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This study of people newly diagnosed of living with HIV (ND-PLHIV) calculated the use, cost and outcome of HIV services at a London HIV centre. ND-PLHIV were followed July 2017-October 2018. Hospital data included inpatient days (IP), outpatient (OP), dayward (DW) visits, tests and procedures, and anti-retroviral drugs (ARVs). Community services were recorded in daily diaries. Mean per patient-year (MPPY) use was multiplied by unit costs. 13.6 MPPY (95%CI 12.4-14.9) OP visits, 0.4 MPPY (95%CI 0.1-0.7) IP days, 0.09 MPPY (95%CI 0.01-0.2) DW visits and 4.6 MPPY community services (95%CI 3.4-5.8). Total annual costs per patient-year (CPPY) was £11,483 (95%CI £10,369-12,597): ARVs comprised 63% and community services 2%. White participants used fewer hospital and more community services compared with minority ethnic community (MEC) participants. Costs for White ND-PLHIV was £10,778 CPPY (95%CI £9629-11,928); £13,214 (95%CI £10,656-15,772) for MEC ND-PLHIV (

Hauptindikationen fur Becken- und Huftgelenksaufnahmen sind Huftdysplasien, Luxationen, Frakturen oder entzundliche und tumorose Erkrankungen. Zur Beurteilung einer Huftdysplasie ist aus Strahlenschutzgrunden im ersten Lebensjahr die Ultraschalluntersuchung der Rontgenaufnahme vorzuziehen, da in diesem Alter die knorpeligen Anteile der Hufte noch uberwiegen. Erganzt wird die Aufnahmetechnik durch Spezialaufnahmen wie Faux-Profil oder die Bestimmung der Antetorsionswinkel nach Rippstein.

Data collected from 224 women living with HIV were analyzed to study quality of life. Quality of life was operationalized as mental health and physical functioning. A structural equation model was tested. The final model demonstrates good fit to data (χ2 = 17.63, p = .48). Mental health was directly and positively associated with being born outside of Canada, social support, and physical functioning but negatively associated with the proportion of people aware of serostatus and experienced discrimination. Physical functioning was directly and positively associated with being born outside of Canada and social support; however, it was negatively associated with time since diagnosis. The proportion of people aware of serostatus was negatively associated with being born outside of Canada and being a mother. Social work interventions aimed at improving quality of life in women living with HIV should target contexts of serostatus disclosure to minimize HIV discrimination and to improve social support sources wi...

Using a United Kingdom (UK)-based National Health Services perspective for 2011 this study first estimated the cost-effectiveness and budget impact implications for lopinavir/ritonavir (LPV/r) vs atazanavir plus ritonavir (ATV+RTV) treatment of antiretroviral therapy (ART)-naïve patients and secondly examined the long-term health-related quality-of-life (HRQoL) and economic implications for LPV/r vs ATV+RTV treatment of ART-experienced patients.A previously published Markov model that integrates epidemiological data of human immunodeficiency virus (HIV) with predictors of coronary heart disease (CHD) was modified under a clearly specified set of assumptions to reflect viral load (VL) suppression profiles and other differences for these two regimens, applying results from the CASTLE study in ART-naïve patients and using data from BMS-045 in ART-experienced patients. ART costs were referenced to current (2011) pricing guidelines in the UK. Medical care costs reflected UK treatment patterns and relevant drug pricing. Costs and outcomes were discounted at 3.5% per year. Costs are expressed in British pounds (£) and life expectancy in quality-adjusted life years (QALYs).In the ART-naïve subjects, the model predicted a marginal improved life expectancy of 0.031 QALYs (11 days) for the ATV+RTV regimen as a result of predicted CHD outcomes based on lower increases in cholesterol levels compared with the LPV/r regimen. The model demonstrated cost savings with the LPV/r regimen. The total lifetime cost savings was £4070 per patient for the LPV/r regimen. LPV/r saved £2133 and £3409 per patient at 5 and 10 years, respectively. Referenced to LPV/r, the incremental cost-effectiveness ratio (ICER) for ATV+RTV was £149,270/QALY. For ART-experienced patients VL suppression differences favored LPV/r, while CHD risk associated with elevated total cholesterol marginally favored ATV+RTV, resulting in a net improvement in life expectancy of 0.31 QALYs (106 days) for LPV/r. Five-year costs were £5538 per patient greater for ATV+RTV, with a discounted lifetime saving of £1445 per LPV/r patient. LPV/r was modestly dominant economically, producing better outcomes and cost savings.The limitations of this study include uncertainty related to how well the model's assumptions capture current practice, as well as the validity of the model parameters used. This study was limited to using aggregated data in the public domain from the two clinical trials. Thus, some of the model parameters may reflect limitations due to trial design and data aggregation bias. This study has attempted to illuminate the effect of these limitations by presenting the results of the comprehensive sensitivity analysis.Based on 2011 costs of HIV in the UK and the published efficacy data from the CASTLE and BMS-045 studies, ATV+RTV-based regimens are not expected to be a cost-effective use of resources for ART-naïve patients similar to patients in the CASTLE study, nor for ART-experienced patients based on the only published comparison of ATV+RTV and LPV/r.

The objective of this study was to compare differences in cost estimates for paediatric HIV hospital service provision based on hospital prices with cost estimates obtained through a research-based service-specific costing exercise.Activity data on the use of hospital services of children by stage of HIV infection were collected from case-notes for 118 HIV antibody positive children, managed at St Mary's Hospital NHS Trust, London, 1 January 1986-31 December 1994. Hospital unit prices were obtained from the Hospital Trust Finance Department; unit cost estimates were obtained from relevant hospital departments through a research-based service-specific costing exercise. Financial data related to the 1993-1994 financial year, and were indexed to 1995-1996 prices. The main outcome measures were cost estimates per patient-year by stage of HIV infection. Three cost scenarios were calculated: first by linking activity data with hospital prices (Trust Prices); second by linking activity data with routinely available hospital prices plus units costs from the costing exercise where no relevant hospital prices existed (Supplemented Trust Prices); third, by linking activity data exclusively with unit costs from the hospital-specific costing exercise (Unit Costs).There were substantial differences between unit cost estimates per patient-year based on Trust Prices and Supplemented Trust Prices compared with those based on Unit Costs. Differences increased with more intense use of services. The deficit based on Trust Prices compared with Unit Costs ranged from Pound Sterling 432 per patient-year for HIV negative children, Pound Sterling 574 for asymptomatic HIV-infected children, Pound Sterling 1288 for indeterminate children, Pound Sterling 1814 for children with symptomatic non-AIDS to Pound Sterling 7418 per patient-year for children with AIDS.In this hospital, reliance on generic hospital prices to derive cost estimates for paediatric HIV services produced considerable underestimates of the cost of service provision compared with data derived through the costing exercise. If this occurs across all or most areas of service provision, this can lead to substantial financial deficits, which in turn may mean that the needs of specific client populations may not be met.

Objective: To estimate the cost effectiveness of universal, voluntary HIV screening of pregnant women in England Design: Cost effectiveness analysis. Cost estimates of caring for HIV positive children were based on the stage of HIV infection and calculated using data obtained from a London hospital between 1986 and 1996. These were combined with estimates of the health benefits and costs of antenatal screening so that the cost effectiveness of universal, voluntary antenatal screening for HIV infection in England could be estimated. Main outcome measures: Lifetime, direct costs of medical care of childhood HIV infection; life years gained as a result of the screening programme; net cost per life year gained for different pretest counselling costs; and different prevalence rates of pregnant women who were unaware that they were HIV positive. Results: Estimated direct lifetime medical and social care costs of childhood HIV infection were £178 300 using a 5% discount rate for time preference (1995-6 prices). In high prevalence areas screening pregnant women for HIV is estimated to be a cost effective intervention with a net cost of less than £4000 for each life year gained. For areas with comparatively low prevalence rates, cost effectiveness could be less than £20 000 per life year gained, depending on the number of pregnant women who are unaware that they are infected and local screening costs Conclusions: Our results confirm recent recommendations that universal, voluntary antenatal HIV screening should be implemented in the London area. Serious consideration of the policy should be given for other areas in England depending on local prevalence and screening costs.

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

The objective of this study was to provide population-based estimates on the cost of HIV service provision in England and the use of dual or triple antiretroviral combination therapy. Contemporary cost estimates of treating HIV-infected individuals by clinical stage of HIV infection (indexed to 1995/96 prices) were linked to the number of diagnosed HIV-infected individuals using statutory medical services in England during 1996. Two cost measures were used: the first one was based on average hospital prices derived from a number of English HIV units. These results were compared with those estimated using standard unit costs obtained through specific costing studies performed at a national HIV referral centre. Overall annual expenditure on HIV service provision was estimated for different treatment scenarios as was expenditure by clinical stage of HIV infection. Using hospital prices, in 1996 the total annual cost estimate for HIV service provision amounted to pound sterling 131 m (range pound sterling 83 m to pound sterling 233 m), or pound sterling 150 m (95% CI pound sterling 126 m to pound sterling 173 m) using standard costs, if all patients with HIV disease were treated with AZT monotherapy. For all eligible patients to be treated with dual therapy, cost estimates amounted to pound sterling 161 m (range pound sterling 126 m to pound sterling 173 m) per year using hospital prices or pound sterling 180 m (95% CI pound sterling 156 m to pound sterling 203 m) when using standard cost estimates, while for triple therapy annual estimated expenditure amounted to pound sterling 204 m per year (range pound sterling 157 m to pound sterling 306 m) when using hospital prices or pound sterling 223 m (95% CI pound sterling 199 m to pound sterling 246 m) using standard costs. Increasingly costs will be more evenly distributed across the 3 stages of HIV infection, with a greater proportion of costs generated by HIV-infected individuals before the onset of AIDS. Using non-standardized hospital prices may systematically underestimate the real cost of service provision. Monitoring prospectively the use, cost and outcome of HIV service provision in a standardized format will provide information on the actual cost impact over the next 2-3 years of combination therapy compared with the scenario-based estimates produced in this paper.

Summary: The relationship between changes in hospital service interventions at St Mary's Hospital, London, reduced case fatality for patients with their first episode of Pneumocystis carinii pneumonia (PCP) and improved survival from diagnosis of AIDS was investigated for the period 1982-1991. Multivariate logistic regression models identified factors independently associated with episode survival; for those patients who survived their first episode of PCP, survival from time of diagnosis of AIDS was analysed using multivariate Cox's proportional hazards models. The case-fatality rate after 1987 was significantly lower for the 159 subjects. Median survival from diagnosis of AIDS increased significantly from 142 days to 554 days ( P =0.01). Improved survival of first episode of PCP was associated with it being the index diagnosis and having a haemoglobin at diagnosis of PCP greater than 12 g/dl. The presence of a concurrent AIDS-defining condition in patients who presented with an A-a gradient equal to or greater than 40 mmHg was associated with reduced episode survival, especially before 1987. For the 126 individuals who survived their first episode of PCP, death rates were lowest in patients treated with primary or secondary PCP prophylaxis and those who received zidovudine since their first episode of PCP. Survival in patients with HIV disease is better in patients who receive appropriate antiretroviral treatment of HIV infection and timely treatment of opportunistic illnesses. Early diagnosis of HIV-1 infection with early diagnosis and treatment of first episode of PCP was associated with improved episode survival. Subsequent medical follow up combined with PCP prophylaxis and zidovudine were significantly associated with long-term survival.

Objective: The aim of the study was to measure the use and estimate the cost of HIV service provision in England.

The aim of this study was to assess the correlation and average cost of total lymphocyte count compared with CD4 count as a broad estimate of immunosuppression in HIV-1 infected individuals. Spearman's partial rank correlation were calculated between total lymphocyte count, absolute CD4 count and CD4 per cent stratified by stage of HIV-1 infection for routinely collected samples. Data were collected prospectively from a T cell-subset register combined with clinical data obtained retrospectively from case notes of HIV-infected patients managed at St Mary's Hospital, London 1982-1991. Costing data were obtained through a survey of the departments of haematology and immunology (1989/90 prices). The correlation between 1534 paired absolute lymphocyte count and CD4 lymphocyte count was found to be high (R = 0.76). When analysed by stage of HIV infection, the correlation increased from R = 0.64 for asymptomatic patients, to R = 0.72 for patients with symptomatic non-AIDS HIV infection and R = 0.73 for AIDS patients. Correlations between absolute lymphocyte count and CD4 per cent were considerably weaker: R = 0.41 all paired counts; R = 0.32 for asymptomatic patients; R = 0.25 for symptomatic non-AIDS patients; R = 0.32 for AIDS patients. Average cost was pounds 8 per full blood count compared with pounds 38 per T-cell subset analysis. The high correlation between total and CD4 lymphocyte counts, especially for patients with symptomatic HIV disease, demonstrates the suitability of the use of total lymphocyte count in the absence of CD4 counts. Given the considerably lower prices of total lymphocyte counts compared with T-cell subset analysis, this is particularly relevant for developing countries.

This essay introduces a series of articles in which authors from Brazil, China, the Netherlands, and New Zealand describe their health care system. The juxtaposition of these four case studies reveals how different systems confront common problems. The four systems use widely differing combinations of the same financing tactics, and all are engaged in limiting inefficient increases in health services expenditures. Thus, they face the common problem of obtaining sufficient knowledge to convince health care professionals and the public that they have the ability to eliminate less cost-effective procedures and control the pace of medical innovation. This series also illustrates how the economic differences between countries result in different resource allocations for health care expenditures. The case studies underscore the fact that health systems must mount a country-specific response to common health challenges. Thus, health care providers must provide the most cost-effective, equitable, and acceptable health care possible within the parameters of their society.

The objectives of this study were firstly to estimate total lifetime care costs for an individual with HIV/AIDS, and secondly to estimate the total costs of caring people with HIV infection and AIDS in England and Wales between 1992 and 1997 inclusive. Questionnaires and monthly diaries were used to collate data on healthcare utilisation from patients with HIV infection over a 6-month period. These data were then used to estimate the annual total direct costs of care (stratified by disease stage), total lifetime costs of care, and present and future total national care costs for England and Wales. Costing data were obtained from providers of services throughout Greater London. In total, 235 patients with HIV infection were recruited from 2 clinics in Greater London. All costs were calculated in 1992-93 pounds sterling (pound; 1 pound = $US1.58, December 1995). Annual care costs were estimated at 4515 pounds ($US7134) for a person with asymptomatic HIV disease, 8836 pounds ($US13,961) for a person with symptomatic non-AIDS and 15 268 pounds ($US24,123) for a person with AIDS. Lifetime care costs were estimated at 84,522 pounds ($US133,545) per patient. The total costs of care for England and Wales were forecast to increase from 116,627,400 pounds ($US184,271,300) in 1992 to 162,638,100 pounds ($US256,968,200) in 1997. In conclusion, our study further emphasises the continued shift in hospital services from the inpatient sector to the outpatient sector. The importance of community care and informal care, in terms of the associated direct economic costs, is also highlighted. This emphasises the need for close collaboration between different agencies and strategic coordination of services. Finally, the study forecasts an increase in care costs in England and Wales during the 1990s.

The aim of the study was to investigate the association between infection with HIV-1 infection and a history of other sexually transmitted diseases (STD). We were able to match 1295 HIV-1 infected patients who attended St Mary's Hospital between 1985 and 1991 with 1273 seronegative controls on gender, sexual orientation, injecting drug use and age at time of test. The cases were 3 times more likely to have a history of ever having had another STD than the controls: multivariate conditional logistic regression showed that, after controlling for sexual behaviour, for known sexual contact with an HIV infected individual or AIDS patient or with a resident from a high HIV prevalence area, area of residence and for year of test, a history of gonorrhoea, syphilis, hepatitis B, genital herpes or genital warts were all significantly associated with HIV-1 seropositive status. These findings reinforce the need for HIV containment strategies to be promoted in conjunction with containment programmes for other STDs.

Objective : To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic. Design : Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London. Results : A total of 19242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years ; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years ; 95% CI, 29.2-35.8) ; mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (χ 2 =21.7, degrees of freedom = 1 ; P< 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events. Conclusions : Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Summary: AIDS-associated Kaposi's sarcoma (KS) is much more frequent in patients acquiring HIV infection via the sexual route. Epidemiological studies have confirmed the likely involvement of a sexually acquired cofactor in the pathogenesis of this form of KS. We have formulated a set of postulates, epidemiological and experimental, to fit a single unifying hypothetical agent. Chlamydia trachomatis is one of 3 agents to fit the epidemiological criteria. Our data suggest a possible association between increased IgG serum antibody to C. trachomatis and the occurrence of KS. Conversely, higher titres of IgG serum antibody to C. pneumoniae were associated with the absence of KS. We feel that it is important to study further the relationship between C. trachomatis and KS.

In order to describe the changing patterns of risk factors for HIV-1 transmission of patients using hospital services at an AIDS referral centre in Porto Alegre, southern Brazil, data on demographic characteristics, referral patterns and risk factors at time of first presentation were collected prospectively on 405 patients between October 1985 and September 1991. Overall HIV-related patient workload increased during the study period, as did the proportion of infected female patients seen (P0.05). Of all patients, 147 (36%) presented with symptomatic HIV disease and 77 (19%) presented with an AIDS defining condition; men were more likely to present with symptomatic disease than women. Approximately 156 (44%) of men were self-referred compared with 4 (8%) of the women (P0.0001). Of the 357 infected men, 82 (23%) were bisexuals; of the 26 heterosexually infected women, 7 (24%) had bisexual male partners. These data suggest the increasing importance of heterosexual HIV transmission in this hitherto 'low' prevalence area, with male bisexuals constituting an important route through which heterosexual females are being infected in this area. The data also suggest that heterosexual women in Southern Brazil do not perceive themselves to be at risk for HIV-1 infection.Unprotected homosexual intercourse and IV drug use were originally described as the predominant routes of HIV transmission in South America. Recent data, however, indicate that heterosexual transmission is becoming increasingly important in the region. With the goal of describing the changing patterns of risk factors for HIV-1 transmission, the authors collected prospectively data on demographic characteristics, referral patterns, and risk factors of patients at the time of first presentation to hospital services at an AIDS referral center in Porto Alegre, southern Brazil. The 357 male and 48 female patients presented over the period October 1985-September 1991. The overall HIV-related patient workload increased during the study period, as did the proportion of infected female patients. 44% of the men and 8% of women were self-referred. 36% of patients presented with symptomatic HIV disease and 19% with an AIDS-defining condition, with the men more likely than women to present with symptomatic disease. 23% of the infected men were bisexual; 24% of the heterosexually infected women had bisexual male partners. These findings suggest the importance of heterosexual HIV transmission in this area, with male bisexuals serving as an important route through which heterosexual females are being infected in the area. The data also suggest that heterosexual women in southern Brazil do not perceive themselves as being at risk for HIV-1 infection.

To describe the use of hospital-based services and associated costs over time for HIV-infected individuals by disease stage and year of treatment.Data on service use were abstracted from inpatient and outpatient case-notes of 459 HIV-infected patients (121 asymptomatic and 338 AIDS patients) treated at St Mary's Hospital, London between 1983 and 1989. Cost estimates were derived from a survey of the 37 departments involved with HIV-related care. The number and type of admissions and outpatient visits, referral and discharge venues, number and type of tests and procedures performed, drugs prescribed and associated costs for the study period were the outcome measures used.Most patients were homosexual men. At the time of first HIV-related visit, 80.7% lived in London. Most day cases and planned admissions were organized through the outpatient clinic; 31% of emergency admissions were initiated by patients themselves. For people with AIDS the number of day case admissions increased while planned admissions decreased. There was a marked reduction in the duration of inpatient stays, especially for AIDS patients. Costs associated with inpatient care decreased concomitantly. The number of outpatient visits for patients with symptomatic disease increased, resulting in increased outpatient expenditure. Asymptomatic patients had fewer inpatient tests, while outpatient tests did not change over time; costs followed similar patterns. Mean inpatient and outpatient drug-days prescribed did not change nor did average inpatient drug-costs although outpatient drug-costs increased. Inpatient tests performed on symptomatic non-AIDS patients decreased, while mean outpatient tests increased; average costs followed similar patterns. Inpatient drug-days prescribed and costs remained the same, while outpatient drug-days and average drug-costs increased during the study period. For AIDS patients, the number of inpatient tests performed and their average costs decreased but outpatient tests performed increased, though their average costs remained the same. Mean inpatient drug-days prescribed and average drug-costs decreased, while number of outpatient drug-days prescribed and average drug-costs increased markedly over time. For each disease category, expenditure on admissions and related tests decreased over time, while expenditure on outpatient visits and drug-costs increased.The shift from an inpatient- to an outpatient-based service has resulted in fewer patients being investigated and treated in hospital and more as outpatients. This has resulted in a reduction of inpatient-related costs, while outpatient-related costs have increased. The overall contribution of drug-costs to the total cost has increased greatly over time. With the anticipated advent of new antiviral compounds, the importance of ascertaining their effectiveness as well as their efficacy will become crucial.

In recent years planners of health services have been urged to design a comprehensive range of services which are responsive to the needs of people with HIV infection and AIDS and those who might be worried about HIV transmission. Models of care have been tried and tested and pilot services which aim to inform the development of the services scrutinised. Though in general this community care is seen as the preferred option with adequate backup support from acute services. More than anything, there is a recognition that the service must be responsive to local needs. Because patterns of HIV infection and prevalence of AIDS are so variable there is no substitute for the systematic development of timely local knowledge as the basis of local planning.

Among 347 AIDS patients seen at St Mary's Hospital, London between 1983 and 1989, cytomegalovirus (CMV) disease was observed in 75 (22%). Of these, 58 (77%) had CMV retinitis, 26 (35%) CMV colitis, and 12 (16%) had CMV infection diagnosed at other sites. Relapse occurred in 71%. A favourable response to the use of ganciclovir as induction therapy for CMV retinitis was observed in 92%. Relapse of CMV retinitis occurred in 54% at a median time of 97 days. Neutropenia was the most frequent and serious side-effect of ganciclovir, 76% patients having neutrophil counts less than 1.0 x 10(9)/l and 48% less than 0.5 x 10(9)/l at some stage of therapy. Thrombocytopenia was also common, and platelet counts of less than 50 x 10(9)/l occurred in 43% patients on ganciclovir. The concurrent use of zidovudine made the development of severe neutropenia and thrombocytopenia more likely. Median survival following the diagnosis of CMV disease increased from 5-8 months between 1984 and 1987, to over 12 months in 1988. Patients with CMV colitis had a worse prognosis than patients with CMV retinitis, with median survival of 4.5 and 7 months respectively. In conclusion, CMV is an important opportunist infection in AIDS and both the disease and its treatment cause considerable morbidity. Hence, it is important to develop more effective and less toxic forms of therapy for CMV infection.

OBJECTIVE--To study the changes in morbidity, mortality, and survival patterns in a population of patients with AIDS in the United Kingdom from 1982 to 1989. DESIGN--A retrospective analysis of inpatient and outpatient records of patients with AIDS. SUBJECTS--347 Patients with AIDS, predominantly homosexual or bisexual men. SETTING--Departments of immunology and genitourinary medicine, St Mary's Hospital, London. MAIN OUTCOME MEASURES--Presenting diagnosis of AIDS, occurrence of other opportunist diseases, cause of death, and survival since AIDS was diagnosed, in particular for those patients with Pneumocystis carinii pneumonia or Kaposi's sarcoma. RESULTS--The overall proportion of patients who developed P carinii pneumonia dropped from 56% (20/36) in 1984 to 24% (46/194) in 1989, although it has remained the index diagnosis in about half of new patients. Kaposi's sarcoma has decreased as index diagnosis from 30% (20/67) to 20% (15/74) over the same period, though the prevalence has remained constant at around 35%. P carinii pneumonia accounted for 46% (16/35) of known causes of death in 1986 but only 3% (1/31) in 1989. Conversely, deaths due to Kaposi's sarcoma rose from 14% (1/7) to 32% (10/31) between 1984 and 1989. Lymphoma accounted for an increased proportion of deaths among these patients with 16% (5/31) of deaths in 1989. Their median survival increased from 10 months in 1984-6 to 20 months in 1987. CONCLUSIONS--The changing patterns of disease in patients with AIDS have important implications both for health care provision and future medical research. Medical and nursing provision must be made for the increased morbidity of these diseases and the increased survival of these patients. Research should now be directed towards developing effective treatments for the opportunist infections which are currently more difficult to treat, the secondary malignancies of AIDS, as well as more effective immunorestorative treatments. Future changes in disease patterns must be recognised at an early stage so that resources can be adequately planned and allocated.

Trends in the number of tests for HIV-1 antibody at a London sexually transmitted diseases clinic showed substantial changes between September 1985 and June 1988. From an average of 100 tests per month between September 1985 and August 1986, the average increased to 365 tests per month for September 1986 to August 1987. This levelled off at 243 tests per month between September 1987 and June 1988. The average number of positive tests per month between September 1985 and June 1988 remained constant, though the number of seropositive tests in females increased. Male and female populations displayed similar temporal patterns. The greatest increase was seen in the tests generated by heterosexual males and females with no other risk factors. This group generated 42% of the 8012 tests performed during the study period. The Clinic's catchment area predominantly included London and surrounding areas and temporal patterns were similar for residents from each of the Thames Regions. The temporal patterns observed coincided with periods of increased media attention on HIV infection/AIDS and involved campaigns by the popular press, television, Department of Health Education Authority. The increase in tests during the time of maximum media exposure, the subsequent plateau at a level substantially higher compared with the period preceding the media campaigns and the large increase in heterosexual males and females tested, all suggest that the campaigns have contributed to increasing awareness of HIV infection/AIDS as a major contemporary public health problem.

To assess the cost-effectiveness of highly active antiretroviral therapy (HAART) compared with two nucleoside reverse transcriptase inhibitors (NRTIs) for HIV infected individuals.Different data sources on the clinical effects and costs of treatments were combined using a Markov model.English HIV treatment centres. Perspective UK public finance.HAART - dual NRTI therapy plus a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor - vs. dual NRTI therapy.Hypothetical cohorts of 1000 individuals infected with HIV. Outcome measures Projected life expectancy, cost-effectiveness in UK pound per life-year saved and per quality-adjusted life-years (QALYs) saved.Assuming a 2-year additional treatment effect of therapy with HAART produced incremental cost-effectiveness ratios of pound14 602 per life-year saved and pound17 698 per QALY saved.The results were sensitive to a number of assumptions including the cost of HAART and the discount rate, but they suggest that the use of HAART in England is at least moderately cost-effective compared with treatment with two NRTIs alone.

Background: Recently the Department of Health announced the introduction in England of voluntary universal HIV screening in early pregnancy to prevent vertical transmission. New data have shown the importance of HIV infection in infants born to mothers who were HIV-negative in early pregnancy and who acquired HIV later in pregnancy or during lactation. This requires consideration of repeat testing in late pregnancy and testing of partners of pregnant women (expanded antenatal HIV testing). Objective: To estimate cost effectiveness of expanded antenatal HIV testing in London (England) within the framework of universal voluntary HIV screening in early pregnancy. Design: Incremental cost-effectiveness analysis. Methods: Cost estimates of service provision for HIV-positive children and adults by stage of HIV infection were combined with estimates of health benefits for infants and parents and with costs of counselling and testing (testing costs). In a pharmacoeconomic model cost effectiveness was estimated for expanded antenatal HIV testing in London for universal and selective strategies. Results: Testing costs in the plausible range of pound4 to pound 40 translate into favourable incremental cost-effectiveness estimates for expanded antenatal HIV testing in London which is already at low numbers of vertical transmissions averted per 100000 pregnant women who test HIV-negative in early pregnancy. Favourable cost effectiveness for universal expanded testing would require testing costs in the lower range, whereas selective expanded testing may produce favourable cost effectiveness at testing costs close to pound 40. Conclusion: Based on pharmaco-economic considerations, the authors believe that implementation of expanded HIV testing in London should be considered. (C) 2000 Lippincott Williams & Wilkins.

To estimate the cost effectiveness of universal screening for HIV of pregnant women in Amsterdam.Pharmaco-economic model calculation.An estimate was made of the minimal and maximal prevalences of undiagnosed HIV infection during pregnancy for the whole of Amsterdam, based on epidemiological data from observation among pregnant women in two Amsterdam hospitals and one obstetrical practice. The calculation was based on universal screening with an ELISA test. The interventions after screening comprised pharmacotherapy during pregnancy, delivery by caesarean section and breast-milk substitution. The issues of pharmaco-economic analysis were whether or not costs were reduced and net costs per year of life gained; the question was also studied at what lifetime costs of care for HIV infected children the net costs would be nil (costs equal benefits).Universal HIV screening in Amsterdam required a total investment of about Dfl 300,000.-per annum. In many of the analysed options for HIV screening the financial profits exceeded the investment. Variation of assumptions showed that the net costs of HIV screening under all conditions investigated would remain below Dfl 1,200.-per life year gained.Universal HIV screening of pregnant women in Amsterdam showed a favourable cost effectiveness. The calculations indicated a possibility of reducing costs.

To investigate the relationship between changing morbidity patterns, the use of hospital services by HIV-infected patients and the uptake of antiretroviral therapy (ART) in England.Prospective serial cross-sectional analyses based on data collected through the National Prospective Monitoring System (NPMS), a multi-centre prospective monitoring system.HIV-infected patients seen in 10 clinics, five London and five non-London, during the three semesters, 1 January 1996 to 30 June 1997.The mean use of hospital services per patient-year, mean new HIV-related opportunistic illnesses per 1000 patient-years and percentage uptake of ART.The use of inpatient services changed particularly among AIDS patients. The mean number of inpatient days for AIDS patients decreased from 19.7 [95% confidence interval (CI) 13.7-25.7] in 1996 to 11.2 (95% CI 6.1-15.6) per patient-year in 1997. Concurrently the number of new AIDS-defining events decreased significantly from 567 (95% CI 529-607) to 203 (95% CI 183-225) per 1000 patient-years. The overall uptake of ART increased significantly from 33% (95% CI 31-35%) to 50% (95% CI 48-52%), and a switch from mono or dual to triple therapy or quadruple or more therapy was observed. However, by mid-1997 only 29% (95% CI 26-32%) of asymptomatic patients and 51% (95% CI 49-54%) of patients with symptomatic non-AIDS were on ART, compared with 69% (95% CI 66-71%) of AIDS patients.The observed reduction in new AIDS-defining events has led to a reduction in the need for inpatient hospital care and has been associated with an increased uptake of ART, including a switch to triple therapy. All of these factors are likely to have contributed to the observed reduction in mortality among English AIDS patients. As the overall uptake of ART remained relatively low in English centres further improvements can be anticipated. However, the medium to long-term effects of these treatment regimens will need to be closely monitored.

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

The aim of the study was to measure the use and estimate the cost of HIV service provision in England.Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996.The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS.Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.

Phosphorylation of the inactivation gate of a K+ channel (Kv3.4) by protein kinase C (PKC) slows rapid N-type inactivation. To demonstrate that such an effect could occur under more physiological conditions, Kv3.4 and a metabotropic serotonin (5-HT) receptor were coexpressed in Xenopus oocytes. Application of 5-HT 10 microM to these oocytes produced two main effects: 1) Enhanced activity of endogenous Ca(++)-dependent Cl- channels; and 2) Kv3.4 currents exhibited significantly slower inactivation than the control currents (time constants at +50 mV: 7.1 +/- 0.6 ms and 14.7 +/- 3 ms, before and after 5-HT, respectively). These results are consistent with the presence of receptor-coupled activation of phospholipase C. 5-HT had little or no effect on Kv3.4 current kinetics when four N-terminal serines were mutated to alanine. Peak currents exhibited, however, a slow run-down. This study demonstrates that physiological activation of PKC may regulate K+ channel inactivation by a direct action.

Protein kinase C inhibits inactivation gating of Kv3.4 K+ channels, and at least two NH2-terminal serines (S15 and S21) appeared involved in this interaction (Covarrubias et al. 1994. Neuron. 13:1403–1412). Here we have investigated the molecular mechanism of this regulatory process. Site-directed mutagenesis (serine → alanine) revealed two additional sites at S8 and S9. The mutation S9A inhibited the action of PKC by ∼85%, whereas S8A, S15A, and S21A exhibited smaller reductions (41, 35, and 50%, respectively). In spite of the relatively large effects of individual S → A mutations, simultaneous mutation of the four sites was necessary to completely abolish inhibition of inactivation by PKC. Accordingly, a peptide corresponding to the inactivation domain of Kv3.4 was phosphorylated by specific PKC isoforms, but the mutant peptide (S[8,9,15,21]A) was not. Substitutions of negatively charged aspartate (D) for serine at positions 8, 9, 15, and 21 closely mimicked the effect of phosphorylation on channel inactivation. S → D mutations slowed the rate of inactivation and accelerated the rate of recovery from inactivation. Thus, the negative charge of the phosphoserines is an important incentive to inhibit inactivation. Consistent with this interpretation, the effects of S8D and S8E (E = Glu) were very similar, yet S8N (N = Asn) had little effect on the onset of inactivation but accelerated the recovery from inactivation. Interestingly, the effects of single S → D mutations were unequal and the effects of combined mutations were greater than expected assuming a simple additive effect of the free energies that the single mutations contribute to impair inactivation. These observations demonstrate that the inactivation particle of Kv3.4 does not behave as a point charge and suggest that the NH2-terminal phosphoserines interact in a cooperative manner to disrupt inactivation. Inspection of the tertiary structure of the inactivation domain of Kv3.4 revealed the topography of the phosphorylation sites and possible interactions that can explain the action of PKC on inactivation gating.

The relationship between changes in hospital service interventions at St Mary's Hospital, London, reduced case fatality for patients with their first episode of Pneumocystis carinii pneumonia (PCP) and improved survival from diagnosis of AIDS was investigated for the period 1982-1991. Multivariate logistic regression models identified factors independently associated with episode survival; for those patients who survived their first episode of PCP, survival from time of diagnosis of AIDS was analysed using multivariate Cox's proportional hazards models. The case-fatality rate after 1987 was significantly lower for the 159 subjects. Median survival from diagnosis of AIDS increased significantly from 142 days to 554 days (P=0.01). Improved survival of first episode of PCP was associated with it being the index diagnosis and having a haemoglobin at diagnosis of PCP greater than 12 g/dl. The presence of a concurrent AIDS-defining condition in patients who presented with an A-a gradient equal to or greater than 40 mmHg was associated with reduced episode survival, especially before 1987. For the 126 individuals who survived their first episode of PCP, death rates were lowest in patients treated with primary or secondary PCP prophylaxis and those who received zidovudine since their first episode of PCP. Survival in patients with HIV disease is better in patients who receive appropriate antiretroviral treatment of HIV infection and timely treatment of opportunistic illnesses. Early diagnosis of HIV-1 infection with early diagnosis and treatment of first episode of PCP was associated with improved episode survival. Subsequent medical follow up combined with PCP prophylaxis and zidovudine were significantly associated with long-term survival.

This study estimates the current and future hospital resources for AIDS patients in the European Union (EU), using multinational scenario analysis (EU Concerted Action BMH1-CT-941723). In collaboration with another EU-project ('Managing the Costs of HIV Infection'), six national European studies on the utilization of hospital care for AIDS have been selected to provide the data for our analysis. The selection criteria involve recentness, quality, comparability, accessibility and representativeness. Baseline hospital resource utilization is estimated for hospital inpatient days and outpatient contracts, using a standardized approach controlling for two severity stages of AIDS (chronic stage and late stage). The epidemiological part of the study is based on standard models for backcalculating HIV incidence and projecting AIDS incidence, prevalence and mortality. In the next step, baseline resource utilization is linked to epidemiological information in a mixed prevalence and mortality-based approach. Several scenarios render different future epidemiological developments and hospital resource needs. For the year 1999, hospital bed needs of 10,000-12,700 in the EU are indicated, representing an increase of 20-60% compared to the estimated current (1995) level. The projected range for 1999 corresponds to a maximum of 0.65% of all hospital beds available in the EU. The growth in the number of outpatient hospital contacts is projected to possibly exceed that of inpatient days up to 1.82 million in 1999. Our methodology illustrates that estimation of current and future hospital care for AIDS has to be controlled for severity stages, to prevent biases. Further application of the multinational approach is demonstrated through a 'what-if' analysis of the potential impact of combination triple therapy for HIV/AIDS. Estimation of the economic impact of other diseases could as well benefit from the severity-stages approach.

Background Contracting for HIV service provision is now an established part of the National Health Service commissioning process. AIDS is a heterogeneous condition, comprising various opportunistic illnesses which require different services and which have different resource implications. This study describes the use of hospital services and associated costs for the management of different AIDS defining conditions. Method A retrospective case-notes analysis was performed, of 335 Al DS patients treated at St Mary's Hospital, London, between 1 January 1983 and 30 September 1989, as well as a costing exercise of 37 clinical departments to calculate HIV-related costs. Results Mean age at time of AIDS diagnosis for these predominantly homosexual men was 38 years. Use of services varied, as did associated costs - from £8163 per patient-year for patients with Constitutional Disease to £42124 for those with Cytomegalovirus Disease. Most diagnostic categories showed a shift over the study period from an in-patient- to an out-patient-based service. Patients diagnosed after 1987 had overall lower costs per patient-year compared with those diagnosed before 1987; whereas out-patient costs for most groups had increased, in-patient expenditure decreased. For most categories, in-patient care costs and out-patient drugs prescribed provided the greatest proportion of total costs. Average costs per in-patient day ranged from £334 to £433, and average costs per out-patient visit ranged from £99 to £411 for different AIDS defining conditions. Conclusions Different opportunistic illnesses of symptomatic HIV disease have different treatment and resource implications. Casemix will need to be taken into consideration when contracting for HIV services, including extra-contractual referrals.

The aim of this study was to evaluate the survival patterns and use and cost of hospital services of AIDS patients treated with azidothymidine (AZT) at St Mary's Hospital, London. A retrospective analysis of inpatient and outpatient case notes was performed, as was a survey of HIV-related care costs in 37 clinical departments. Of the 183 AIDS patients managed between 1 January 1987 and 30 September 1989, 132 were treated with AZt and 51 without AZT. Mean age at time of AIDS diagnosis for these predominantly homosexual men was 37.5 years for those treated with AZT compared with 40.7 years for those not on AZT. Median survival time from date of AIDS diagnosis was significantly longer for patients treated with AZT compared with those not treated with AZT (23 vs 13.5 months, P = 0.0004). The interval from diagnosis of HIV infection to date of AIDS diagnosis did not differ significantly between groups. Inpatients and outpatients use of services was greater for those receiving AZT than for those who did not. Costs reflected this increase use of services and the costs for those treated with AZT were pounds 3061 per AIDS patient-year higher compared with AIDS patients not receiving AZT; 36% of this cost was directly attributable to the cost of AZT itself. The introduction of AZT into routine clinical practice seems to have been a cost-effective intervention though it has been associated with an increased use of hospital services and associated costs per AIDS patient-year as well as increases survival time from AIDS diagnosis.

The objectives of this study were to describe the expressed needs for community services of HIV-infected individuals by disease stage, gender and transmission category and the barriers which prevent the receipt of such services. Structured interviewer-administered questionnaires concerning a 6-month retrospective period were used to obtain information on need for community services and problems which prevented the receipt of services. The study sample included 70 homosexual men with asymptomatic HIV disease, 42 homosexual men with symptomatic non-AIDS, 53 homosexual men with AIDS, 23 heterosexual men, 29 heterosexual women, 9 male and 9 female injecting drug users. The main outcome measures were the extent to which needs for community services were met and person/service combinations for which problems or barriers prevented the receipt of community services. On average, subjects expressed a need for 10 categories of community services over the 6-month period: homosexuals expressed a mean of 10, heterosexuals 10, injecting drug users 11, subjects with asymptomatic HIV infection 9, subjects with symptomatic non-AIDS 11, subjects with AIDS 13, men 9 and women 14. A total of 58% of community service needs were always met, 6% were rarely not met, 16% were sometimes not met, 6% were often not met and 14% were not met at all. The extent to which subjects felt that their needs were met was similar for the different study groups, but the needs of women were met somewhat less frequently than those of men. Similarly, people with AIDS felt that their needs were met slightly less often. Reported levels of unmet need were high for a wide range of services. The most common reason subjects gave for not having received a community service for which they expressed a need was ignorance of where or how to obtain the service. This was mentioned in one-third of all such cases. Anxieties over the competence with which a service would be rendered was mentioned in 13% of cases and long waiting times in 11%. The frequencies of unmet need for many community services were high and often seemed to arise either from a lack of awareness on the part of subjects on how and where services could be obtained or from doubts about the relevance of services offered. Both of these barriers should be surmountable through the provision of better information to patients, extending user involvement in service development and the better co-ordination of service delivery through care management approaches.

The aim of this study was to describe the sexual behaviour of a sample of genitourinary medicine (GUM) clinic attenders, 5 years after the launch of the UK government HIV media campaigns. A gender-specific and anonymous cross-sectional self-completion questionnaire was modified from the National Survey of Sexual Attitudes and Lifestyle and completed by 250 men and 250 women. The majority of the respondents were in their twenties, lived in London and were employed or students. Sixty-eight per cent of the men reported that one or more of their last 3 partners was not a regular partner. For those men whose last sexual encounter was with a new partner, 27% of heterosexuals and 33% of homosexuals reported using a condom. Fifty-one per cent of women reported one or more non-regular partners among their last 3 partners. For those women whose last sexual encounter was with a new partner, 43% of heterosexuals and 75% of bisexuals used a condom. Seventy-eight per cent of men and 75% of women had had a previous sexually transmitted disease (STD). These findings highlight the persistence of practices associated with the risk of contracting or transmitting HIV infection and which needs to be addressed in future educational campaigns. The GUM clinic population is an important population to monitor over time, either by longitudinal or serial cross-sectional studies. The results of this study provide a baseline against which to gauge the effects of future educational interventions.

The aim of the study was to describe survival patterns of Southern Brazilian AIDS patients: 224 predominantly working class AIDS patients were treated in an AIDS referral centre in Porto Alegre between October 1986 and September 1991. The caseload increased progressively, as did the number of female AIDS cases treated at the Hospital during the study period. Self-referred patients were more likely to present with an AIDS defining condition ( P < 0.03) and they ( n = 106) had significantly worse survival patterns compared with patients referred by other health care professionals ( n = 112; P < 0.04). Median survival from the time of AIDS diagnosis was 5 months which did not change significantly during the study period ( P = 0.38). Patients ( n = 42) presenting with opportunistic infections other than mycobacterial disease ( n = 42), Pneumocystis carinii pneumonia ( n = 37) or candidiasis ( n = 18), had significantly worse survival patterns ( P = 0.001). Patients treated with zidovudine ( n = 33) survived significantly longer from time of AIDS diagnosis than those not on zidovudine ( n = 185; P = 0.0002). No significant survival differences were observed from time of AIDS diagnosis between those who commenced on zidovudine before developing AIDS ( n = 17) and those who were treated with zidovudine since diagnosed with AIDS ( n = 16; P = 0.80). During the study period zidovudine was only available through private prescriptions. Survival of Southern Brazilian AIDS patients has not improved: earlier access to HIV-related services and the provision of effective and affordable therapeutic interventions are two measures which could improve future survival patterns.

OBJECTIVE To describe the use of services and associated costs for HIV-infected patients by stage of infection in the context of changing patterns of presentation and survival. METHODS A retrospective analysis of inpatient and outpatient case-notes of 335 AIDS patients and a survey of HIV-related care provided by 37 departments at St Mary's Hospital, London. Survival from time of diagnosis of AIDS, time from diagnosis of HIV infection to AIDS, and use and costs of services per patient-year were outcome measures. RESULTS During the study period 1 January 1982 to 30 September 1989, 152 AIDS patients were diagnosed before 1987 (group 1) and 183 since 1987 (group 2), most of whom were homosexual men. The median interval of first HIV-related visit to diagnosis of AIDS increased from 0 (group 1) to 264 days (group 2; P < 0.0001). Median survival from AIDS diagnosis increased from 14.6 (group 1) to 21.0 months (group 2; P < 0.02). Group 2 patients used fewer inpatient services than group 1 patients irrespective of disease stage. Symptomatic patients in group 2 used more outpatient services than group 1 patients. Total HIV-related expenditure was lower for patients without AIDS in group 2 than in group 1, while expenditure for AIDS patients remained similar. CONCLUSION Earlier patient presentation, a shift from inpatient- to outpatient-based clinical care and increased survival from time of AIDS diagnosis has occurred. Increased drug expenditure was offset by reduced inpatient expenditure. Total expenditure per patient-year was stable; increased survival and introduction of new drugs will increase future lifetime use of resources.

For 227 episodes of Pneumocystis carinii pneumonia (PCP) treated at St Mary's between 1983 and 1989, factors predictive of fatal outcome were age, haemoglobin levels, peripheral lymphocyte count and alveolar-arterial oxygen gradient. Case fatality for the 47 empirically-treated episodes was significantly higher compared with the 180 cytologically proven episodes (55% vs 18%, χ2 = 25.7, P2 = 4.5, P9/l vs 0.87×109/l, P=0.05) and oxygen gradient (77.7 mmHg vs 58.9 mmHg, P Case fatality decreased significantly over time ( b = –0.39, SE=0.14, P

Factors determining the outcome of an episode of Pneumocystis carinii pneumonia (PCP) in 149 AIDS patients treated at St Mary's Hospital were identified and their importance on improved survival evaluated between 1984 and 1989. The proportion of fatal episodes of PCP decreased over time. Fatal compared with non-fatal episodes had lower mean alveolar-arterial oxygen gradient (82.5 mmHg vs 53.8 mmHg, P9/l vs 0.92 times 109/l, P=0.05) and more coinfections (31% vs 5%, P Patients were being treated at an earlier stage in their disease course as indicated by their reduced alveolar arterial oxygen gradient. This is due either to earlier patient presentation, earlier medical diagnosis or both. The widespread introduction of zidovudine and PCP prophylaxis may further contribute to improve morbidity and mortality patterns in the future.

In this multicenter study 191 practitioners treated 532 patients with coronary artery disease and chronic stable angina pectoris by isosorbide-5-mononitrate (IS-5-MN), 20 mg 2-3 times daily. At the end of this period the frequency of anginal attacks was reduced by 83% and nitroglycerin consumption by 85.7% (p less than 0.0001). 40.1% of the patients categorized this treatment as very good, 28.6% as excellent and 23% as good. Serious adverse effects were observed in 2% of the patients and 6.4% of the patients discontinued treatment during the study because of inefficacy, infarction, death, or adverse effects. At the end of the study 90.2% of the patients were still on IS-5-MN. In conclusion, IS-5-MN is an effective treatment for patients with chronic stable angina pectoris. It is well tolerated, with minimal side effects.

Integrated intervention strategies, appropriate to the specific socioeconomic context, are required to address the needs of the 18 million adults projected to be infected with the human immunodeficiency virus (HIV) by the year 2000. Such interventions must operate on two levels. The first is aimed at minimizing the devastating effects of HIV and acquired immunodeficiency syndrome (AIDS) on individuals, while the second is geared toward halting HIV transmission in populations. The median two-year survival time for people with AIDS had doubled from 10 months before 1987 to 20 months in 1990, primarily because of treatments such as zidovudine that slow down the rate of virus replication, but AIDS patients who survive longer develop more intractable opportunistic infections than in the past. Viral transmission throughout populations can be halted only through a comprehensive strategy that addresses agent, host, and environmental factors in a complementary manner. For example, whether or not high-risk individuals will be willing and able to adopt safer sex practices depends, in large part, on the social, economic, and psychological forces acting on and within those individuals. Finally, public attitudes toward sexuality, drug use, and racial discrimination comprise the moral context in which AIDS prevention strategies must be implemented. The mass media, which have already created public awareness of the problem and corrected many misconceptions, must continue to motivate individuals to adopt behavioral changes that reduce the risk of HIV infection.