HIV/AIDS
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Objectives: Emergency departments (EDs) are increasingly proposed as high-yield venues for providing preventive health education to a population at risk for unhealthy behaviors and unmet primary care needs. This study sought to determine the preferred health education topics and teaching modality among ED patients and visitors.

Methods: For two 24-hour periods, patients aged 18 years and older presenting to four Boston EDs were consecutively enrolled, and waiting room visitors were surveyed every 3 hours. The survey assessed interest in 28 health conditions and topics, which were further classified into nine composite health education categories. Also assessed was the participants' preferred teaching modality.

Results: Among 1,321 eligible subjects, 1,010 (76%) completed the survey, of whom 56% were patients and 44% were visitors. Among the health conditions, respondents were most interested in learning about stress and depression (32%). Among the health topics, respondents were most interested in exercise and nutrition (43%). With regard to learning modality, 34% of subjects chose brochures/book, 25% video, 24% speaking with an expert, 14% using a computer, and 3% another mode of learning (e.g., a class). Speaking with an expert was the overall preferred modality for those with less than high school education and Hispanics, as well as those interested in HIV screening, youth violence, and stroke. Video was the preferred modality for those interested in learning more about depression, alcohol, drugs, firearm safety, and smoke detectors.

Conclusions: Emergency department patients and visitors were most interested in health education on stress, depression, exercise, and nutrition, compared to topics more commonly targeted to the ED population such as substance abuse, sexual health (including HIV testing), and injury prevention. Despite many recent innovations in health education, most ED patients and visitors in our study preferred the traditional form of books and brochures. Future ED health education efforts may be optimized by taking into account the learning preferences of the target ED population.

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Publication Type
Policy Briefs
Publication Date
Journal Publisher
Academic Emergency Medicine
Authors
Mucio Kit Delgado
Ginde AA
Pallin DJ
Camargo CA
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BACKGROUND: The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results. OBJECTIVE: To examine the costs and benefits of strategies to improve HIV testing and receipt of results. DESIGN: Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. SETTING/TARGET POPULATION: Primary-care patients with unknown HIV status. INTERVENTIONS: Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling. MAIN MEASURES: Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness. KEY RESULTS: Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses. CONCLUSIONS: In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of General Internal Medicine
Authors
Gillian D. Sanders
Anaya HD
Asch S
Hoang T
Golden JF
Bayoumi AM
Douglas K. Owens
Douglas Owens
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Publication Type
Journal Articles
Publication Date
Journal Publisher
JAIDS
Authors
Anis AH
Nosyk B
Sun HSun H
Guh DPGuh DP
Bansback NBansback N
Li X
Paul G. Barnett
Vilija Joyce
Swanson KM
Kyriakides TC
Mark Holodniy
Mark Holodniy
Cameron DW
Brown ST
OPTIMA TEAM
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Abstract

BACKGROUND:

Raltegravir is a potential treatment option for virologically suppressed HIV-1 infected patients on enfuvirtide with injection site reactions.

OBJECTIVES:

To characterize safety and efficacy of an enfuvirtide to raltegravir switch including changes in T-cells, quality of life, and residual viremia.

STUDY DESIGN:

In patients with viral load <50 copies/mL and injection site reactions, enfuvirtide was switched to raltegravir without additional changes to the antiretroviral regimen. Virologic failure was defined as a viral load >1000 copies/mL or two consecutive viral load measurements between 50 and 1000 copies/mL (low-level viremia). Over the 24 week study, we compared changes in T-cells, injection site reactions, quality of life, and residual viremia, as measured through the single-copy assay which can detect plasma virus down to a single copy, using paired t-tests.

RESULTS:

Fourteen patients with a median CD4+ T-cell count of 420 cells/microL were enrolled. After the switch, two patients experienced virologic failure due to confirmed low-level viremia. However, both patients subsequently were re-suppressed, one without any changes to his regimen. There was no change in CD4+ T-cell count. Injection site reactions resolved. However, there was little reported change in quality of life. The baseline median level of residual viremia was 6 copies/mL and did not change after the switch to raltegravir.

CONCLUSIONS:

A switch to raltegravir in virologically suppressed patients on enfuvirtide is effective in maintaining immunologic and virologic control at 24 weeks but did not result in a change in residual viremia.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of Clinical Virology
Authors
Grant, P. M.
Palmer, S.
Eran Bendavid
Eran Bendavid
Talbot, A.
Slamowitz, D. C.
Cain, P.
et al
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This paper develops a mathematical/economic framework to address the following question: Given a particular population, a specific HIV prevention program and a fixed amount of funds that could be invested in the program, how much money should be invested?

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Health Care Management Science
Authors
Margaret L. Brandeau
Margaret L. Brandeau
Gregory S. Zaric
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Despite recommendations for voluntary HIV screening, few medical centres have implemented screening programmes. The objective of the study was to determine whether an intervention with computer-based reminders and feedback would increase screening for HIV in a Department of Veterans Affairs (VA) health-care system. The design of the study was a randomized controlled trial at five primary care clinics at the VA Palo Alto Health Care System. All primary care providers were eligible to participate in the study. The study intervention was computer-based reminders to either assess HIV risk behaviours or to offer HIV testing; feedback on adherence to reminders was provided. The main outcome measure was the difference in HIV testing rates between intervention and control group providers. The control group providers tested 1.0% (n = 67) and 1.4% (n = 106) of patients in the preintervention and intervention period, respectively; intervention providers tested 1.8% (n = 98) and 1.9% (n = 114), respectively (P = 0.75).In our random sample of 753 untested patients, 204 (27%) had documented risk behaviours. Providers were more likely to adhere to reminders to test rather than with reminders to perform risk assessment (11% versus 5%, P < 0.01). Sixty-one percent of providers felt that lack of time prevented risk assessment. In conclusion, in primary care clinics in our setting, HIV testing rates were low. Providers were unaware of the high rates of risky behaviour in their patient population and perceived important barriers to testing. Low-intensity clinical reminders and feedback did not increase rates of screening.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
International Journal of STDs and AIDS
Authors
Vandana Sundaram
Laura Lazzeroni
Douglass LR
Gillian Sanders
Tempio P
Douglas K. Owens
Douglas Owens
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Estimating the potential health benefits and expenditures of a partially effective HIV vaccine is an important consideration in the debate about whether HIV vaccine research should continue. We developed an epidemic model to estimate HIV prevalence, new infections, and the cost-effectiveness of vaccination strategies in the U.S. Vaccines with modest efficacy could prevent 300,000-700,000 HIV infections and save $30 billion in healthcare expenditures over 20 years. Targeted vaccination of high-risk individuals is economically efficient, but difficulty in reaching these groups may mitigate these benefits. Universal vaccination is cost-effective for vaccines with 50% efficacy and price similar to other infectious disease vaccines.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Vaccine
Authors
Long EF
Margaret L. Brandeau
Margaret Brandeau
Douglas K. Owens
Douglas Owens
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Objectives To assess the concurrent validity and responsiveness of the Health Utility Index 3 (HUI3) in patients with advanced HIV/AIDS, and to determine the responsiveness of this measure, the MOS-HIV and EQ-5D to HIV-related clinical events.

Methods Data from the OPTIMA (OPTions In Management with Antiretrovirals) trial was analyzed. Two aspects of the validity of the HUI3 were considered: concurrent validity was evaluated using Spearman correlations with MOS-HIV component and summary scores. Responsiveness to AIDS-defining events (ADE) and all adverse events (our external change criterion) was assessed using area under the receiver operating characteristic (AUROC) curves.

Results The study enrolled 368 patients (mean follow-up: 3.66 years); 82% had at least one severe adverse event and 27% had at least one ADE. The HUI3 scale and items showed good concurrent validity, with 85% of the expected relationships with the MOS-HIV subscales verified. The HUI3 was responsive to both adverse events (AUROC [95%CI]: 0.68 [0.57, 0.80]) and ADEs (0.62 [0.51, 0.74]). The EQ-5D was responsive to ADEs (0.66 [0.56, 0.76]), but not responsive to adverse events (0.56 [0.46, 0.68]).

Conclusion The HUI3 is a valid and responsive measure of the change in HRQoL associated with clinical events in an advanced HIV/AIDS population.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Quality of Life Research
Authors
Nosyk B
Sun H
Bansback N
Guh DP
Li X
Paul G. Barnett
Bayoumi A
Griffin S
Vilija Joyce
Mark Holodniy
Mark Holodniy
Douglas K. Owens
Douglas Owens
Anis AH
Number
0962-9343
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Background: Since 2003, the President's Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown.

Objective: To assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa.

Design: Comparison of trends before and after the initiation of PEPFAR's activities.

Setting: 12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations).

Intervention: A 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003.

Measurements: HIV-related deaths, the number of people living with HIV, and HIV prevalence.

Results: Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR's activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis.

Limitation: The selection of the focus countries was not random, which limits the generalizability of the results.

Conclusion: After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR's evaluation programs.

Primary Funding Source: Agency for Healthcare Research and Quality.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Annals of Internal Medicine
Authors
Eran Bendavid
Eran Bendavid
Jay Bhattacharya
Jay Bhattacharya
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Background Current World Health Organization (WHO) guidelines for treatment of HIV in resource-limited settings call for 2 antiretroviral regimens. The effectiveness and cost-effectiveness of increasing the number of antiretroviral regimens is unknown.

Methods Using a simulation model, we compared the survival and costs of current WHO regimens with two 3-regimen strategies: an initial regimen of 3 nucleoside reverse transcriptase inhibitors followed by the WHO regimens and the WHO regimens followed by a regimen with a second-generation boosted protease inhibitor (2bPI). We evaluated monitoring with CD4 counts only and with both CD4 counts and viral load. We used cost and effectiveness data from Cape Town and tested all assumptions in sensitivity analyses.

Results Over the lifetime of the cohort, 25.6% of individuals failed both WHO regimens by virologic criteria. However, when patients were monitored using CD4 counts alone, only 6.5% were prescribed additional highly active antiretroviral therapy due to missed and delayed detection of failure. The life expectancy gain for individuals who took a 2bPI was 6.7-8.9 months, depending on the monitoring strategy. When CD4 alone was available, adding a regimen with a 2bPI was associated with an incremental cost-effectiveness ratio of $2581 per year of life gained, and when viral load was available, the ratio was $6519 per year of life gained. Strategies with triple-nucleoside reverse transcriptase inhibitor regimens in initial therapy were dominated. Results were sensitive to the price of 2bPIs.

Conclusions About 1 in 4 individuals who start highly active antiretroviral therapy in sub-Saharan Africa will fail currently recommended regimens. At current prices, adding a regimen with a 2bPI is cost effective for South Africa and other middle-income countries by WHO standards.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Journal of Acquired Immune Deficiency Syndromes
Authors
Eran Bendavid
Eran Bendavid
Wood R
Katzenstein DA
Bayoumi AM
Douglas K. Owens
Douglas Owens
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