Cost and utilisation of community services for people with HIV infection in London

This study aimed to describe the use and costs of community services for HIV-infected people by disease stage, sex and transmission category (homosexual, heterosexual, injecting drug use) by use of a prospective cohort study in which people were followed up for six months. There were two major components; gathering quantitative information on service utilisation from people with HIV infection using two interviewer-administered questionnaires and six self-completed monthly diaries; and estimating the costs of the services provided. People were recruited from two London clinics: the Jefferiss Wing Genito-urinary Medicine (GUM) clinic at St. Mary's Hospital, Paddington, and the Patrick Clements GUM clinic at the Central Middlesex Hospital, Harlesden. Costing data was obtained from providers of community services throughout Greater London. The main outcome measures were contacts per person-year, and costs per person-year, for all community services stratified by service sector. The people studied each made, on average, 139 community service contacts per year at a cost of 2,806 pounds; there was little difference in average utilisation between the three transmission categories. There were differences in both the utilisation of services and costs within the formal and informal sectors for subjects from different disease stages. Although the average number of contacts per person-year were similar for women and men, the total cost of community services was higher for women than for men, reflecting the differences in types of services used. The results indicated a high proportion of total care costs for people with HIV and AIDS is incurred through community-based social care.(ABSTRACT TRUNCATED AT 250 WORDS)     

AIDS/HIV Infection and Employment: the Role of Occupational Health Services

Occupational health services need to be active in the developmentof local policies about AIDS/HIV and employment. Employmentissues include the possible hazards from HIV infected employees,which are more fears than real risks, and the problems facedby HIV infected employees. Pre-employment HIV screening doesnot eliminate HIV from the workforce and involves much extrawork. The occupational health service can be a source of confidentialcounselling for HIV infected individuals and will need to adviseon work fitness. HIV as a bar to certain jobs is difficult tojustify. The problems relating to HIV infection at work arebest dealt with by education of staff at all levels. Requests for reprints should be addressed to: Dr Anne Cockcroft, Consultant in Occupational Medicine, Occupational Health Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK     

艾滋病病毒感染者和艾滋病患者卫生服务利用及医疗费用的研究

目的 了解艾滋病病毒(HIV)感染者和艾滋病(AIDS)患者对卫生服务的利用及直接医疗费用。方法 于1999年12月对北京佑安医院收治的HIV感染者和AIDS患者进行回顾性研究。收集一般人口学特征、HIV感染及疾病进程的相关信息、过去一年内卫生服务利用情况及医疗费用资料。结果 共调查29例HIV感染者，其中17例(58．62％)为无症状期的HIV感染者，12例为AIDS患者。无症状期的HIV感染者平均每人年门诊6次，住院1．23次，每人年住院58．6天；AIDS患者平均每人年门诊7．8次，住院2．1次，住院200．2天。无症状期的HIV感染者平均每人年门诊费用为13729元，住院费用为4745元；AIDS患者平均每人年门诊及住院费用分别为15053元和22242元。既门诊又住院平均每人年的门诊及住院医疗费用，无症状期的HIV感染者为16248元，AIDS患者为36795元。结论 HIV感染者和AIDS患者医疗费用昂贵，对卫生服务的需求量大。需要进一步在更大范围内了解国内HIV感染者和AIDS患者对卫生服务利用的现状及需求。     

Knowledge of partner risk and secondary transmission of HIV

BACKGROUND: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission. METHODS: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV. RESULTS: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners. CONCLUSIONS: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.     

AIDS: an update

In sub-Saharan Africa, where the acquired immunodeficiency syndrome (AIDS) epidemic threatens to undermine the social and economic structure of society, there has been insufficient attention to health care demand, supply, and quality issues. Most of those currently infected with human immunodeficiency virus (HIV) will register their demand for increased health services within the next six years. A study of medical insurance claims in Zimbabwe indicated that the claims of HIV-infected persons in the last 7-15 months of their lives were 700% higher than the average claim for the same age group. Absenteeism by HIV-infected health care workers is affecting the quality of care in hospitals, and countries that provide sickness benefits for public sector workers face the double drain of financing these benefits and paying for replacement staff. Emerging evidence suggests that HIV screening and counseling is not an effective intervention in this culture. Pregnant Kenyan women screened for HIV tended not to want the results, failed to inform their partner of a positive result, or were subjected to violence and abandonment when they did inform their husbands. Most effective, in this region, have been programs aimed at improving the diagnosis and treatment of sexually transmitted diseases. Other recommendations include decentralization of care to district health systems where costs are lower, increased support for home-based care, AIDS education for traditional healers, and informational campaigns to counter discrimination against HIV-infected community members.     

Self-perceived unmet health care needs of persons enrolled in hiv care

We examined the prevalence of, and factors associated with unmet health service needs among persons with HIV disease. Data were examined from 1,851 participants in the U.S. AIDS Cost and Service Utilization Study, drawn from 26 medical care providers in 10 cities. Geographic areas with large numbers of AIDS cases, and health care providers within them were chosen as study sites. After completing a screener questionnaire, potential participants at each site were stratifed by illness stage, HIV exposure route, and insurance status; a systematic random sample within those strata were selected for the study. Participants completed a comprehensive survey of HIV-related service use and costs, which also asked them to identify unmet health service needs. Analyses identified the relationship between unmet needs and: stage of illness, type of insurance, source of care, living arrangement, and AIDS prevalence of respondents' geographic region. At least one unmet need was reported by 20% of the sample. Needs for non-institutional services, e.g., dental care, mental health, and medications were more likely to be unmet than need for emergency room and hospital care. While most factors significantly affected the odds of having an unmet need, the greatest effects were found for private insurance and HIV asymptomatic status, both of which decreased the odds of unmet needs by approximately 50%. These findings suggest that insurance coverage for services required during the chronic phase of HIV illness is inadequate and should be augmented.This study was conducted under a subcontract with Westat Inc.     

A method for estimating baseline health care costs.

STUDY OBJECTIVES--Studies estimating the cost of specific illnesses do not generally take into account the fact that health care costs would have been incurred in the absence of the disease of interest. The goal of this study was to develop a method of estimating age specific baseline health care costs. These costs were calculated for Australian men, and their magnitude was compared with the costs of caring for men with HIV infection. DESIGN--Information about health service usage was obtained from the 1989-90 national health survey and linked with data on the costs of services to obtain average monthly costs for individual and total health services. SETTING--The Australian community. PARTICIPANTS--Average total health service costs per man per month were $103 (Australian). Hospital admissions comprised approximately 40% of these costs and casualty/outpatient visits, consultations with a doctor, and prescribed medication comprised 10%, 13%, and 12%, respectively. Costs increased with age, from around $60 per month for men aged 20-39 years to $213 per month for men aged 60 and over. CONCLUSION--Baseline costs comprised around 18% of health care costs for men with asymptomatic HIV infection, but less than 1% of costs for men with AIDS. These estimates provide an essential baseline for determining the costs attributable to specific diseases.     

Planning health care for people with HIV infection and AIDS.

In recent years planners of health services have been urged to design a comprehensive range of services which are responsive to the needs of people with HIV infection and AIDS and those who might be worried about HIV transmission. Models of care have been tried and tested and pilot services which aim to inform the development of the services scrutinised. Though in general this community care is seen as the preferred option with adequate backup support from acute services. More than anything, there is a recognition that the service must be responsive to local needs. Because patterns of HIV infection and prevalence of AIDS are so variable there is no substitute for the systematic development of timely local knowledge as the basis of local planning.     

Facing the HIV / AIDS challenge: a study on household and community responses

In countries where the health care system cannot cope with the growing number of AIDS cases, the family and the community are significant sources of care and treatment. A qualitative study conducted in Mumbai, India, in 1994 sought to identify household- and community-based strategies for effective AIDS care. Enrolled were 26 individuals with HIV or AIDS, 4 couples (both partners infected), and 25 members of households with an HIV-infected person; in addition, 18 focus group discussions were held with low-income youth. None of the households contacted had abandoned a member with HIV. Household dynamics played a crucial role in the nature and quality of care received, however. The most supportive care was received by men, even when their female partner was also sick. In-laws often showed little compassion toward widowed, infected daughters-in-law. Individuals without open sores or lesions were better accepted by family members and perceived as less likely to transit the virus. Concerns about social stigmatization and isolation prevented many family members from turning to their community for support. Recommended, on the basis of these findings, are measures such as support programs to reduce the burden on female caregivers, subsidized and appropriate medical care, support groups for people with AIDS, HIV/AIDS community awareness programs, and increased involvement on the part of nongovernmental organizations in integrated programming.     

States' responses to Title II of the Ryan White CARE Act.

Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 provides formula-based grants to States to help them improve the quality, availability, and organization of health care and support services for people with human immunodeficiency virus (HIV) infection. This article reviews State expenditures during the first year of CARE Act funding (April 1991-March 1992) within the context of Title II guidelines and the federally funded grant programs that preceded and helped shape Title II. The authors also discuss future challenges that require development of resources, the assessment of program impact, and the evaluation of the quality and appropriateness of HIV-related services. Ninety-one percent of the $77.5 million awarded to States during fiscal year 1991 went for the provision of medical and support services through HIV care consortia, drug reimbursement programs, home and community-based care programs, and health insurance initiatives. The remaining monies were used for planning, evaluation, and program administration. Forty States allocated $38.9 million for the establishment of HIV care consortia to assess service needs and to develop comprehensive continuums of health and support services in the areas most affected by HIV disease. Fifty States allocated an additional $28.3 million for the continuation or expansion of FDA-approved drug therapies for low-income people with HIV infection. Twenty-five States allocated $2.2 million for the provision of home- and community-based health services, and 16 States allocated $1.3 million for programs that help low-income people with HIV infection to purchase or maintain health insurance coverage.     

Exploring Pathways Between HIV+ Status and Excellent Overall Health Among Kenyan Women: Family Functioning,Meaningfulness of Life,Seroconcordance, Social Support and Considering the Need for Integrated Care

As people living with HIV/AIDS (PLWHA) live longer, and HIV incidence declines, health systems are transitioning from vertical-only care delivery to horizontal integration with social and other services. This is essential to responding to the chronic nature of the disease, and health systems must respond to full-breadth of socio-economic conditions facing PLWHA. We use excellent self-rated health as a referent, and assess the role of non-biomedical conditions in mediating HIV+ status and excellent overall health among a large community sample of Kenyan women. After controlling for age and wealth, we found significant mediation by social support, partner HIV status, meaningfulness of life, family functioning, food sufficiency, and monthly income. If the goal of health systems is to help all people attain the highest level of health, integrating vertical HIV services with socio-economic support and empowerment may be required. Further investigation of the relative contribution of social support, family functioning, food and financial sufficiency should be conducted longitudinally, ideally in collaboration with HIV clinical services.     

HIV / AIDS,STDs and the workplace

Even though the workplace is ideal for promoting HIV/STD (sexually transmitted disease) prevention to benefit workers and employers, many workplaces are not convinced that they should be involved in HIV/AIDS and STD education, prevention, and support. They do not realize that time and money spent on health programs save them money. Perhaps they do not feel obligated to protect the health of their employees. The AIDS epidemic adversely affects society and the economy at both the macro and micro level. AIDS tends to strike the productive age group, thereby seriously affecting the workplace. In many Sub-Saharan African countries, at least 20% of the urban workforce may be infected with HIV. Persons living with HIV include top management, skilled professionals, general hands, and farm laborers. HIV/AIDS costs for formal employment are assumed through reduced productivity; increased costs of occupational benefits and social security measures; loss of skilled labor, professionals, and managerial expertise as well as the experience among workers; increased costs of training and recruitment; and low morale from stigmatization, discrimination, and subsequent industrial relation problems. Needed are comprehensive HIV/AIDS and STD workplace programs that ensure the rights of persons with HIV and compassionate treatment of these persons. Trade union or other labor representatives, management, and appropriate government departments should work together and build on existing health legislation and policy to bring about effective negotiation and policy development concerning AIDS and employment. Training of peer educators, support services (counseling, STD referral and/or treatment), community action, management commitment, monitoring and evaluation, and supportive workplace conditions make for effective comprehensive workplace programs. Successful programs operate in fishing villages in Tanzania, tea plantations in India, the University of Papua New Guinea, and Ugandan army camps.     

Longitudinal patterns of medical service use and costs among people with AIDS.

OBJECTIVE. This study examines the effect of race, HIV transmission group, and decedent status on the use and cost of inpatient and outpatient care among people with AIDS. DATA SOURCES. Data come from 914 people with AIDS who were receiving services in nine cities across the United States in 1990-1991 and who indicated that a hospital clinic was their usual source of care. Review of hospital medical and billing records provided data on use and costs of medical services over an 18-month period. Vital status was determined from hospital records and death certificates. STUDY DESIGN. Data from each respondent were aggregated into three-month intervals, beginning with the last quarter of data and working backward. Regression analyses using random-effect models and generalized estimating equations were conducted to assess temporal patterns of inpatient and outpatient use and costs. PRINCIPAL FINDINGS. Inpatient utilization and costs were higher for decedents than for nondecedents. However, differences between decedents and nondecedents varied as a function of race. Nonwhites had more inpatient use and higher costs than whites, but lower outpatient use, and these differences were greater among decedents. Inpatient nights and costs rose sharply in the six months prior to death. Outpatient use and costs did not display as strong a temporal trend. CONCLUSIONS. Much of the cost of treating HIV infection is concentrated in the period immediately preceding death. The intensity of service use in the terminal period should be considered when developing estimates of annual costs of care and when designing programs to provide community-based treatment.     

Help-seeking patterns in HIV/AIDS outpatients

This study investigates factors associated with requests for professional services, made by newly registered HIV/AIDS Clinic outpatients, referred by general practice physicians to a large urban hospital serving a broad metropolitan/rural area in Canada. Professional service requests were divided into two primary help-seeking categories: practical support (assistance with financial aid, housing, medication costs, etc.) and emotional support (i.e., psychological counselling). Slightly more than half of the sample (51%) of people living with HIV/AIDS (PHA) requested professional services. Service requesters are indistinguishable from non-requesters on a large number of variables, including age, gender, family awareness of HIV/AIDS diagnosis, time elapsed since diagnosis, employment status, spousal status, overall support network size, physical health indicators (Karnofsky Performance Status, CD4 count, symptoms, opportunistic infections) and receipt of community support services elsewhere. Similarly, requesters and non-requesters report comparable levels of overall perceived social support and quality of life. However, requesters of practical support services report significantly fewer friends, lower emotional-informational social support and poorer quality of life due to body pain than non-requesters. Requesters of emotional support services report experiencing significantly lower positive social interaction compared to non-requesters. Implications for the provision of practical and emotional support services for PHA are discussed.     

A time to gain, a time to lose: new directions for western European HIV/AIDS alliances

The complex and varied needs of people with HIV/AIDS have prompted major changes in the way that health care is organized and delivered. In the USA, the Netherlands and the UK, many HIV service providers have formed alliances to better coordinate policies and programs. These structural reforms have been accompanied by extensive reforms in the financing of health services. Drawing upon case studies of seven HIV/AIDS alliances in the Netherlands and the UK, the article examines how alliances are adapting their missions, organizational structures and functions to be responsive to changing community attitudes and the gradual elimination of earmarked HIV/AIDS funding. The case studies suggest strategies for maintaining interorganizational cooperation around public health issues in unstable and competitive funding environments.     

Identifying a Sample of HIV-Positive Beneficiaries From Medicaid Claims Data and Estimating Their Treatment Costs

Objectives. We sought to identify people living with HIV/AIDS from Medicare and Medicaid claims data to estimate Medicaid costs for treating HIV/AIDS in California. We also examined how alternate methods of identifying the relevant sample affect estimates of per capita costs.Methods. We analyzed data on Californians enrolled in Medicaid with an HIV/AIDS diagnosis reported in 2007 Medicare or Medicaid claims data. We compared alternative selection criteria by examining use of antiretroviral drugs, HIV-specific monitoring tests, and medical costs. We compared the final sample and average costs with other estimates of the size of California’s HIV/AIDS population covered by Medicaid in 2007 and their average treatment costs.Results. Eighty-seven percent (18 290) of potentially identifiable HIV-positive individuals satisfied at least 1 confirmation criterion. Nearly 80% of confirmed observations had claims for HIV-specific tests, compared with only 3% of excluded cases. Female Medicaid recipients were particularly likely to be miscoded as having HIV. Medicaid treatment spending for Californians with HIV averaged $33 720 in 2007.Conclusions. The proposed algorithm displays good internal and external validity. Accurately identifying HIV cases in claims data is important to avoid drawing biased conclusions and is necessary in setting appropriate HIV managed-care capitation rates.In 2010, the White House Office of National AIDS Policy outlined an ambitious National HIV/AIDS Strategy for the United States that called for evaluation strategies that would “obtain data (core indicators) that capture the care experiences of people living with HIV without substantial new investments.”1 Surveillance systems already in place in each state provide the Centers for Disease Control and Prevention with comprehensive data on incident HIV and AIDS cases.2 However, much less is known about the medical treatments received by people living with HIV/AIDS and the cost of those treatments.Much of the cost of HIV/AIDS treatment is borne by public insurance programs, principally Medicaid and Medicare. These 2 programs provide health insurance for more than half of people living with HIV/AIDS who are receiving care.3,4 The importance of Medicaid as a source of funding for HIV/AIDS treatment of low-income persons will grow substantially after full implementation of the Affordable Care Act, which eliminates the additional disability requirement for Medicaid eligibility in states accepting the Medicaid expansion, thereby extending coverage to nondisabled, low-income people living with HIV/AIDS in those states.Because of its prominent role in insuring low-income people living with HIV/AIDS, Medicaid can provide a rich source of data on the types and costs of treatments delivered to some of the most vulnerable individuals with HIV/AIDS. Insurance claims data can potentially allow us to monitor HIV/AIDS treatment without substantial new investments because most claims data are stored as computerized records. Claims data provide a comprehensive picture of medical care received from a variety of providers in multiple settings (outpatient, inpatient, laboratory, pharmacy), contain procedure codes that detail the services provided, and include cost of the treatment. By contrast, medical records tend to have smaller scope, in terms of both numbers of patients and services covered. Furthermore, medical records most often lack payment information.Insurance claims data can provide information on a large number of individuals, even among those with relatively low-prevalence conditions, which is valuable in reducing the variability of estimates of per capita expenditures. However, the greater precision afforded by large administrative data sets is of little value if estimates are based on an inappropriate sample. Claims data are primarily designed for billing purposes; thus, they generally lack clinical detail important for selecting cases with a particular disease.3,5 For example, claims data will document whether a laboratory test was performed, but not the test result. Therefore, analysts must rely on the diagnosis information on insurance claims.6 Professional medical records specialists code diagnoses on inpatient claims, leading to greater accuracy and reliability of diagnosis information coming from inpatient stays. However, diagnosis coding is more error-prone in the outpatient sector, which has accounted for an increasing percentage of HIV/AIDS care since 1996 when antiretroviral medication (ARV) began to dramatically reduce hospitalization for HIV/AIDS.7 This has increased the challenges of identifying people living with HIV/AIDS from insurance claims data.We applied a practical algorithm for identifying people living with HIV/AIDS in insurance claims data to estimate Medicaid costs for treating HIV/AIDS in California. We also examined how alternate methods of identifying the relevant sample affect estimates of per capita costs.     

Decentralization of the provision of health services to people living with HIV/AIDS in rural China: the case of three counties

This study is based on a large-scale household survey and in-depth interviews of key informants that was conducted in villages in three counties of two provinces in China. We assess the new decentralized service provision system for people living with HIV/AIDS in rural populations in China. Since 2003, new social assistance schemes, and, more importantly, decentralization of routine treatment and care to community health stations, were progressively implemented in rural areas most affected by the HIV/AIDS epidemic. Though some problems remain, such as persistent discrimination towards infected patients and the lack of sufficient training of medical staff, the new decentralized pattern of service provision has lowered barriers to health access and alleviated economic pressure on affected households.     

The indirect cost of AIDS

AIDS afflicts mainly people aged 15-45 years. The syndrome seriously threatens the social and economic development, and even political stability, of nations by depriving them of citizens in their most productive years. AIDS now dominates public health programs and health services in several countries and may eventually dominate in many more. As the number of AIDS cases rises steeply over the next few years, the economic, social, political, and cultural impact will be difficult to control. AIDS deserves special attention. The spread of AIDS, HIV, sex education, risk groups, desired interventions, and saving costs are discussed. Public health surveillance for HIV is critical in areas where an extensive spread of the virus has not yet occurred. Nongovernmental organizations can play a vital role in prevention, care, and community support programs.