Background: HIV prevention funds are often allocated by decision makers at multiple levels. High-level decision makers may allocate funds to regions, and regional decision makers then allocate those funds to specific programs. Often, funds are allocated proportionally (e.g., in proportion to HIV incidence) rather than efficiently (i.e., to maximize HIV infections averted). The authors investigate the impact of efficient and proportional allocation methods at 2 different decision levels.

Methods: The authors developed an optimization model of resource allocation at 2 levels-an aggregate upper level and multiple local levels-and considered efficient allocation and allocation proportional to HIV incidence. Using data from 40 U.S. states, they compared 4 strategies for allocating HIV prevention funds.

Results: The greatest health benefit (HIV infections averted) occurred when efficient allocations were made at both levels. When funds were allocated proportionally at the higher level and efficiently at the lower level, the health benefit was about 5% less than when efficient allocations were made at both levels. When funds were allocated efficiently at the higher level and proportionally at the lower level, the health benefit was 15% less than when efficient allocations were made at both levels. The least health benefit (23% less than when efficient allocations were made at both levels) occurred with proportional allocation at both levels.

Conclusions: Efficient allocation only at the higher level cannot overcome poor allocations at lower levels. Moreover, efficient allocation at the lower level is likely to yield greater gains than efficient allocation at the higher level. Thus, upper-level decision makers, such as donor organizations, should develop incentives to promote efficient allocation by lower-level decision makers.

This issue of CHP/PCOR's Quarterly Update covers news from the Spring 2007 quarter and includes articles about:

• the HIV/AIDS International Conference in St. Petersburg, Russia, that was attended by the CHP/PCOR National Institute on Drug Abuse project team;
• a special international health section that highlights HIV/AIDS research in Zimbabwe, and two Payne lecturer talks, given by David Heymann and Peter Piot, speaking on infectious diseases and HIV/AIDS, respectively;
• two Research in Brief selections -- one highlights health care financing structures in high-income countries, and the second covers an ongoing trial that incorporates a smoking cessation program into posttraumatic stress disorder treatment at the VA;
• a Staff Spotlight feature on new CHP/PCOR core faculty member Sally Horwitz;
• two conferences -- one hosted by the Stanford International Initiative and the other a National Summit on America's Children at the Capitol.

This issue of CHP/PCOR's Quarterly Update covers news from the Winter 2007 quarter and includes articles about:

• two Veterans Affairs-related items -- this year's recipient of the Under Secretary's Award for Health Science Research, and the Health Services Research & Development Annual meeting;
• the importance of proper HIV resource allocation: What method of allocation is best to ensure that HIV prevention and treatment program funds are being used effectively? One study looks at this issue from an aggregate-level analysis;
• the use of functional magnetic resonance imaging technology to examine how financial decisions are made. Researchers were able to identify specific areas of the brain that are activated prior to when individuals actually make purchasing decisions;
• the report series concerning the quality gap, as identified by the Institute of Medicine. Two recently-released reports about the quality gap in asthma care and healthcare-associated infections are covered;
• CHP/PCOR research activities and updates, including a year-in-review of the Patient Safety Research Group that examines the notion of safety culture;
• a Research in Brief selection that highlights recently-published CHP/PCOR research. This piece examines the public-private partnerships model used to improve health and welfare systems.

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.