Health care and its costs for children with perinatally acquired HIV infection

The cost of HIV treatment and care. A global review

This review of published studies on the costs of HIV treatment and care describes some of the recent developments that have influenced these costs in industrialised and industrialising countries, especially within the context of changing drug treatments. Some of the different approaches to estimating the economic impact of HIV infection are briefly presented. The methods used to review the literature are described, particularly the criteria of a scoring system that was specifically developed to systematically screen some of the studies identified. The mean review score for studies dealing with direct hospital costs increased significantly (p = 0.003) over the 3 periods analysed (before 1987, 1987 to 1995, and 1996 and beyond), indicating that the overall 'quality' of studies increased over time. All cost estimates, other than those from non-industrialised regions, were converted to 1996 US dollars using country-specific total health expenditure inflaters and country-specific Gross Domestic Product Purchasing Power Parity converters. A summary of hospital cost estimates over time and by region demonstrated that the costs of treating asymptomatic individuals and people with symptomatic non-AIDS increased over the period, but that the costs of treating individuals with AIDS appears to have stabilised since the late 1980s. As fewer studies could be identified on the costs of community and informal care, indirect productivity costs and population cost estimates, and costs of care for children with HIV infection, all of these studies were reviewed without the use of the scoring system. Finally, the discussion explores the evidence on the global costs of HIV in non-industrialised economies and the affordability of HIV treatment and care. Some suggestions for the direction of future HIV costing studies are also presented. A need remains for good quality cost data. Adequate research effort should be directed to improving the scope and quality of information on costs of HIV service provision around the world.

Use and cost of hospital and community service provision for children with HIV infection at an English HIV referral centre

OBJECTIVE

To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy.

DESIGN

Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations.

SETTING

Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996.

PATIENTS AND PARTICIPANTS

118 children with positive HIV antibody status.

MAIN OUTCOME MEASURES AND RESULTS

Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was 18,600 Pounds per symptomatic non-AIDS patient per year and 46,600 Pounds per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to 8300 Pounds and 4800 Pounds per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to 152,400 Pounds (44,300 Pounds to 266,800 Pounds) compared with discounted lifetime costs of 122,700 Pounds (42,000 Pounds to 182,200 Pounds); nondiscounted lifetime costs for community care amounted to 24,300 Pounds (7900 Pounds to 41,600 Pounds) compared with discounted lifetime costs of 21,000 Pounds (6800 Pounds to 32,000 Pounds).

CONCLUSIONS

The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospital and community-based services.

Health care utilization and survival among patients with AIDS in Belo Horizonte, Minas Gerais, Brazil

A historical cohort study was conducted in three public AIDS referral services in Belo Horizonte, Minas Gerais, to assess the relationship between health care utilization and patient survival following AIDS diagnosis. A review of medical and laboratory records was performed for HIV-infected patients seeking care for the first time in 1989-92. Among 291 patients initially categorized as 'A' [asymptomatic, acute HIV, or persistent generalized lymphadenopathy-PGL] or 'B' [symptomatic, non-'A', or AIDS-indicator conditions] (CDC, 1992) and who progressed to AIDS, 57.0% died. Mortality rate was 34.9 person-months. Overall median survival time following AIDS diagnosis was 14.3 months. Multivariate analysis showed that lack of AZT use (RR=1.87; 95% CI=1.34-2.61), advanced initial staging (RR=1.68; 95% CI=1.20-2.35), 9 or more inpatient days (RR=1.55; 95% CI=1.11-2.17), and intervals between outpatient visits longer than 6 months (RR=0.30; 95%CI= 0.16-0.56) were associated with death. The analysis suggests that: Patients who used health services more often had poorer prognosis; Patients who received AZT survived longer than those who did not; and variables used to assess health care utilization actually express the end of a process involving seeking and obtaining care.