Cost-effectiveness of prevention referrals for high-risk HIV-negatives in San Francisco.

We retrospectively assessed the cost-effectiveness of providing prevention referrals to high-risk seronegatives at HIV test sites in San Francisco. We examined the costs and effects from the perspectives of society and the San Francisco Department of Public Health (SFDPH). Cost categories assessed included referral materials, counsellor training and time required to make referrals, prevention services and the value of client time. Effect data are drawn from a study of 289 high-risk seronegatives and the published literature, and are applied to a city-wide caseload of 6,626 high-risk seronegatives. We estimate that a city-wide programme in San Francisco averts two HIV infections per year and yields net savings to society of $43,765, with a cost to the SFDPH of $20,738 per HIV infection averted. We conclude that providing HIV prevention referrals to high-risk seronegatives receiving antibody testing imposes significant costs, but has attractive cost-effectiveness when applied to a large high-risk population.

Barriers to getting needed services for Ryan White CARE clients.

To determine why HIV-infected persons do not access needed services, we interviewed clients of Ryan White CARE-funded agencies in San Francisco, San Mateo and Marin Counties. From July to September 1996, we interviewed 519 clients receiving services at 65 CARE-funded sites. Just over half the clients (54.5%) had at least one unmet service need in the previous four months; persons in an unstable living situation and those with lower perceived health status were significantly more likely to have an unmet need. For persons with unmet needs, agency barriers were most common (54.0%), followed by emotional issues (44.8%), lack of information (44.0%) and financial/practical barriers (19.4%). None of the client characteristics (sex, race/ethnicity, age, living situation, perceived health status and risk group) were consistently or significantly (p < 0.05) associated with specific barriers. We believe that the similarity between clients with and without unmet needs reflects the success of CARE in eliminating many barriers. However, the persistence of certain barriers and lack of sub-group-specific barriers suggests the need for individualized interventions to improve service delivery, publicize service availability and address the emotional barriers to accessing HIV-related care.

Postexposure prophylaxis for HIV after sexual assault.

PIP: This paper presents the findings of a retrospective review of charts of sexual assault survivors who were offered postexposure prophylaxis (PEP) between April 1998 and November 1999 at San Francisco General Hospital. The total cost of PEP medications was also computed. Overall, it is noted that one-third of the 367 sexual assault survivors chose to initiate PEP. Men who were anally raped are at the highest risk for HIV transmission and were most likely to initiate PEP. Among women, on the other hand, those who were non-White and homeless were less likely to accept PEP. In the context of cost, the total per-person cost of medication dispensed during the study period (US$65 per person offered PEP) is comparable to other medications offered routinely following sexual assault, such as azithromycin for chlamydia prophylaxis (US$43 per treatment). However, there is no definitive evidence that PEP is effective in preventing HIV seroconversion after sexual assault. It is suggested that in developing rational policy recommendation offering HIV PEP after sexual assault, further studies are needed to better delineate the rates of HIV seroprevalence among sexual assailants, the efficacy of PEP after sexual exposure, and the psychological benefits or harm incurred by the sexually assaulted patients.^ieng

Linking clients from HIV antibody counseling and testing to prevention services.

The effectiveness of HIV antibody counseling and testing as a prevention intervention is limited: persons testing seronegative do not usually change their risk behaviors, some actually increase their risk behaviors, and decreases in risk behaviors are usually short-lived. Referrals to additional prevention and other needed services are therefore recommended, although the extent and determinants of referral provision for persons testing seronegative are unknown. We assessed the prevalence of referrals and the association between risk behaviors and prevention referrals among seronegatives. We reviewed HIV testing and referral data on all persons receiving confidential seronegative test results in San Francisco (SF) in the first 10 months of 1995 (n = 5,595), and gathered more detailed referral information at the municipal STD clinic from November 1995 through May 1996 (n = 747). The overall prevalence of referrals was low: a referral was given to 19.1% of the SF sample and 10.6% of the STD clinic sample; 15.4% of the SF sample and 5.9% of the STD clinic sample received a prevention referral. Injection drug users (IDUs) were the most likely to receive a prevention referral (48.5% of SF IDUs, 36.4% of STD clinic IDUs); men having sex with men and women with high-risk partners were also more likely to get a prevention referral than others. For SF IDUs, unsafe sex and needle sharing were not associated with an increased likelihood of receiving a prevention referral. Opportunities to link high-risk clients from counseling and testing to HIV prevention services are being missed. The referral component of HIV counseling and testing should be improved.

Projected incidence of AIDS in San Francisco: the peak and decline of the epidemic.

To predict the incidence of AIDS from 1978 through 1998 in San Francisco, we developed a model that combined annual HIV seroconversion rates for homosexual and bisexual men and for heterosexual injecting drug users with estimates of the incubation period distribution between HIV seroconversion and AIDS diagnosis and with estimates of the size of the at-risk populations. Our model assumed the availability of antiretroviral therapy at the efficacy level of zidovudine monotherapy. The annual number of new AIDS cases is estimated to have peaked at 3332 in 1992, and is projected to decline to 1196 annually by 1998. Although the projected number of cases decreased steadily during this period for homosexual and bisexual men, the projected number of cases for injection drug users, women, and persons with other risks increased between 1993 and 1998. The decline in the incidence of AIDS in San Francisco reflects the dramatic reductions in new HIV infections that occurred a decade previously and that were achieved as a result of significant changes in high-risk behaviors, primarily among homosexual and bisexual men. Changes in HIV seroincidence must be factored in before attributing the decrease in AIDS incidence to more effective combination antiretroviral treatment.

Prevention of Pneumocystis carinii pneumonia: who are we missing?

OBJECTIVE: To obtain population-based information on the characteristics of persons who were not receiving chemoprophylaxis against Pneumocystis carinii pneumonia (PCP) by examining the use of primary and secondary PCP prophylaxis among San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993. DESIGN: Retrospective medical record review. SETTING: Medical charts were obtained from San Francisco hospitals and outpatient facilities at which AIDS patients received their initial AIDS diagnosis. PARTICIPANTS: San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993. MAIN OUTCOME MEASURES: Use of primary and secondary PCP prophylaxis. RESULTS: Of the 326 eligible patients, 35% received primary PCP prophylaxis. Non-whites were significantly less likely to have received primary PCP prophylaxis than white patients [22 versus 40%, respectively; odds ratio (OR), 0.49; 95% confidence intervals (CI), 0.28-0.87]. Uninsured individuals-were also less likely to have received primary PCP prophylaxis than those with insurance (18 versus 41%; OR, 0.35; 95% CI, 0.17-0.73). The sociodemographic characteristics of patients who did and did not receive secondary PCP prophylaxis did not differ significantly. The most frequently cited reasons for not receiving primary PCP prophylaxis were that patients were unaware of their infection with HIV or were not receiving regular medical care. CONCLUSIONS: Barriers to receipt of PCP prophylaxis exist and are resulting in cases of preventable disease and unnecessary medical costs. Interventions to increase counseling, testing, and referral to medical care for persons at high risk for HIV infection are needed.

Cryptosporidiosis among patients infected with human immunodeficiency virus. Factors related to symptomatic infection and survival.

The authors reviewed the medical records of 194 human immunodeficiency virus (HIV)-positive patients newly diagnosed with cryptosporidiosis and all 3,564 patients with newly diagnosed acquired immunodeficiency syndrome (AIDS) at San Francisco General Hospital for the period 1986-1992. The study was designed to address three questions: 1) How do AIDS patients who present with cryptosporidiosis differ from other patients with AIDS? 2) What factors are associated with survival among AIDS patients with newly diagnosed cryptosporidiosis? 3) Does a diagnosis of cryptosporidiosis impact survival after AIDS diagnosis? A total of 194 cases of cryptosporidiosis among HIV-infected patients were identified during the study period. Of the 194 patients, 109 (56%) had no prior diagnosis of AIDS. These 109 patients represented 3.1% of the 3,564 newly diagnosed cases of AIDS in the same period. Among the 134 patients with CD4 T-lymphocyte counts performed within 3 months of Cryptosporidium diagnosis, 34 (25%) had CD4 counts greater than 209 cells/ml. In a multivariate conditional logistic regression model, the incidence of Cryptosporidium was related to ethnicity (for blacks vs. whites, matched odds ratio (OR) = 0.15, 95% confidence interval (CI) 0.03-0.73), CD4 count (for a CD4 count of < or = 53 cells/ml vs. > 53 cells/ml, matched OR = 12.60, 95% CI 4.01-39.61), and age (for a 10-year increase, matched OR = 0.51, 95% CI 0.27-0.98). Two factors measured at the time of Cryptosporidium diagnosis were identified as being independently associated with survival (p < 0.001) in the proportional hazards model: CD4 count < or = 53 cells/ml versus > 53 cells/ml (relative hazard = 6.18, 95% CI 2.99-12.76) and hematocrit < or 37% versus > 37% (relative hazard = 2.27, 95% CI 1.22-4.22). The median durations of survival in the four subgroups of Cryptosporidium-infected patients defined by these two variables differed significantly from each other (range, 204-1,119 days). Cryptosporidiosis as an initial AIDS-defining diagnosis was associated with an elevated relative hazard of death in comparison with other AIDS-defining diagnoses (relative hazard = 2.01, 95% CI 1.38-2.93). These data identify the groups of HIV-infected individuals at risk for presentation with symptomatic Cryptosporidium infection; the distinct survival patterns among subgroups of those patients already infected with this parasite; and the survival of AIDS patients with newly diagnosed cryptosporidiosis relative to patients with other AIDS-defining conditions. Such information is necessary for the design of prospective studies, the development of prophylactic strategies, the evaluation of candidate therapies, and the provision of prognostic information to patients.

Seroprevalence of HIV and risk behaviors among young homosexual and bisexual men. The San Francisco/Berkeley Young Men's Survey.

OBJECTIVE: To estimate the prevalence of human immunodeficiency virus (HIV) infection and risk behaviors among young homosexual and bisexual men sampled from public venues in San Francisco and Berkeley, Calif. DESIGN: A survey of 425 young homosexual and bisexual men sampled from 26 locations during 1992 and 1993. Participants were interviewed and blood specimens were drawn and tested for HIV, level of CD4+ T lymphocytes, and markers of hepatitis B and syphilis. SETTING: Public venues in San Francisco and Berkeley, including street corners and sidewalks, dance clubs, bars, and parks. POPULATION STUDIED: Homosexual and bisexual men aged 17 to 22 years. MAIN OUTCOME MEASURES: Prevalence of HIV infection and risk behaviors. RESULTS: The HIV seroprevalence was 9.4% (95% confidence interval, 6.8% to 12.6%). The prevalence of markers for hepatitis B was 19.8% (95% confidence interval, 16.1% to 23.9%), and that for syphilis was 1.0% (95% confidence interval, 0.3% to 2.4%). The HIV seroprevalence was significantly higher among African Americans (21.2%) than among other racial/ethnic groups (P = .002). Approximately one third (32.7%) of the participants reported unprotected anal intercourse, and 11.8% reported injecting drug use in the previous 6 months. At the time of interview, 70.0% of the HIV-infected men did not know that they were HIV seropositive, and only 22.5% were receiving medical care for HIV infection. CONCLUSIONS: The prevalence of HIV infection is high among this young population of homosexual and bisexual men, particularly among young African-American men. The high rates of HIV-related risk behaviors suggest a considerable risk for HIV transmission in this population. Prevention programs and health services need to be tailored to address the needs of a new generation of homosexual and bisexual men.

Temporal trends of opportunistic infections and malignancies in homosexual men with AIDS.

Temporal changes in the lifetime occurrence of opportunistic infections and malignancies among 1115 homosexual men diagnosed with AIDS were examined. Information from the AIDS surveillance registry, hospital pathology and microbiology logs, patient chart reviews, cancer registries, and death certificates was used to calculate the frequency of specific opportunistic infections and malignancies as lifetime (initial or subsequent) diagnoses. The most common lifetime diagnoses were Pneumocystis carinii pneumonia (PCP; 66.5%), Kaposi's sarcoma (KS; 50.7%), disseminated Mycobacterium avium complex (DMAC) infection (29.6%), and cytomegalovirus (CMV) infection (19.6%). From 1981 to 1990, there was a significant decrease in the rate of KS (P = .003) and a significant increase in the rate of DMAC infection (P = .03). PCP decreased during 1985-1990 (P = .009), while CMV infection increased from 1987 through 1990 (P = .03). Thus, KS and PCP have declined over time, while DMAC and CMV are causing substantial and increasing morbidity among AIDS patients.

Causes of death among persons reported with AIDS.

OBJECTIVES: This study describes causes of death in persons with acquired immunodeficiency syndrome (AIDS) and assesses the completeness of reporting of human immunodeficiency virus (HIV) infection or AIDS on death certificates of persons with AIDS. METHODS: AIDS case reports were linked with death certificates in 11 local/state health departments; underlying and associated causes of death were available for 32,513 persons with AIDS who died. RESULTS: HIV/AIDS was designated as the underlying cause of death for 46% of persons with AIDS who died between 1983 and 1986 and 81% of persons with AIDS who died since 1987 (the year specific coding procedures were implemented for HIV/AIDS). Most other underlying causes of death were conditions within the AIDS case definition (notably Pneumocystis carinii pneumonia), pneumonia, infections outside the AIDS case definition, and drug abuse. Unintentional injuries, suicide, and homicide were less common. HIV/AIDS was listed as underlying or associated on 88% of death certificates from 1987 to 1989; reporting varied primarily by HIV exposure category and time between diagnosis and death. CONCLUSIONS: Physicians and other health care professionals should realize their critical role in accurately documenting HIV-related mortality on death certificates. Such data can ultimately influence the allocation of health care resources for HIV-infected individuals.

Survival for women and men with AIDS.

To compare trends in the length of survival for women and men after diagnosis of AIDS, data were analyzed for 139 women and 7045 men who were reported with AIDS in San Francisco between July 1981 and 31 December 1990. Patients were followed prospectively through 15 May 1991. The median survival for women (11.1 months) was significantly shorter than that for men (14.6 months). When data were stratified by year of diagnosis, significantly improved survival was observed in recent years for both women and men, although survival for women remained significantly shorter than that for men. Among those who received either zidovudine or 2',3'-dideoxyinosine, survival did not differ by gender. However, among those not receiving therapy, survival was significantly shorter for women. These results suggest that the shorter survival of women may be a result of factors other than gender, possibly including less use of antiretroviral therapy.