Tomlinson Dr

The Use and Cost of HIV Service Provision in England in 1996

AbstractObjective: The aim of the study was to measure the use and estimate the cost of HIV service provision in England. Design and Setting: 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. Main Outcome Measures and Results: 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 (95% CI: £3769 to £5648) for asymptomatic patients, to £7605 (95% CI: £6273 to £8909) for symptomatic non-AIDS patients to £20 358 (95% CI: £17 681 to £23 206) for patients with AIDS. Conclusions: Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatientrelated 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.

Adult male victims of sexual assault: an underdiagnosed condition.

The records of 28 male victims of sexual assault were analysed retrospectively. The mean age at time of assault was 21.7 years and the mean number of assailants was 2.8. Sixteen victims (57%) reported skin or mucosal damage and 25 (89%) sustained penetrative anal intercourse. The threat of transmission of HIV was used by the assailant in 16 cases and sexually transmitted diseases, presumed consequent upon the attack, were found in 5 (18%). These observations suggest that male victims of sexual assault may be at particular risk of sexually transmitted infections, including HIV, and that efforts should be made to encourage them to come forward for help.

Male prostitution and sexually transmitted disease

There has been a relatively small number of studies of male prostitution compared with female prostitution. Cultural blindness to the existence of male prostitutes, together with difficulties in gaining access to a representative sample of such individuals, has led to a situation where male prostitution is poorly recognized, poorly understood and inadequately managed. Male prostitutes may be important in the spread of the human immunodeficiency virus (HIV) and other infections to both the homosexual and heterosexual communities, particularly in areas of the world where prostitution and drug abuse are common. Despite the high risk activities performed by male prostitutes, they are poor users of available health service resources. We review the existing literature on male prostitution, the acquisition of sexually transmitted infection and discuss possible ways of improving the provision of health care services for this group.

Management of Chlamydia trachomatis genital tract infection in Genitourinary Medicine clinics in the United Kingdom's North Thames Region 1999

Assessment of clinical management of Chlamydia trachomatis genital tract infection was made, with particular regard to the UK National Guideline. Questionnaires for self-completion, mailed to lead clinicians in 31 Genitourinary Medicine (GUM) clinics in the North Thames Region between May and June 1999, focused on policies and practice. Audit of actual management of up to 10 most recent cases (5 male and 5 female) attending each clinic within the past 2 years was also undertaken. Twenty-two units (71% response) completed the survey questionnaire and 23 units (74% response) audited a total of 229 cases (males=108, females=118, sex not stated=3). Findings indicate that GUM clinics are managing these infections largely as recommended in the national guideline. Nucleic acid amplification techniques will supersede established diagnostic tests for GUM clinics in North Thames, increasing costs for the service, but also sensitivity of detection.

Setting up a Support Service for Male Prostitutes in London

Estimating the number of male prostitutes working at any given time is fraught with difficulties. We suggest that perhaps around 600–700 men were selling sex in London in 1989. We report some preliminary observations gained during the setting up of a specific service for male prostitutes. Of 32 male prostitutes seen, 26 worked as rent-boys, 4 worked through agencies and 2 worked independently from home. Forty-one per cent had evidence of at least one sexually transmissible disease and 3 of 16 men tested (19%) were human immunodeficiency virus (HIV) positive.

Screening for Cervical Abnormalities in Women with Anogenital Warts in an STD Clinic: An Inappropriate Use of Colposcopy

An audit of the use of colposcopy in women with anogenital warts was performed. Fifty women attending a clinic for sexually transmitted diseases in a District General Hospital with anogenital warts were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 20 (40%) had evidence of cervical infection by HPV and 11 (22%) epithelial abnormalities consistent with CIN 1 or 2. However, neither CIN 3 nor invasive disease was detected. Colposcopy in this setting was shown to be a specific but insensitive tool and its role in the routine management of women with anogenital warts at our institution is not warranted.

Early Aggressive Management of Cryptosporidial Infection in AIDS

We report two cases of cryptosporidiosis in patients with the acquired immunodeficiency syndrome (AIDS) which responded to early intervention with intravenous zidovudine and total parenteral nutrition (TPN).

Management of Protozoan Infections in AIDS

The key to diagnosis is a CT scan of the brain, performed with, and without, iv contrast enhancement. Typically, multiple intracerebral ring-enhancing hypodense lesions (1-3crn) are seen bilaterally, with a predilection for the basal ganglia and cerebral corticomedullary junction (Figure 1). However a single lesion does not rule out toxoplasmosis. Haemorrhage into the lesions is uncommon. Serological tests may be helpful as most patients will have serum antibodies to Toxoplasma gondii but there is rarely an IgM response and often no rise in IgG, so they cannot be considered diagnostic. If the CT scan is normal or shows only atrophy, consistent with HIV encephalopathy, an MRI should be performed as this will demonstrate basal ganglia lesions in almost all patients with toxoplasmosis. Lumbar puncture in the absence of any mass effect is safe, although usually nondiagnostic in cerebral toxoplasmosis, but will exclude other pathology, such as cryptococcal or tuberculous meningitis. . A~ St Marys we perform baseline serological testmg for toxoplasmosis in all patients to

Management of Pneumocystis carinii pneumonia

Table 1. Symptoms and signs typically associated with PCP Deep inspiratory efforts are difficult to take and often precipitate coughing. Symptoms may persist for many weeks especially if patients are taking prophylaxis. As the disease progresses dyspnoea at rest occurs. PCP rarely causes obvious abnormalities on physical examination. The most noticeable are tachypnoea and pyrexia. Occasionally patients present with symptoms and signs indicating a pneumothorax or extrapulmonary disease.

Chronic giant ulceration of the vulva in an HIV seropositive woman

Herpes simplex virus (HSV) infection is a common cause of genital ulceration. Primary presentation is usually with multiple, small, discrete, tender ulcers. We report an unusual case of chronic, giant ulceration of the vulva in a woman immunosuppressed by the human immunodeficiency virus (HIV). This was the first presentation of symptomatic disease. The diagnosis of HSV infection was made initially on histological examination of a punch biopsy from the ulcer and subsequently confirmed by viral isolation. The response to antiviral therapy with acyclovir was rapid. Other causes of genital ulceration are discussed and we highlight the diagnostic benefit of histological examination of a punch biopsy.