Objective: Early identification of HIV infection is critical for patients to receive life-prolonging treatment and risk-reduction counseling. Understanding HIV screening practices and barriers to HIV testing is an important prelude to designing successful HIV screening programs. Our objective was to evaluate current practice patterns for identification of HIV.

Methods: We used a retrospective cohort analysis of 13,991 at-risk patients seen at 4 large Department of Veterans Affairs (VA) health-care systems. We also reviewed 1,100 medical records of tested patients. We assessed HIV testing rates among at-risk patients, the rationale for HIV testing, and predictors of HIV testing and of HIV infection.

Results: Of the 13,991 patients at risk for HIV, only 36% had been HIV-tested. The prevalence of HIV ranged from 1% to 20% among tested patients at the 4 sites. Approximately 90% of patients who were tested had a documented reason for testing.

Conclusion: One-half to two-thirds of patients at risk for HIV had not been tested within our selected VA sites. Among tested patients, the rationale for HIV testing was well documented. Further testing of at-risk patients could clearly benefit patients who have unidentified HIV infection by providing earlier access to life-prolonging therapy.

Public-private partnerships have become a common approach to health care problems worldwide. Many public-private partnerships were created during the late 1990s, but most were focused on specific diseases such as HIV/AIDS, tuberculosis, and malaria.

Recently there has been enthusiasm for using public-private partnerships to improve the delivery of health and welfare services for a wider range of health problems, especially in developing countries. The success of public-private partnerships in this context appears to be mixed, and few data are available to evaluate their effectiveness.

This analysis provides an overview of the history of health-related public-private partnerships during the past 20 years and describes a research protocol commissioned by the World Health Organization to evaluate the effectiveness of public-private partnerships in a research context.

The case of a 52-yr-old female with rheumatoid arthritis and HIV who developed massive, progressive, cavitary pulmonary nodules is described. Multiple diagnostic bronchoscopies and lung biopsies failed to demonstrate the presence of any microorganisms. Pathological analysis showed palisading histiocytes with necrobiosis consistent with rheumatoid nodules. The effect of co-existing HIV infection on the course and prognosis of rheumatoid arthritis is discussed, and it is concluded that the complex relationship between these two disease processes warrants further investigation.

Numerous health decision aids (HDAs) have been developed to increase the participation of patients in shared decision-making, but many have limited accessibility and narrow applicability in clinical care. In the Health e-Decision project, we address these limitations in our work on building general HDAs targeted for older adults. Our approach uses a decision-support software architecture that enables principled methods for HDAs. We have formalized a novel knowledge-based decision model (KBDM), using Protege OWL, that developers and clinicians can instantiate to tailor the components of the architecture for a particular health problem. In this paper, we present the methods used in the architecture and the knowledgebase design; the latter encompasses influence-diagram concepts, specific health problems, health outcome states, and probabilistic relationships. We discuss how this approach improves upon prior HDA methods. We also show that our use of computer-interpretable knowledge provides a structured, customizable means of enabling patient-centered decision support.

Objective:

To assess the effectiveness and cost-effectiveness of treating HIV-infected injection drug users (IDUs) and non-IDUs in Russia with highly active antiretroviral therapy HAART.

Design and Methods:

A dynamic HIV epidemic model was developed for a population of IDUs and non-IDUs. The location for the study was St. Petersburg, Russia. The adult population aged 15 to 49 years was subdivided on the basis of injection drug use and HIV status. HIV treatment targeted to IDUs and non-IDUs, and untargeted treatment interventions were considered. Health care costs and quality-adjusted life years (QALYs) experienced in the population were measured, and HIV prevalence, HIV infections averted, and incremental cost-effectiveness ratios of different HAART strategies were calculated.

Results:

With no incremental HAART programs, HIV prevalence reached 64% among IDUs and 1.7% among non-IDUs after 20 years. If treatment were targeted to IDUs, over 40 000 infections would be prevented (75% among non-IDUs), adding 650 000 QALYs at a cost of USD 1501 per QALY gained. If treatment were targeted to non-IDUs, fewer than 10 000 infections would be prevented, adding 400 000 QALYs at a cost of USD 2572 per QALY gained. Untargeted strategies prevented the most infections, adding 950 000 QALYs at a cost of USD 1827 per QALY gained. Our results were sensitive to HIV transmission parameters.

Conclusions:

Expanded use of antiretroviral therapy in St. Petersburg, Russia would generate enormous population-wide health benefits and be economically efficient. Exclusively treating non-IDUs provided the least health benefit, and was the least economically efficient. Our findings highlight the urgency of initiating HAART for both IDUs and non-IDUs in Russia.

This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2006 quarter, includes articles about:

• research by CHP/PCOR investigators that influenced the Centers for Disease Control and Prevention to recommend widespread voluntary HIV screening for all Americans ages 13 to 64 -- a significant change from the CDC's previous HIV screening guidelines;
• a CHP/PCOR study on patient safety culture in U.S. hospitals -- the largest effort to date to measure hospitals' safety culture and seek to improve it through an intervention that gets hospital executives out of their offices and on to the hospital floors;
• an early-stage project in which CHP/PCOR is collaborating with the Center on Democracy, Development and the Rule of Law to study the relationship between health interventions, governance and development;
• an evidence report examining the challenges of diagnosing and treating anthrax in children, prepared by the Stanford-UCSF Evidence-based Practice Center; and
• a study by CHP/PCOR fellow Kate Bundorf which found that depending on the definition of "affordability" that is used, health insurance is "affordable" to between one-quarter and three-quarters of the uninsured -- and many of those who can't afford insurance purchase it anyway.