary and secondary outcomes. RESULTS: Annual costs across HIV-outpatient services increased by 8%: €1073 (95%CI €999-€1157) to €1158 (95%CI €1084-€1238). Annual cost of ARVs was €7,557; total annual costs increased by 1% from €8430 (95%CI €8356-8514) to €8515 (95%CI €8441-8595). Annual cost for 433 participants managed in face-to-face (F2F) clinics decreased by 5% from €958 (95%CI 905-1018) to €904 (95%CI 863-945); participants transferred from virtual to F2F outpatient clinics (V2F) increased their annual cost by a factor of 2.2, from €115 (95%CI 94-139) to €251 (95%CI 219-290). No substantive changes were observed in primary and secondary outcomes. CONCLUSION: EmERGE Pathway is an efficient and acceptable intervention. Increases in costs were caused by internal structural changes. The cost reduction observed in F2F clinics were off-set by the transfer of participants from the virtual to the F2F clinics due to the closure of the virtual clinic during the second year of the Study. Greater efficiencies are likely to be achieved by extending the use of the Pathway to other PLHIV.

Efficiency of the EmERGE Pathway to provide continuity of care for Spanish people living with medically stable HIV.

OBJECTIVE: Calculate the efficiency of the EmERGE Pathway of Care for medically stable people living with HIV at the Hospital Clínic-IDIBAPS, Barcelona, Spain. METHODS: 546 study participants were followed between 1st July 2016 and 30th October 2019 across three HIV outpatient clinics, but the virtual clinic was closed during the second year. Unit costs were calculated, linked to mean use outpatient services per patient year, one-year before and after the implementation of EmERGE. Costs were combined with primary and secondary outcomes. RESULTS: Annual costs across HIV-outpatient services increased by 8%: €1073 (95%CI €999-€1157) to €1158 (95%CI €1084-€1238). Annual cost of ARVs was €7,557; total annual costs increased by 1% from €8430 (95%CI €8356-8514) to €8515 (95%CI €8441-8595). Annual cost for 433 participants managed in face-to-face (F2F) clinics decreased by 5% from €958 (95%CI 905-1018) to €904 (95%CI 863-945); participants transferred from virtual to F2F outpatient clinics (V2F) increased their annual cost by a factor of 2.2, from €115 (95%CI 94-139) to €251 (95%CI 219-290). No substantive changes were observed in primary and secondary outcomes. CONCLUSION: EmERGE Pathway is an efficient and acceptable intervention. Increases in costs were caused by internal structural changes. The cost reduction observed in F2F clinics were off-set by the transfer of participants from the virtual to the F2F clinics due to the closure of the virtual clinic during the second year of the Study. Greater efficiencies are likely to be achieved by extending the use of the Pathway to other PLHIV.

Ocean thermal gradient hydraulic power plant.

Solar energy stored in the oceans may be used to generate power by exploiting ploiting thermal gradients. A proposed open-cycle system uses low-pressure steam to elevate vate water, which is then run through a hydraulic turbine to generate power. The device is analogous to an air lift pump.

Treatment outcome and cost-effectiveness of different highly active antiretroviral therapy regimens in the UK (1996-2002).

The aim of this study was to estimate the outcome and cost-effectiveness per life-year-gained (LYG) of first-, second- and third-line non-nucleoside reverse transcriptase inhibitors (NNRTI) versus protease inhibitor (PI) containing highly active antiretroviral therapy regimens. Hospital care costs (2002 US dollars discounted 3.5% per annum) were linked to treatment failure times. Results show that the median time-to-treatment failure for first-line (nucleoside reverse transcriptase inhibitors) 2NRTIs + NNRTI was substantially longer than that for 2NRTIs + PI(boosted), 2NRTIs + PI and 2NRTIs + 2PIs, whereas for second- and third-line they were similar. Comparing first-line 2NRTIs + NNRTI with 2NRTIs + PI(boosted) cost per LYG was US$ 12,375; US$ 12,139 per LYG when compared with 2NRTIs + PI and US$ 2948 per LYG when compared with 2NRTIs + 2PIs. For second-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 19,501; US$ 18,364 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. For third-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 2708; US$ 11,559 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. In conclusion, first-line 2NRTIs + NNRTI was cost-effective or cost-saving when compared with PI-containing regimens for all lines of therapy. Such information is required by clinicians and managers of HIV services to make appropriate treatment decisions based on clinical and financial grounds, and given the increasing number of people living with HIV, such information will become more important over time.

Efficiency of the EmERGE Pathway to provide continuity of care for Spanish people living with medically stable HIV / Eficiencia de la vía EmERGE para brindar continuidad asistencial a personas españolas que viven con VIH clínicamente estable

Objective:Calculate the efficiency of the EmERGE Pathway of Care for medically stable people living with HIV at the Hospital Clínic-IDIBAPS, Barcelona, Spain. Methods: 546 study participants were followed between 1st July 2016 and 30th October 2019 across three HIV outpatient clinics, but the virtual clinic was closed during the second year. Unit costs were calculated, linked to mean use outpatient services per patient year, one-year before and after the implementation of EmERGE. Costs were combined with primary and secondary outcomes. Results:Annual costs across HIV-outpatient services increased by 8%: €1073 (95%CI €999–€1157) to €1158 (95%CI €1084–€1238). Annual cost of ARVs was €7,557; total annual costs increased by 1% from €8430 (95%CI €8356–8514) to €8515 (95%CI €8441–8595). Annual cost for 433 participants managed in face-to-face (F2F) clinics decreased by 5% from €958 (95%CI 905–1018) to €904 (95%CI 863–945); participants transferred from virtual to F2F outpatient clinics (V2F) increased their annual cost by a factor of 2.2, from €115 (95%CI 94–139) to €251 (95%CI 219–290). No substantive changes were observed in primary and secondary outcomes. Conclusion: EmERGE Pathway is an efficient and acceptable intervention. Increases in costs were caused by internal structural changes. The cost reduction observed in F2F clinics were off-set by the transfer of participants from the virtual to the F2F clinics due to the closure of the virtual clinic during the second year of the Study. Greater efficiencies are likely to be achieved by extending the use of the Pathway to other PLHIV.(AU)

Objetivo: Calcular la eficiencia de la vía asistencial EmERGE para personas clínicamente estables que viven con VIH en el Hospital Clínic-IDIBAPS, en Barcelona, España. Métodos: Se realizó un seguimiento a 546 participantes del estudio, entre el 1 de julio de 2016 y el 30 de octubre de 2019, en tres clínicas ambulatorias de VIH, pero la clínica virtual se cerró durante el segundo año. Se calcularon los costes unitarios, vinculados al uso medio de los servicios ambulatorios por paciente al año, un año antes y después de la implementación de EmERGE. Los costes se combinaron con criterios de valoración principales y secundarios. Resultados: Los costes anuales en los servicios ambulatorios para el VIH aumentaron un 8%: 1.073 € (IC 95%: 999-1.157 €) a 1.158 € (IC 95%: 1.084-1.238 €). El coste anual de los fármacos antirretrovirales (ARV) fue de 7.557 €; los costes anuales totales aumentaron en un 1%, de 8.430 € (IC 95%: 8.356-8.514 €) a 8.515 € (IC 95%: 8.441-8.595 €).El coste anual para 433 participantes que recibieron tratamiento en clínicas presenciales (face to face, F2F) disminuyó en un 5%, de 958 € (IC 95%: 905-1.018 €) a 904 € (IC 95%: 863-945 €); los participantes transferidos de clínicas ambulatorias virtuales (V2F) a F2F aumentaron su coste anual en un factor de 2,2, de 115 € (IC 95%: 94-139 €) a 251 € (IC 95%: 219-290 €). No se observaron cambios sustanciales en los criterios de valoración principales y secundarios. Conclusión: La vía EmERGE es un tratamiento eficaz y aceptable. Los aumentos de los costes fueron el resultado de cambios estructurales internos. La reducción de costes observada en las clínicas F2F se compensó con la transferencia de participantes de las clínicas virtuales a las F2F debido al cierre de la clínica virtual durante el segundo año del estudio. Es probable que se logre una mayor eficiencia si se amplía el uso de la vía a otras personas que viven con VIH (PVVIH).(AU)

Interactions between multiple phosphorylation sites in the inactivation particle of a K+ channel. Insights into the molecular mechanism of protein kinase C action.

Protein kinase C inhibits inactivation gating of Kv3.4 K+ channels, and at least two NH2-terminal serines (S15 and S21) appeared involved in this interaction (. Neuron. 13:1403-1412). Here we have investigated the molecular mechanism of this regulatory process. Site-directed mutagenesis (serine --> alanine) revealed two additional sites at S8 and S9. The mutation S9A inhibited the action of PKC by approximately 85%, whereas S8A, S15A, and S21A exhibited smaller reductions (41, 35, and 50%, respectively). In spite of the relatively large effects of individual S --> A mutations, simultaneous mutation of the four sites was necessary to completely abolish inhibition of inactivation by PKC. Accordingly, a peptide corresponding to the inactivation domain of Kv3.4 was phosphorylated by specific PKC isoforms, but the mutant peptide (S[8,9,15,21]A) was not. Substitutions of negatively charged aspartate (D) for serine at positions 8, 9, 15, and 21 closely mimicked the effect of phosphorylation on channel inactivation. S --> D mutations slowed the rate of inactivation and accelerated the rate of recovery from inactivation. Thus, the negative charge of the phosphoserines is an important incentive to inhibit inactivation. Consistent with this interpretation, the effects of S8D and S8E (E = Glu) were very similar, yet S8N (N = Asn) had little effect on the onset of inactivation but accelerated the recovery from inactivation. Interestingly, the effects of single S --> D mutations were unequal and the effects of combined mutations were greater than expected assuming a simple additive effect of the free energies that the single mutations contribute to impair inactivation. These observations demonstrate that the inactivation particle of Kv3.4 does not behave as a point charge and suggest that the NH2-terminal phosphoserines interact in a cooperative manner to disrupt inactivation. Inspection of the tertiary structure of the inactivation domain of Kv3.4 revealed the topography of the phosphorylation sites and possible interactions that can explain the action of PKC on inactivation gating.

Changing use of hospital services and costs at a London AIDS referral centre, 1983-1989.

OBJECTIVE: To describe the use of hospital-based services and associated costs over time for HIV-infected individuals by disease stage and year of treatment. METHODS: Data on service use were abstracted from inpatient and outpatient case-notes of 459 HIV-infected patients (121 asymptomatic and 338 AIDS patients) treated at St Mary's Hospital, London between 1983 and 1989. Cost estimates were derived from a survey of the 37 departments involved with HIV-related care. The number and type of admissions and outpatient visits, referral and discharge venues, number and type of tests and procedures performed, drugs prescribed and associated costs for the study period were the outcome measures used. RESULTS: Most patients were homosexual men. At the time of first HIV-related visit, 80.7% lived in London. Most day cases and planned admissions were organized through the outpatient clinic; 31% of emergency admissions were initiated by patients themselves. For people with AIDS the number of day case admissions increased while planned admissions decreased. There was a marked reduction in the duration of inpatient stays, especially for AIDS patients. Costs associated with inpatient care decreased concomitantly. The number of outpatient visits for patients with symptomatic disease increased, resulting in increased outpatient expenditure. Asymptomatic patients had fewer inpatient tests, while outpatient tests did not change over time; costs followed similar patterns. Mean inpatient and outpatient drug-days prescribed did not change nor did average inpatient drug-costs although outpatient drug-costs increased. Inpatient tests performed on symptomatic non-AIDS patients decreased, while mean outpatient tests increased; average costs followed similar patterns. Inpatient drug-days prescribed and costs remained the same, while outpatient drug-days and average drug-costs increased during the study period. For AIDS patients, the number of inpatient tests performed and their average costs decreased but outpatient tests performed increased, though their average costs remained the same. Mean inpatient drug-days prescribed and average drug-costs decreased, while number of outpatient drug-days prescribed and average drug-costs increased markedly over time. For each disease category, expenditure on admissions and related tests decreased over time, while expenditure on outpatient visits and drug-costs increased. CONCLUSIONS: The shift from an inpatient- to an outpatient-based service has resulted in fewer patients being investigated and treated in hospital and more as outpatients. This has resulted in a reduction of inpatient-related costs, while outpatient-related costs have increased. The overall contribution of drug-costs to the total cost has increased greatly over time. With the anticipated advent of new antiviral compounds, the importance of ascertaining their effectiveness as well as their efficacy will become crucial.

Changing presentation and survival, service utilization and costs for AIDS patients: insights from a London referral centre.

OBJECTIVE: To describe the use of services and associated costs for HIV-infected patients by stage of infection in the context of changing patterns of presentation and survival. METHODS: A retrospective analysis of inpatient and outpatient case-notes of 335 AIDS patients and a survey of HIV-related care provided by 37 departments at St Mary's Hospital, London. Survival from time of diagnosis of AIDS, time from diagnosis of HIV infection to AIDS, and use and costs of services per patient-year were outcome measures. RESULTS: During the study period 1 January 1982 to 30 September 1989, 152 AIDS patients were diagnosed before 1987 (group 1) and 183 since 1987 (group 2), most of whom were homosexual men. The median interval of first HIV-related visit to diagnosis of AIDS increased from 0 (group 1) to 264 days (group 2; P < 0.0001). Median survival from AIDS diagnosis increased from 14.6 (group 1) to 21.0 months (group 2; P < 0.02). Group 2 patients used fewer inpatient services than group 1 patients irrespective of disease stage. Symptomatic patients in group 2 used more outpatient services than group 1 patients. Total HIV-related expenditure was lower for patients without AIDS in group 2 than in group 1, while expenditure for AIDS patients remained similar. CONCLUSION: Earlier patient presentation, a shift from inpatient- to outpatient-based clinical care and increased survival from time of AIDS diagnosis has occurred. Increased drug expenditure was offset by reduced inpatient expenditure. Total expenditure per patient-year was stable; increased survival and introduction of new drugs will increase future lifetime use of resources.

Risk factors for HIV-1 infection in a British population: lessons from a London sexually transmitted diseases clinic.

Between September 1985 and June 1988, 6923 people (4550 men and 2373 women) were tested for HIV-1 antibodies at a sexually transmitted disease clinic, London, UK. Of the 6923 individuals tested, 558 (8%) were seropositive, of whom 523 (94%) were men and 35 (6%) women. Of the seropositives, 84% were homosexual or bisexual men, 5% were intravenous drug users, 4% were heterosexual contacts of HIV seropositives, 4% had multiple risk factors, 2% were heterosexual contacts of central African partners and 1% were heterosexuals with no other risk factors. This prevalence pattern conforms to that observed in other industrialized nations. For the women, heterosexual intercourse with an HIV-infected partner, intravenous drug use and heterosexual contact with a partner from central Africa were the main risk factors for infection. The important risk factors among the men were heterosexual contact with an HIV-seropositive partner, being homosexual or bisexual, intravenous drug use and heterosexual contact with a resident from central Africa. heterosexual and homosexual transmission were implicated as the main routes for viral spread in this British population.

HIV media campaigns and HIV-1 testing trends at London genitourinary medicine clinic, 1985-1993.

OBJECTIVE: To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic. DESIGN: Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London. RESULTS: A total of 19,242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years; 95% CI, 29.2-35.8); mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (chi 2 = 21.7, degrees of freedom = 1; P < 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events. CONCLUSIONS: Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Cost effectiveness of expanded antenatal HIV testing in London.

BACKGROUND: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). OBJECTIVE: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. DESIGN: Incremental cost-effectiveness analysis. METHODS: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. RESULTS: Testing costs in the plausible range of pounds sterling 4 to pounds sterling 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pounds sterling 40. CONCLUSION: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered.

Decreased morbidity and use of hospital services in English HIV-infected individuals with increased uptake of anti-retroviral therapy 1996-1997. National Prospective Monitoring System Steering Group.

OBJECTIVE: To investigate the relationship between changing morbidity patterns, the use of hospital services by HIV-infected patients and the uptake of antiretroviral therapy (ART) in England. DESIGN: Prospective serial cross-sectional analyses based on data collected through the National Prospective Monitoring System (NPMS), a multi-centre prospective monitoring system. SETTING: HIV-infected patients seen in 10 clinics, five London and five non-London, during the three semesters, 1 January 1996 to 30 June 1997. MAIN OUTCOME MEASURES: The mean use of hospital services per patient-year, mean new HIV-related opportunistic illnesses per 1000 patient-years and percentage uptake of ART. RESULTS: The use of inpatient services changed particularly among AIDS patients. The mean number of inpatient days for AIDS patients decreased from 19.7 [95% confidence interval (CI) 13.7-25.7] in 1996 to 11.2 (95% CI 6.1-15.6) per patient-year in 1997. Concurrently the number of new AIDS-defining events decreased significantly from 567 (95% CI 529-607) to 203 (95% CI 183-225) per 1000 patient-years. The overall uptake of ART increased significantly from 33% (95% CI 31-35%) to 50% (95% CI 48-52%), and a switch from mono or dual to triple therapy or quadruple or more therapy was observed. However, by mid-1997 only 29% (95% CI 26-32%) of asymptomatic patients and 51% (95% CI 49-54%) of patients with symptomatic non-AIDS were on ART, compared with 69% (95% CI 66-71%) of AIDS patients. CONCLUSION: The observed reduction in new AIDS-defining events has led to a reduction in the need for inpatient hospital care and has been associated with an increased uptake of ART, including a switch to triple therapy. All of these factors are likely to have contributed to the observed reduction in mortality among English AIDS patients. As the overall uptake of ART remained relatively low in English centres further improvements can be anticipated. However, the medium to long-term effects of these treatment regimens will need to be closely monitored.

The cost-effectiveness of triple nucleoside analogue therapy antiretroviral regimens in the treatment of HIV in the United Kingdom.

PURPOSE: Treatment of HIV infection has improved markedly in recent years due to the use of combination antiretroviral therapies. However, the cost of these treatments remains a concern for those who fund health services. This article reports the results of an economic evaluation to determine the incremental cost-effectiveness of triple combination nucleoside analogue (NA) therapy compared with dual NA therapy. METHOD: A Markov model was developed to assess the incremental cost effectiveness of triple therapy treatment versus dual therapy treatment. Clinical data was derived from published clinical trials and large observational cohorts whilst cost data was derived from a prospective database that monitors health care resource use in the UK HIV population. RESULTS: The model predicted that triple NA combination treatment extended life expectancy by an additional 1.2 years compared with dual therapy NA treatment with an incremental cost-effectiveness ratio of 8,419 pounds per life-year saved. The incremental cost per quality-adjusted life-year (QALY) was estimated to be between 10,072-16,168 pounds per QALY gained depending on the assumptions. CONCLUSION: The results show triple nucleoside analogue therapy to be a cost effective means of delaying HIV progression and extending life expectancy. However, further research into this issue is warranted.

Indirect cost of HIV infection in England.

BACKGROUND: Few studies have estimated the indirect costs of care for HIV infection in England by stage of infection at a population level. OBJECTIVE: This study estimated annual indirect costs of the HIV epidemic in England in 1997-1998 from both a public-sector and societal perspective. METHODS: Service costs for HIV-infected individuals were indexed to 1997-1998 English prices. Average annual indirect costs included the costs of statutory, community, and informal services; disability payments; and lost economic productivity by stage of HIV infection. Disability payments were excluded from the societal perspective, whereas the degree of lost economic productivity was varied for the sensitivity analyses. Total average annual indirect costs by stage of HIV infection were calculated, as were population-based costs by stage of HIV infection and overall population costs. RESULTS: Annual indirect costs from the public-sector and societal perspectives, respectively, ranged from pound sterling 3169 (dollars 5252) to pound sterling 3931 (dollars 6515) per person-year for asymptomatic individuals, pound sterling 5302 (dollars 8787) to pound sterling 7929 (dollars 13,140) for patients with symptomatic non-AIDS, and pound sterling 9956 (dollars 16,499) to pound sterling 21,014 (dollars 34,825) for patients with AIDS. Estimated population-based indirect costs from the public-sector perspective varied between pound sterling 109 million (dollars 181 million) and pound sterling 145 million (dollars 241 million) for 1997-1998, respectively, comprising between 58% and 124% of direct treatment costs for triple drug therapy in England during 1997. From the societal perspective, estimated population-based costs varied between pound sterling 84 million (dollars 138 million) and pound sterling 119 million (dollars 198 million) in 1997-1998, comprising between 45% and 102% of direct treatment costs and cost of care, respectively, during 1997. CONCLUSIONS: Average indirect costs increase as HIV-infected individuals' illness progresses. Whether one takes a public-sector or societal perspective, indirect costs add a considerable amount to the cost of delivering health care to HIV-infected individuals. Both direct and indirect costs, when obtainable, should be used to assess the economic consequences of HIV infection and treatment interventions.