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D R Holtgrave

Publications and source records attributed to D R Holtgrave.

At least 19 recordsLinked to original sources
PubMed1997

Cost-effectiveness of chemoprophylaxis after occupational exposure to HIV.

OBJECTIVES: To assess the economic efficiency of recent US Public Health Service recommendations for chemoprophylaxis with a combination of antiretroviral drugs following high-risk occupational exposure to human immunodeficiency virus (HIV). To provide a framework for evaluating the relative effectiveness and costs associated with candidate postexposure prophylaxis (PEP) regimens. METHODS: Standard techniques of cost-effectiveness and cost-utility analysis were used. The analysis compares the costs and consequences of a hypothetical, voluntary combination-drug PEP program consisting of counseling for all HIV-exposed health care workers, followed by chemoprophylaxis for those who elect it vs an alternative in which PEP is not offered. A societal perspective was adopted and a 5% discount rate was used. Hospital costs of recommended treatment regimens (zidovudine alone or in combination with lamivudine and indinavir) were used, following the dosing schedules recommended by the US Public Health Service. Estimates of lifetime treatment costs for HIV and acquired immunodeficiency syndrome were obtained from the literature. Because the effectiveness of combination PEP has not been established, the effectiveness of zidovudine PEP was used in the base-case analyses. MAIN OUTCOME MEASURES: Net PEP program costs, number of HIV infections averted, cost per HIV infection averted, and cost-utility ratio (net cost per discounted quality-adjusted life-year saved) for zidovudine, lamivudine, and indinavir combination PEP. Lower bounds on the effectiveness required for combination regimens to be considered incrementally cost saving, relative to zidovudine PEP alone, were calculated. Multiple sensitivity and threshold analyses were performed to assess the impact of uncertainty in key parameters. RESULTS: Under base-case assumptions, the net cost of a combination PEP program for a hypothetical cohort of 10,000 HIV-exposed health care workers is about $4.8 million. Nearly 18 HIV infections are prevented. The net cost per averted infection is just less than $400,000, which exceeds estimated lifetime HIV and acquired immunodeficiency syndrome treatment costs. Although combination PEP is not cost saving, the cost-utility ratio (about $37,000 per quality-adjusted life-year in the base case) is within the range conventionally considered cost-effective, provided that chemoprophylaxis is delivered in accordance with Public Health Service guidelines. Small incremental improvements in the effectiveness of PEP are associated with large overall societal savings. CONCLUSIONS: Under most reasonable assumptions, chemoprophylaxis with zidovudine, lamivudine, and indinavir following moderate- to high-risk occupational exposures is cost-effective for society. If combination PEP is minimally more effective than zidovudine PEP, then the added expense of including lamivudine and indinavir in the drug regimen is clearly justified.

Adult↗
PubMed1997

Updates of cost of illness and quality of life estimates for use in economic evaluations of HIV prevention programs.

To allocate limited economic and other resources for HIV prevention and treatment for maximum benefit, health policy planners and decision makers require accurate, current estimates of the lifetime costs of HIV-related illness and the impact of therapy on the quality of life of HIV-infected persons. These data are central input parameters to the economic evaluation methodology known as cost-utility analysis. The estimates available in the literature are already outdated, and this paper presents updated estimates of the projected lifetime health care costs associated with HIV disease in the United States and the number of quality-adjusted life years (QALYs) lost to HIV in light of recent advancements in HIV diagnostics and therapeutics. Results indicate that the lifetime cost of HIV medical care has grown from about $55,000 U.S. to more than $155,000 U.S., while the number of QALYs lost per case of HIV infection has decreased from 9.26 to 7.10, when discounted at a 5% annual rate. When these figures are discounted instead at the newly recommended 3% rate, lifetime costs rise to more than $195,000 U.S. and lost QALYs increase to 11.23. The net effect of these increases in the medical costs of care and treatment saved by averting an HIV infection and in QALYs makes HIV prevention a relatively more cost-effective strategy than other, non-HIV health-related programs.

Adult↗
PubMed1997

Influence of behavioral and social science on public health policymaking.

Public health policies are important guiding principles that serve to shape the well-being of individuals, groups, and society. Behavioral and social scientists can play key influential roles in public health policymaking. The actors and processes involved in setting public health policy are described, and several substantive examples of public health decision making are discussed, emphasizing HIV prevention policy experiences at the Centers for Disease Control and Prevention. The significant influence of behavioral and social science in each of these examples is identified and critiqued. Challenges to further integration of behavioral science and public health policy are identified, and potential solutions are proposed.

Behavioral Sciences↗
PubMed1997

Cost-effectiveness of HIV-prevention skills training for men who have sex with men.

OBJECTIVE: A previous study empirically compared the effects of two HIV-prevention interventions for men who have sex with men: (i) a safer sex lecture, and (ii) the same lecture coupled with a 1.5 h skills-training group session. The skills-training intervention led to a significant increase in condom use at 12-month follow-up, compared with the lecture-only condition. The current study retrospectively assesses the incremental cost-effectiveness of skills training to determine whether it is worth the extra cost to add this component to an HIV-prevention intervention that would otherwise consist of a safer sex lecture only. DESIGN: Standard techniques of incremental cost-utility analysis were employed. METHODS: A societal perspective and a 5% discount rate were used. Cost categories assessed included: staff salary, fringe benefits, quality assurance, session materials, client transportation, client time valuation, and costs shared with other programs. A Bernoulli-process model of HIV transmission was used to estimate the number of HIV infections averted by the skills-training intervention component. For each infection averted, the discounted medical costs and quality-adjusted life years (QALY) saved were estimated. One- and multi-way sensitivity analyses were performed to assess the robustness of base-case results to changes in modeling assumptions. RESULTS: Under base-case assumptions, the incremental cost of the skills training was less than $13,000 (or about $40 per person). The discounted medical costs averted by incrementally preventing HIV infections were over $170,000; more than 21 discounted QALY were saved. The cost per QALY saved was negative, indicating cost-savings. These results are robust to changes in most modeling assumptions. However, the model is moderately sensitive to changes in the per-contact risk of HIV transmission. CONCLUSIONS: Under most reasonable assumptions, the incremental costs of the skills training were outweighed by the medical costs saved. Thus, not only is skills training effective in reducing risky behavior, it is also cost-saving.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Lifetime cost of care for children with human immunodeficiency virus infection.

BACKGROUND: Knowledge of the cost of care for children with HIV infection is necessary to analyze the economic impact of recommendations for universal counseling and voluntary HIV testing of pregnant women. OBJECTIVES: To estimate the total cost of care for children with HIV infection. METHODS: We performed a retrospective cohort study of all 88 children with (n = 29) or at risk for (n = 59) perinatally acquired HIV infection cared for at Children's Hospital of Wisconsin between February 2, 1987, and June 1, 1995. Review of medical records for all 29 children with perinatally acquired HIV infection or AIDS identified: date of HIV diagnosis; date of classification into Category N, A, B or C; date of AIDS diagnosis; and date of death or transfer of care. The time each subject remained in each CDC category was calculated and the Kaplan-Meier product-limit method was used to calculate survival time for all patients in each CDC category. Hospital-based inpatient and outpatient charges per patient per month in each CDC category (N, A, B, C and AIDS) were calculated with information from the hospital financial services database, and lifetime hospital-based inpatient and outpatient charges were estimated as the sum of the charges for each category. From that, total charges were calculated assuming that hospital-based charges were 83% of total charges. RESULTS: Based on a median survival time of 120 months, the mean lifetime charges for hospital-based care for children with HIV infection was $408307 (estimates ranged from $172217 to $498539). If hospital-based care represents 83% of the total charges for care of children with HIV infection, then mean total lifetime charges for care of children with HIV infection were $491936 ($207490 to $600649). CONCLUSIONS: The care of children with HIV infections is expensive. This information may be useful in planning for care programs and for analyzing the economic impact of recommendations for universal counseling and voluntary HIV testing of pregnant women.

Child↗
PubMed1997

The evaluation of HIV counseling-and-testing services: making the most of limited resources.

The evaluation of HIV counseling, testing, referral, and partner notification (CTRPN) services are especially important given the rapid, relevant changes in counseling strategies, public policies, and testing technologies. Here we briefly review the important components of a comprehensive HIV CTRPN evaluation. However, resources for evaluation are usually quite limited, thus making comprehensive evaluations impossible. Yet even with limited resources, meaningful evaluative activities can be performed and some pressing evaluation questions answered. As an illustration, we present a practical evaluation project (conducted with limited resources) that assessed at a systems level the HIV counseling and testing (HIV CT) program in the state of Wisconsin. We describe how some of this evaluative information was utilized by the state's division of health.

AIDS Serodiagnosis↗
PubMed1996

Economic evaluation of HIV prevention programs.

Program managers and policy makers need to balance the costs and benefits of various interventions when planning and evaluating HIV prevention programs. Resources to fund these programs are limited and must be used judiciously to maximize the number of HIV infections averted. Economic evaluation studies of HIV prevention interventions, which we review and critique here, can provide some of the needed information. Special emphasis is given to studies dealing with interventions to reduce or avoid HIV-related risk behaviors. Ninety-three cost-benefit, cost-effectiveness and cost-utility analyses were identified overall. However, only 28 dealt with domestic, behavior change interventions; the remainder focused on screening and testing without prevention counseling, and on care and treatment services. There are compelling demonstrations that behavioral interventions can be cost-effective and even cost-saving. The threshold conditions under which these programs can be considered cost-effective or cost-saving are well defined. However, several important intervention types and multiple key populations have been unstudied. Research in these areas is urgently needed.

Adolescent↗
PubMed1996

Preventing HIV/AIDS among high-risk urban women: the cost-effectiveness of a behavioral group intervention.

OBJECTIVES: A human immunodeficiency virus (HIV) intervention trial for women at high risk for acquired immunodeficiency syndrome and attending an urban clinic was reported previously. The behavioral group intervention was shown to increase condom use behaviors significantly. This study retrospectively assessed the intervention's cost-effectiveness. METHODS: Standard methods of cost and cost-utility analysis were used. RESULTS: The intervention cost was just over $2000 for each quality-adjusted life-year saved; this is favorable compared with other life-saving programs. However, the results are sensitive to changes in some model assumptions. CONCLUSIONS: Under most scenarios, the HIV prevention intervention was cost-effective.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Methodological issues in evaluating HIV prevention community planning.

To be effective, HIV prevention programs should be planned in partnership with affected communities and should be built on a solid scientific foundation. In 1994, the Centers for Disease Control and Prevention (CDC) and its prevention partners implemented HIV prevention community planning to achieve primarily these two objectives. In order to manage the community planning process effectively, extensive evaluation activities were employed at both the grantee and national level. This paper describes the first year evaluation goals and methods in detail. Throughout, reasons for collecting specific types of information and for using particular methodologies are highlighted.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Advances in public health communication.

There have been tremendous advances in recent years in the innovative use of communication to address public health problems. This article outlines the use of communication techniques and technologies to (positively) influence individuals, populations, and organizations for the purpose of promoting conditions conducive to human and environmental health. The approaches described include social marketing, risk communication, and behavioral decision theory, entertainment education, media advocacy, and interactive decision support systems. We also address criticism of these approaches among public health professionals because of perceived discrepancies in their inherent goals and objectives. In conclusion, we call for the rapid diffusion of state-of-the-art public health communication practices into public health service agencies and organizations.

Advertising↗
PubMed1995

Developmental status, gender, age, and self-reported decision-making influences on students' risky and preventive health behaviors.

This study used decision-making theory to analyze the developmental changes associated with children's and adolescents' health behavior. High school and elementary school children completed surveys concerning (1) the extent to which they engage in a variety of preventive and risky health behaviors, and (2) influence sources used in decision making concerning the enactment of these behaviors. Multiple regression analysis revealed that the sources of influence children and adolescents report considering in making health-related decisions change developmentally and as a function of gender. Moreover, within and across age, children's sources of influence with respect to health decision making are dependent on the health domains being considered. The findings are discussed in relation to decision-making theory and the implications for the content and timing of health education initiatives for adolescents.

Adolescent↗
PubMed1994

HIV prevention programs.

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Centers for Disease Control and Prevention, U.S.↗