Paul Gaist

Alternatives to the randomized controlled trial

Public health researchers are addressing new research questions (e.g., effects of environmental tobacco smoke, Hurricane Katrina) for which the randomized controlled trial (RCT) may not be a feasible option. Drawing on the potential outcomes framework (Rubin Causal Model) and Campbellian perspectives, we consider alternative research designs that permit relatively strong causal inferences. In randomized encouragement designs, participants are randomly invited to participate in one of the treatment conditions, but are allowed to decide whether to receive treatment. In quantitative assignment designs, treatment is assigned on the basis of a quantitative measure (e.g., need, merit, risk). In observational studies, treatment assignment is unknown and presumed to be nonrandom. Major threats to the validity of each design and statistical strategies for mitigating those threats are presented.

Contemporary costs of Hiv healthcare in the Haart era

Background:The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996–1998. We provide updated estimates of expenditures for HIV management. Methods:We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51–200, 201–350, 351–500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care. Results:Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US

Neurobiology of Seasonal Affective Disorder and Phototherapy

19 912, with an interquartile range from US

The impact of illicit drug use and substance abuse treatment on adherence to HAART

11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US

Hospital and outpatient health services utilization among HIV-infected patients in care in 1999

40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US

Alcohol use among HIV-infected persons in care: results of a multi-site survey

16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest. Conclusion:HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

HAART receipt and viral suppression among HIV-infected patients with co-occurring mental illness and illicit drug use

I. To whom all correspondence should be addressed, at the Clinical Psychobiology Branch, NIMH. Building 1.0/Room 4S-239, 9000 Rockville Pike, Bethesda. Maryland 20892. The investigation of the biochemical basis of seasonal affective disorder (SAD) and light therapy is a new field. As with any body of knowledge undergoing rapid expansion, the data, though interesting, are incomplete and at times even conflicting. In this paper, we attempt to organize and synthesize the information currently available into a coherent and understandable form.

Use of complementary and alternative medicines among a multistate, multisite cohort of people living with HIV/AIDS

Abstract High levels of adherence to highly active antiretroviral therapy (HAART) are essential for virologic suppression and longer survival in patients with HIV. We examined the effects of substance abuse treatment, current versus former substance use, and hazardous/binge drinking on adherence to HAART. During 2003, 659 HIV patients on HAART in primary care were interviewed. Adherence was defined as ≥95% adherence to all antiretroviral medications. Current substance users used illicit drugs and/or hazardous/binge drinking within the past six months, while former users had not used substances for at least six months. Logistic regression analyses of adherence to HAART included demographic, clinical and substance abuse variables. Sixty-seven percent of the sample reported 95% adherence or greater. However, current users (60%) were significantly less likely to be adherent than former (68%) or never users (77%). In multivariate analysis, former users in substance abuse treatment were as adherent to HAART as never users (Adjusted Odds Ratio (AOR)=0.82; p>0.5). In contrast, former users who had not received recent substance abuse treatment were significantly less adherent than never users (AOR=0.61; p=0.05). Current substance users were significantly less adherent than never users, regardless of substance abuse treatment (p<0.01). Substance abuse treatment interacts with current versus former drug use status to affect adherence to HAART. Substance abuse treatment may improve HAART adherence for former substance users.

Effects of bright light on resting metabolic rate in patients with seasonal affective disorder and control subjects

Background: The evolving epidemiology and therapeutic management of HIV disease has important implications for health care resource utilization in HIV‐infected patients, and health care resource use data are also needed to support policy and financial decision making. Methods: Demographic, clinical, and resource utilization data were collected from 9 U.S. HIV primary and specialty care sites in calendar year 1999. Rates of resource use were calculated for hospital admission, length of hospital stay, and outpatient clinic/office visits. Results: The sample included 5255 patients from HIV primary care sites in 3 eastern, 3 midwestern, and 3 western areas of the United States. Hospital admissions accounted for an annual mean of 297 days per 100 persons/y in 1999. Hospital days ranged from a low of 165 per 100 persons/mo for a CD4 > 500 cells/mm3 to 840 per 100 persons/mo for a CD4 < 50 cells/mm3 (p < .01). Mean annual outpatient clinic/office visits were 10.7 per person in 1999. A declining CD4 level and an increasing HIV‐1 RNA level were both associated with higher hospital and outpatient utilization. HAART use was associated with fewer hospital days, and a higher outpatient visit rate. Injecting drug use risk was associated with an increase in hospital days. African American race was associated with a higher number of hospital days, but a lower outpatient visit rate. Female gender was associated with higher outpatient utilization. Mean monthly inpatient and outpatient expenditures in 1999 were

Ethical issues in research on preventing HIV infection among injecting drug users.

423 and