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This study describes how hospital-at-home care (HHC) use by persons with acquired immune deficiency syndrome (PWA) has changed since the introduction of combination antiretroviral therapy (ART). For this study, all adult PWA (877) admitted for the first time to the HHC program, established for PWAs in the metropolitan area of Rome, between January 1994 and December 1998, were enrolled. Temporal changes in sociodemographic and clinical characteristics were evaluated. For subjects who concluded their first HHC cycle (851/877), the reasons for ending the service were assessed over time. From 1994 to 1998, the proportion of patients admitted to HHC of those living with AIDS in the Rome area decreased significantly (from 15.1% to 7.5%), while the median CD4+ cell count at HHC entry increased significantly. The proportion of patients referred to outpatient services at the end of their cycle of HHC increased sevenfold from 1994 to 1998, with a steep increase between 1996 and 1997. In multivariate analysis, only the use of triple-combination ART was significantly associated with referral to outpatient care (odds ratio [OR] = 4.26; 95%, confidence interval [CI] = 1.94-9.34). The results suggest that HHC use by PWAs in the ART era has diminished, while the HHC use pattern has also changed: there is a growing tendency to provide care to patients with less advanced human immunodeficiency virus (HIV) disease, prior to the beneficial effects of drugs, and the consequent referral to outpatient care.

We conducted a multicenter, hospital-based case-control study to identify specific characteristics of AIDS patients which determine referral to hospital care at home. The cases were patients referred to a hospital-based home care scheme, in the metropolitan area of Rome, during 1997. Each case was matched with two controls. Social, demographic and clinical characteristics were collected at referral. Univariate and multivariate analysis were performed. In the study period, 119 cases and 238 controls were recruited. In logistic regression analysis, social characteristics were not found to affect referral to the hospital-at-home scheme. A severely impaired functional status--assessed by the Functional Independent Measure--identified by a score below 100 (Odds Ratio [OR]=15.2, 95% confidence interval [CI] 2.8-82.7), and the need for prolonged intravenous therapy (OR=12.4, 95% CI=3.3-46.3) were the only two independent predictors of home-care referral. We conclude that home care, even in a period when new potent combination antiretroviral therapies are widely available, is an important integrated service component for persons with AIDS with severe functional impairment or requiring intravenous therapy.

We estimated the AIDS survival by neighborhood socioeconomic status before (1993-1995) and after (1996-1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993-1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993-1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996-1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38-5.76), and HR = 2.55 (95% confidence interval = 1.27-5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.

Objectives: To investigate temporal changes in survival of persons with AIDS (PWA) diagnosed in Lazio, Italy., Design: Longitudinal study of 2862 PWA registered at the AIDS Surveillance System in the period 1 January 1993 to 30 June 1997 and followed for vital status up to 31 May 1998., Methods: Hazard ratios (HR) of death were calculated by year of diagnosis and by year of follow-up, adjusting for gender, age, modality of exposure, CD4 cell count at diagnosis, and AIDS-defining illness, using the Cox proportional regression model., Results: In the period 1 January 1993 to 31 May 1998, 1914 PWA died. The multivariate model showed a decrease of the risk of death for patients diagnosed from 1995 onward compared with patients diagnosed in 1993 [1995: HR 0.82; 95% confidence intervals (CI) 0.73-0.93; 1996: HR 0.44; 95% CI 0.38-0.51; first semester of 1997: HR 0.47; 95% CI 0.37-0.59]. The model with the year of follow-up modeled as time-dependent variable showed a statistically significant decline in the risk of death starting from the first quarter of 1997 (HR 0.62; 95% CI 0.48-0.80) and reached the minimum in the first two quarters of 1998 (first quarter: HR 0.13; 95% CI 0.08-0.21; second quarter: HR 0.14, 95% CI 0.08-0.25). There was a small difference in the magnitude of the risk estimates among genders, with a slower improvement in survival among females [first semester of 1997 for males HR was 0.51 (95% CI 0.39-0.66) whereas for females HR was 0.80 (95% CI 0.51-1.27)]., Conclusions: Survival of PWA in a population-based study improved significantly in the era when highly active antiretroviral therapy became available, but such improvement is not homogeneous among genders.

There has been a limited number of studies in Italy investigating the relationship between socioeconomic inequalities and efficacy of treatments. This paper reviews three case studies on the association between socioeconomic status and disease outcome in the Lazio Region, Italy. The studies investigated: a) the probability of renal transplantation among patients with endstage renal disease; b) the survival of AIDS patients before and after the introduction of the new antiretroviral therapies; c) the 30-day mortality of patients who underwent coronary artery bypass graft surgery. The three studies demonstrate the complex relationship between socioeconomic status and both access to, and efficacy of, important health interventions.

A multidisciplinary home care service for people with AIDS (PWAs) was started in Rome in September 1990. This paper describes the features of the home care service offered by the Associated Health Care Workers' Co-operative (OSA), an example of the integration of private and state systems. We detail the types and numbers of visits that PWAs have needed, and we explore the possible correlation between demographic and clinical variables and the care required. As of September 1994 service had been provided to 372 PWAs. During the 4-year period, 62,927 home care visits were made (an average of 4.3 visits/patient/week): 66% were made by psychologists, social workers and home helps, and 34% by health professionals. PWAs who, at the outset of their home care, suffered from AIDS-dementia complex (ADC), toxoplasmosis, wasting syndrome or cytomegalovirus retinitis required the highest number of visits. Psychologists, social workers and home care helps made more frequent visits than health professionals for all AIDS-defining conditions except retinitis (for which 63% of visits were for health care). Our study shows that careful assessment of patients receiving home care helps in planning visits and in organizing available resources. A controlled randomized multicentre study is under way with the aim of determining the effectiveness of home care in terms of survival, quality of life and care workload and related costs.

Two cross-sectional surveys have been conducted in Rome in 1990 and 1992 to investigate prevalence and temporal differences of risk behaviours among drug injectors. A total of 487 drug injectors in 1990, and 450 in 1992 have been interviewed both in the street and in treatment services. Twenty-four percent of the subjects interviewed in 1990 reported having used second-hand syringes in the preceding 6 months, as compared to 14% in 1992; in the two years 29% and 13%, respectively, reported having passed a second-hand syringe to other drug injectors. Fifty-six percent (46% in 1992) of primary partners of drug injectors interviewed were not drug users themselves, while the prevalence of non drug using occasional partners was 34% and 43% in the two surveys. In 1990 condom use with primary partner was reported by 48% of drug injectors, and by 41% in 1992; condom use with occasional partners was 56% and 64% in the two years. The differences in sharing behaviours were observed for HIV-1 positive subjects, while HIV-1 negatives reported the same prevalence of use of second-hand syringes in 1990 and 1992; no statistically significant differences have been found for sexual behaviours among the HIV-1 positives, while the HIV-1 negatives reported a lower prevalence of condom use with primary partner. The observed differences in the two years remain also adjusting for the socio-demographic characteristics of the two populations in a multiple logistic regression model. Prevalence of HIV-1 related risk behaviours among drug injectors is still too high.(ABSTRACT TRUNCATED AT 250 WORDS)

Data gathered through the Latium HIV Surveillance System were used in conjunction with a compartmental mathematical model to describe the transmission dynamics of HIV-1 in Italy. In the Latium region, as in the rest of Italy, fewer than 1 in 5 cumulative cases of AIDS are attributable to male homosexual transmission, while 55-60 per cent of the cases have been observed among intravenous drug users (IVDUs). Moreover, the number of non-drug-using heterosexual cases is increasing (14 per cent of cumulative cases). Anonymous notification of positive HIV-1 tests, mandatory in Latium since 1985, were used to produce a time series of new HIV-1 diagnoses; just over 400 new cases of infection per quarter were diagnosed from mid 1989 to mid 1990, with no evidence of increasing incidence. A minimum of 6009 and a maximum of 10,000 individuals with HIV-1 as of the end of 1989 were estimated, 80 per cent of adult cases occurring among IVDUs. The model included two main subgroups: IVDUs and non-drug-using heterosexuals, both with behavioural heterogeneities. Sharing of needles among IVDUs and heterosexual contact were considered as possible ways of transmitting HIV-1. A mathematical framework was developed to reproduce different mixing patterns within and between subgroups. A scenario analysis of the model showed incident cases of HIV-1 among IVDUs peaking early, then declining dramatically and stabilising at low values, with a stable-state prevalence higher than 0.75. Heterosexual interaction with IVDUs resulted in a significant, but non-self-sustaining, virus spread in the general population, affecting females more than males. The extent of this spread is associated with the assortativeness of the sexual mixing pattern adopted. The qualitative features of the Italian epidemic are well represented by the model, which highlights the role of IVDUs as an infection reservoir. However, the need emerges for more accurate information on the key parameters influencing the transmission dynamics of HIV-1.

A review of legislative and regulatory policies regarding the issues of HIV infection and AIDS epidemic in correctional facilities is conducted. Screening and prevention policies, mainly in the US State and Federal legislation, are particularly reviewed. Liberal and compulsory policies, including voluntary and mandatory screening tests for various prison population groups are analyzed.

The effectiveness of premarital screening program for HIV infection is discussed, in relation to hypothetical objectives: improvement of individual health, prevention of transmission of HIV infection and estimate of prevalence among sexually active population. Taking into account validity of screening test, natural history of HIV infection, availability of effective early treatment and possible social outcomes, the hypothesis of lack of effectiveness of this program is held.