bluuebunny/crossref_metadata_2025 huggingface dataset:
Financing HIV service provision in England: estimated impact of the cost of antiretroviral combination therapy
Authors: Beck E J , Tolley K
Published: October 2002

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 131 m range 83 m to 233 m , or 150 m 95 CI 126 m to 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 161 m range 126 m to 173 m per year using hospital prices or 180 m 95 CI 156 m to 203 m when using standard cost estimates, while for triple therapy annual estimated expenditure amounted to 204 m per year range 157 m to 306 m when using hospsital prices or 223 m 95 CI 199 m to 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.
Efficacy of surgical and or podophyllotoxin treatment against flat acetowhite penile human papillomavirus associated lesions
Authors: Wikstrom Arne , Krogh Geo Von
Published: October 2002

In order to investigate the efficacy of treatment modalities favoured by us against flat acetowhite penile human papillomavirus HPV induced lesions, we studied retrospectively standardized medical records of 81 men who had been treated for this condition. The patients were treated surgically with diathermy n =32 or with a combination of both chemical topical application of podophyllotoxin and surgical treatment n =49 . The mean number of clinic visits was 9.1 range 1-19 , during a follow up time of mean 30.9 range 1-104 months for 78 of the men, 3 of them only visited the clinic once. The mean time for cure was 19.9 range 0-103 months. Only 12 15 patients were healed after one single treatment session, while as many as 50 62 required > 4 sessions. The mean number of surgical treatment sessions required for cure differed significantly P =0.0006 between the previously treated patients who needed a mean of 5.6 treatment sessions, compared to the previously untreated men who required surgery a mean of 3.4 times for cure.
Cytomegalovirus pp65 antigenaemia as an indicator of end organ disease in AIDS
Authors: Fox E. F. , Smith N. A. , Rice P. , Dunn H. , Peters B. S.
Published: October 2002

We aim to assess the usefulness of the cytomegalovirus CMV pp65 antigenaemia test, also called the CMV direct antigen test DAT , in the management of patients with advanced human immunodeficiency virus HIV infection; we studied all patients who had pp65 assays between 8 September 1995 and 30 August 1996. Twenty three patients had 31 tests. The mean CD4 cell count was 20 mm 3. The tests were negative in 16 patients, of whom 12 have not developed CMV end organ disease after a mean follow up of 114 days range 14- 269 days , whilst the remaining 4 patients had previously treated CMV disease. Eleven patients had positive tests: 4 had active CMV disease, 2 subsequently developed CMV retinitis, 2 died within a fortnight of multi drug resistant tuberculosis MDR TB , one was lost to follow up and 2 have remained disease free. This test has a positive predictive value of 43 and a negative predictive value of 94 , Fisher s exact test P =0.03. The pp65 antigenaemia assay can be performed in a standard virology laboratory avoiding the problems associated with polymerase chain reaction PCR , a result is available within 5 h, and it is semi quantifiable. However, a large prospective study is required to determine the comparative value and roles of the pp65 antigenaemia assay and DNA PCR in the management of CMV disease, especially with regard to the use of primary prophylaxis and pre emptive therapy.
Circumcision and HIV Infection: Review of the Literature and Meta-Analysis
Authors: Van Howe R S
Published: October 2002

Thirty-five articles and a number of abstracts have been published in the medical literature looking at the relationship between male circumcision and HIV infection. Study designs have included geographical analysis, studies of high-risk patients, partner studies and random population surveys. Most of the studies have been conducted in Africa. A meta-analysis was performed on the 29 published articles where data were available. When the raw data are combined, a man with a circumcised penis is at greater risk of acquiring and transmitting HIV than a man with a non-circumcised penis (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.01-1.12). Based on the studies published to date, recommending routine circumcision as a prophylactic measure to prevent HIV infection in Africa, or elsewhere, is scientifically unfounded.
Sexually Transmitted Infections in Estonia
Authors: Põder Airi , Bingham J S
Published: October 2002

Estonia, one of the Baltic countries, regained its independence in 1991, after the collapse of the USSR. This process led to great changes in every sphere of life — in politics, in the economy and in medicine. The service providing care for sexually transmitted infections (STIs) was involved in the process of these changes, too. However, freedom was followed not only by great happiness, but also by social destabilization and transformation of the old moral norms, the most evident features of which were the dramatic rise in crime, a sexual revolution and public prostitution. These 2 great simultaneous transformations in the STI care system and public mores led to the rapid increase of STIs in Estonia in the first half of the 1990s. Now some stabilization, and even a fall in incidence has occurred.
Audit of Cervical Screening and Colposcopy in HIV-Positive Women at a Central London Teaching Hospital
Authors: Vonau B U , Boag F , Barton S E
Published: October 2002

The purpose of this audit was to assess the prevalence of cervical pathology and clinical outcome in HIV-infected women as well as adherence to local screening guidelines. As there are no national screening guidelines for HIV-positive patients, recommendations vary widely. At St Stephen's Centre, these included annual cytology and a baseline colposcopy. We audited this recommendation by a clinical notes review using a computer database. Analysis was performed using Statistical Package for Social Sciences (SPSS). Two hundred and twenty-two patients were eligible for analysis, their mean age was 33.6 years, median CD4 count was 239 and median viral load was 7836 RNA copies. Cytology was undocumented in 72 women (32.4%), while overall 42 (28%) smears of the remaining 150 patients were abnormal: borderline 17.3%, mild dyskaryosis 4.6%, moderate dyskaryosis 4%, severe dyskaryosis 2%. The results were normal in 64% and unsatisfactory in 4.6%. Colposcopy was offered to 93 (42%) women who attended at least once in 71 cases (32%). Thirty-one women had biopsies taken (43.6% of all colposcopies). Twenty-four (77.4%) had a histology more severe than HPV and 15 (48.4%) more severe than cervical intraepithelial neoplasia (CIN)-1. Overall, 49.7% had management not complying with the guidelines. This audit led to a critical literature review and of local screening guidelines. A computer aided reminder program has now been installed and re-auditing of the management of HIV-positive women is planned.
Lay People's Perceptions of Sexually Transmitted Infections in Uganda
Authors: Nuwaha Fred , Faxelid Elisabeth , Neema Stella , Höjer Bengt
Published: October 2002

In order to understand lay people's perceptions of sexually transmitted infections (STIs) focus group discussions and semi-structured interviews were held with community members and patients with STIs in Mbarara and Kampala, Uganda. Symptoms of common STIs and the modes of transmission methods were known. STIs were perceived as naturalistic diseases caused by a tiny insect called akakoko or akawuka, although female infertility, one of the common complications of STIs, was perceived as a supernatural ailment. There was no stigma towards people with AIDS, although stigma towards people with other STIs was high. There were also strong negative attitudes towards the use of condoms. More than 60% of the patients interviewed had received treatment from the informal sector which included self-treatment and traditional healers. To reduce the incidence and complications of STIs, there may be a need to collaborate with the informal sector, to further evaluate the beliefs and practices identified in this study and to target them for health education.
Many hands make light work
Authors: Hiscock Ted
Published: October 2002

As part of an ongoing minute of the Association of Genito-Urinary Medicine (AGUM's) national body, this committee's non consultant career grade (NCCG) representative has added another reflective chapter about this heterogeneous group of doctors working in genitourinary medicine (GUM) throughout the British Isles. Here, current progress is briefly explained and some of the revelations unmasked by the compilation of a national database for NCCG are enumerated along with a few personal suggestions for improving the mutual benefits of NCCG contribution within GUM in the UK.
Network structural dynamics and infectious disease propagation
Authors: Potterat J J , Rothenberg R B , Muth S Q
Published: October 2002

We aimed to relate dynamic changes in risk-network (sex and/or injecting drug) structure to observe STD/HIV transmission. We analysed macroand micro-structural elements in 2 heterosexual networks, augmented by ethnographic observations. In a Colorado cohort of injecting drug users (n=595), measures of subgroup formation and of density of activity show decrease of network cohesion over time; only one HIV transmission was observed in 3 years. In a group of adolescent heterosexuals in Georgia (n=99), the reverse process (increase in structural cohesion) was associated with efficient syphilis transmission: 10 cases were observed. Changes in personal risk behaviours over time were modest. STD/HIV transmission patterns were associated with intensification or diminution of network cohesion. Network and ethnographic data suggest that enhanced connectivity facilitates transmission while segmentation impedes it, suggesting opportunities for interventions. These data also emphasize the need to re-evaluate purely behavioural explanations of STD/HIV transmission.
Genitourinary Physicians and Vulval Clinics: A UK Survey
Authors:   British Co-operative Clinical Group, Kinghorn G R , Carne C A , McMillan A , Mandal D , Pattman R S , Alawattegama A B , Wilson J , Maw R D , Williams O , O'Mahoney C , Radcliffe K W , Bignell C , Meaden J D , Scott J , Taylor P K , Luzzi G , Goh B T , Lawrence A G , de Ruiter A , Nayagam A T , Willmott F E , Harris W , Mercey D , Dinsmore W , Nicoll A , Catchpole M
Published: October 2002

Our objectives are to examine the extent to which genitourinary physicians participate in vulval clinics in the UK; to determine the geographic distribution of such clinics and to study aspects of clinical practice and staffing of the vulval clinics identified in the survey.

In February/March 1998 a questionnaire on vulval clinics was distributed via regional representatives of the British Co-operative Clinical Group to all the 174 consultants in charge of genitourinary medicine clinics in the UK.

One hundred and sixty-four replies were received which identified a total of 61 vulval clinics in the UK. All former health regions had at least one vulval clinic or equivalent. Three former regions had 7 vulval clinics each. Forty-six vulval clinics had a dermatologist, 38 a genitourinary physician, and 30 had a gynaecologist. Only 7 vulval clinics claimed to have a counsellor or health adviser present. Ninety-four per cent took biopsies but only half this proportion met with a pathologist to discuss the histology. Eighty per cent had colposcopes and cameras available but rather fewer actually used them. Twenty-nine per cent had performed research in the past 5 years and 24% had either published or presented this. The majority of vulval clinics would accept direct referrals from all the agencies.

This survey has demonstrated an increased number of genitourinary physicians participating in vulval clinics. Other studies have demonstrated the value of such clinics in improving diagnosis and management. It is to be hoped that further such clinics will be set up, particularly in parts of the country which are poorly served at present.
Sexual Behaviour, STDs and Drug use in a Crack House Population
Authors: Ross Michael W , Hwang Lu-Yu , Leonard Lori , Teng Ming , Duncan Lawrence
Published: October 2002

We aimed to investigate the prevalence of ulcerative sexually transmissible diseases (STDs) and hepatitis in crack users. We interviewed 435 crack users on site in crack houses in Houston, Texas and took blood for laboratory analysis. There was evidence of syphilis infection in 13%, herpes simplex virus-2 (HSV-2) in 61%, HIV in 12%, hepatitis B in 52%, and hepatitis C in 41% of cases. On DSM–III–R criteria, 12% were crack abusers and 84% crack dependent: over half reported previous treatment. Forty per cent reported also injecting. Sexual behaviour indicated a mean of 2.4 partners in the past month for men, 3.7 for women. Sexual behaviour was largely vaginal, although women also reported more than twice the level of oral sex of men. Significant multivariate predictors for HIV and hepatitis B and C were previous reported STD and injecting drug use (including sharing needles), while female gender for syphilis and HSV-2, and additionally condom use for HSV-2, were significant risks. These data confirm high rates of STDs in a crack house population as inferred from previous clinic-based and community studies, and the link between STDs, injecting and HIV. The high rates of STDs found should lead to considering STDs and substance abuse to be dual diagnoses in crack users and the integration of STD diagnosis and treatment into crack outreach and treatment programmes.
French General Practitioners’ Attitudes toward Therapeutic Advances in HIV Care: Results of a National Survey
Authors: Obadia Y , Souville M , Morin M , Moatti J-P
Published: October 2002

We aimed to assess attitudes to French primary care providers towards recent advances in HIV care. Telephone surveys in a random sample of French general practitioners (GPs) were carried out in April 1996 (response rate=70.3%; n=1186). Only 40.5% of the sample had participated in the regular medical follow-up of HIV-infected patients during the previous year. Among these 480 respondents, only a few (13.3%) declared that they would take care of an asymptomatic patient with a high (>500 cells/mm3) CD4 count as the unique provider. A majority (66.2%) had referred at least one HIV-infected patient to a hospital specialist in the previous year. A total of 31.4% declared that they considered it appropriate for an antiretroviral treatment to be initiated to an asymptomatic patient with 300 CD4 cells/mm3, and only 23.5% were already in favour of combination therapies rather than zidovudine monotherapy as treatment of choice. GPs with the most experience with HIV care tended to be the most reluctant to modify their attitude in favour of earlier initiation of antiretroviral therapies and of the switch from monotherapy to combination therapies.

The survey suggests there is a gap between attitudes of GPs and those of AIDS specialists toward preliminary reports of therapeutic advances in HIV care. Whether or not such a gap may create problems for an appropriate diffusion of new antiretroviral therapies should be carefully monitored, in the context of current reforms emphasizing the key role of primary providers in most health-care systems.
Chlamydia Trachomatis Infection in Women with and without Cervical Intraepithelial Neoplasia
Authors: Takač I , Gorišek B
Published: October 2002

The aim of the study was to compare the frequency of Chlamydia trachomatis infection in patients with cervical intraepithelial neoplasia (CIN) and in women without cervical pathology. In a study group of 423 patients with histologically proven CIN and in 108 controls with normal cervical smear, cytological material for direct immunofluorescence analysis was obtained. Among 423 patients, 24 (5.7%) had CIN 1,108 (25.5%) CIN 2 and 291 (68.8%) CIN 3. Among all patients with CIN, 27 (6.4%) were C. trachomatis positive and 396 (93.6%) C. trachomatis negative. In the control group 6 (5.6%) were C. trachomatis positive and 102 (94.4%) C. trachomatis negative. The difference between C. trachomatis infection incidence in patients with CIN and in women without cervical pathology was not significant (χ2=0.29; P>0.05). In this study, no difference in C. trachomatis infection incidence was detected between patients with CIN and women with normal cervical smears. The impact of C. trachomatis infection seems not to interfere with the development or even the promotion of CIN.
HIV/AIDS in Bangladesh: An Assessment of Biomedical Risk Factors for Transmission
Authors: Gibney L , Choudhury P , Khawaja Z , Sarker M , Islam N , Vermund S H
Published: October 2002

Behavioural risk factors for HIV/AIDS in Bangladesh were reviewed in a preceding article in this journal. Omitted from that review was a discussion of potential biomedical risk factors including: (i) an unregulated blood supply system in which blood used in transfusions is not screened for HIV and is donated primarily by professional donors: (ii) unsterile injections in non-formal and formal health-care settings; and (iii) a high prevalence in high-risk groups of other sexually transmitted diseases (STDs) which may function as co-factors for HIV transmission, particularly if chronically untreated. Studies elsewhere in the world suggest that the unregulated blood supply system, in particular, poses a serious danger in terms of the spread of the HIV epidemic. While certain socio-cultural factors may be contributing to low levels of HIV in Bangladesh, the prevalence of biomedical and behavioural risk factors suggest the importance of implementing targeted costeffective interventions now.
Bacterial Vaginosis in Lesbians: Evidence for Lack of Sexual Transmission
Authors: Mccaffrey M , Varney P , Evans B , Taylor-Robinson D
Published: October 2002

The effect of non-heterosexual factors on the vaginal flora has been studied. Ninety-one lesbians attending a specialist genitourinary medicine service for lesbians were studied. Bacterial vaginosis (BV) was diagnosed in 51.6% of them. While most of the women had previously had a male sexual partner, the presence of BV was not associated with a male sexual partner in the previous 12 months. A detailed analysis of lesbian sexual practices in the group did not relate BV to any sexual practice which would have the propensity to pass vaginal secretions from one to the other.
Inadequate Treatment for Sexually Transmitted Diseases in the South African Private Health Sector
Authors: Connolly A M , Wilkinson D , Harrison A , Lurie M , Karim S S Abdool
Published: October 2002

Correct management of sexually transmitted diseases (STDs) is important for their control, and to reduce HIV transmission. Guidelines on syndromic management of STDs were introduced by the provincial Department of Health in KwaZulu/Natal (KZN) in South Africa in 1995. The drug treatment provided for STDs by the 11 private general practitioners in one rural district was assessed and compared with provincial guidelines. Information was gathered through semi-structured interviews which asked the 11 doctors, who all dispense prescribed drugs as part of the consultation fee, how they would treat 3 hypothetical cases of STD syndromes. In all 33 prescriptions, the treatment did not correspond exactly with provincial recommendations and only 3 (9%) were adequate. All other prescriptions were inadequate because dose or duration was incorrect in 6 (18%), or because incorrect drugs were prescribed in 24 (73%) of cases. Eight of the 11 doctors did not provide adequate treatment for any of their cases. A continuing medical education programme for the doctors and their staff was devised to improve the STD treatment in the private sector in this South African district.
High prevalence of sexually transmitted and blood-borne infections amongst the inmates of a district jail in Northern India
Authors: Singh Sarman , Prasad Rajendra , Mohanty Alok
Published: October 2002

Two hundred and forty male and 9 female jail inmates confined for various crimes in a district jail near Delhi were screened for sexually transmitted and blood-borne diseases including HIV, syphilis and hepatitis B and C viral infections, skin diseases etc. The inmates were aged 15-50 years with a mean of 24.8 +/- 0.11. Their alleged criminal background, period of stay in the jail, drug addiction, education, birth place, marital status, sexual activity, and clinical complaints were recorded by an anonymous questionnaire. Serum samples were tested for antibodies against HIV (1+2), hepatitis C (HCV), Treponema pallidum and for hepatitis B surface antigen (HBsAg). Sputum examination was done for acid-fast bacilli. Out of the 240 men, 115 were married and 125 unmarried. One hundred and eighty-four (76.6%) men gave history of penetrative sex. Of the 184, 53 (28.8%) were homosexuals or bisexuals and 131 (71.2%) had sex with women only. Sixty of the 131 (45.8%) were faithful to their partners while 124 gave a history of having multiple sexual partners and 100 of them (80.6%) had unprotected sex. Eighty-three of these 100 also had had sex with commercial sex workers (CSWs). One hundred and twenty-six were addicted for alcohol, 44 for smack / charas and 8 had a history of intravenous drug abuse. One hundred and seventy-four were not aware of AIDS. On examination 28 of the 240 (11.6%) had active hepatitis with or without a history of jaundice in the last 2 years, 25 (10.4%) active pulmonary tuberculosis (TB) and 11 (4.6%) had syphilitic ulcers on the penis. Four-fifths of the teenagers confined to a particular barrack had moderate to severe scabies. Three males (1.3%) were found to be Western blot confirmed HIV-1 positive while 28 (11.1%) men and 2 (22.2%) women were positive for HBsAg. Twelve (5.0%) men but no women, were found to be positive for anti-HCV antibodies. Out of the 3 HIV-positive persons, one was an intravenous drug user (IVDU), second was a drug addict and frequent CSW visitor while the third was a homosexual. This pilot study gives an indication that sexually transmitted and blood-borne infections are highly prevalent in jail premises and pose a threat of rapid spread of these infections through IVDU and homosexuality.
Reactivity of a dual amplified chlamydia immunoassay with different serovars of Chlamydia trachomatis
Authors: Okadome Aya , Notomi Takashi , Nomura Shuichi , Nagayama Ariaki
Published: October 2002

A study was undertaken with different serovars (D, E, F, L2, MoPn) of Chlamydia trachomatis to determine the analytical sensitivity of a new dual amplified immunoassay (IDEIA PCE Chlamydia) for detecting chlamydial lipopolysaccharide. IDEIA PCE Chlamydia incorporates a polymer conjugate consisting of multiple copies of antibody and enzyme molecules to provide signal amplification. The test was also assessed with different protein A producing strains of Staphylococcus aureus in order to assess whether the use of a multiple antibody conjugate increased nonspecific binding. The detection limits varied for each serovar with a detection limit of 38 IFU/ml obtained with serovar F and 237 IFU/ml obtained with serovar D. The incorporation of the polymer conjugate resulted in a 2-5 fold increase in analytical sensitivity compared to an earlier version of the test using a conventional conjugate. No increase in cross reactivity with protein A producing strains of S. aureus was obtained. The new dual amplified test format offers potential as a sensitive low-cost screening assay for C. trachomatis infections.
HIV-associated risk factors among young Canadian Aboriginal and non-Aboriginal men who have sex with men
Authors: Heath Katherine V. , Cornelisse Peter G. A. , Strathdee Steffanie A. , Palepu Anita , Miller Mary-Lou , Schechter Martin T. , O'Shaughnessy Michael V. , Hogg Robert S.
Published: October 2002

Young Aboriginal men face marginalization distinct in cause but similar in pattern to those seen among men who have sex with men (MSM) and may be at increased risk for HIV infection. We compared sociodemographic characteristics and risk taking behaviours associated with HIV infection among MSM of Aboriginal and non-Aboriginal descent. Data for this comparison were gathered from baseline questionnaires completed by participants in a cohort study of young MSM. Data collection included: demographic characteristics such as age, length of time residing in the Vancouver region, housing, employment, income and income sources; mental health and personal support; instances of forced sex and sex trade participation and; sexual practices with regular and casual male sex partners. Data were available for 57 Aboriginal and 624 non-Aboriginal MSM. Aboriginal MSM were significantly less likely to be employed, more likely to live in unstable housing, to have incomes of <$10,000 and to receive income assistance than non Aboriginals (all P<0.01). Aboriginals also had higher depression scores (P<0.01), were more likely to report non-consensual sex (P=0.03), sexual abuse during childhood (P=0.04) and having been paid for sex (P<0.01). In the past year they were no more likely to have had sex with a male partner they knew to be HIV positive, to have had more than 50 male partners or to have unprotected anal insertive or receptive intercourse with their male partners (all P 0.05). Our data indicate that among MSM, Aboriginal men are at increased risk of antecedent risk factors for HIV infection including sexual abuse, poverty, poor mental health and involvement in the sex trade.
Acid-alcohol fast bacilli in sputa of HIV-infected patients
Authors: Sullivan A K , Hannan M M , Azadian B S , Easterbrook P J , Gazzard B G , Nelson M R
Published: October 2002

We identified 34 HIV-infected patients with sputum smear positive for acid-alcohol fast bacilli (AAFB) to determine any factors predictive of subsequent species identification. There were 20 cases of Mycobacterium tuberculosis (MTB), 9 cases of Mycobacterium avium-intracellulare (MAI), 3 cases of Mycobacterium kansasii and one each of Mycobacterium malmoense and Mycobacterium fortuitum . Factors associated with isolation of MAI were lower CD4 cell count, a higher incidence of previous AIDS diagnosis, a history of dyspnoea and a normal chest X-ray. The organism was isolated from blood cultures in 58% of patients with MTB and 78% of patients with MAI infection. Disseminated disease was diagnosed in 45% of MTB patients and 33% of MAI patients.
PCR detection of Epstein-Barr virus, herpes simplex virus and human papillomavirus from the anal mucosa in HIV-seropositive and HIV-seronegative homosexual men
Authors: Lowhagen G B , Bergbrant I M , Bergstrom T , Voog E
Published: October 2002

This study aimed to examine the prevalence of the Epstein-Barr virus (EBV), herpes simplex virus (HSV) and human papillomavirus (HPV) in the anal and oral mucosa of homosexual men with and without HIV infection and to correlate these findings to CD4+ count and anal cytology. Anal and oral cell samples from 20 HIV-infected and 14 non-infected homosexual men attending the STD clinic at Sahlgrenska University Hospital, Goteborg were examined for EBV, HSV and HPV by the polymerase chain reaction (PCR) technique. Proctoscopy was performed in all patients and swabs for cytology were taken. EBV was demonstrated in 32% (6/19) of anal cell samples from the HIV-positive group but in none from 13 HIV-negative men. Asymptomatic shedding of HSV type 2 from the anus was detected in 3 of 19 HIV-positive men, all with low CD4+ counts and abnormal cytology. No patient in the HIV-negative group shed HSV from the anus. HPV was demonstrated in 16 of 17 anal cell samples in the HIV-infected group and in 7 of 13 HIV-negative men. More than one HPV type was detected in 7 HIV infected men. Five (29%) of 17 HIV-positive patients exhibited abnormal cytology whereas none did so in the HIV-negative group. Those with abnormal cytology all had CD4+ counts below 0.35 and were infected with multiple HPV types including HPV 16/18. In conclusion, our results demonstrate an enhanced expression of HPV as well as EBV from the anus in HIV-infected homosexual men. In this small number of patients EBV was not related to low CD4+ count or to abnormal cytology.
Can simulation be used to reduce errors in health care delivery? The hospital drug distribution system
Authors: Dean Bryony , Barber Nick , van Ackere Ann , Gallivan Steve
Published: October 2002

Objectives: To construct a simulation model of the hospital drug distribution system, to evaluate the effects of different changes to the system on unavailability-related medication administration errors (U-MAEs), to test the most promising system in a controlled trial and to explore the model's validity.

Methods: A discrete-event simulation model of the drug distribution system was constructed, using data collected on a vascular surgery ward and a renal medicine ward as model inputs. The model's output was the U-MAE rate. The model was used to explore the effects on U-MAEs of different changes to the system. One of the changes predicted to reduce U-MAEs, a patients' own drugs scheme, was introduced on each study ward; U-MAE rates were measured using observations before and after its introduction and compared with those predicted by the model.

Results: The model predicted that the introduction of a patients' own drugs system would reduce unavailability-related errors on each ward; in practice, there was a slight decrease on the medical ward but an increase on the surgical ward. Reasons for these findings were explored and four contributing factors identified. Three of these related to failure to follow hospital procedures, the fourth to an issue for which no policy existed. If these factors had been taken into account, the error rates predicted by the model would have been similar to those observed.

Conclusions: Simulation modelling is a potentially useful approach to the study of U-MAEs, although care must be taken to ensure that such models reflect actual practice rather than stated policy.
Vascular patients' preferences for local treatment: an application of conjoint analysis
Authors: Shackley Phil , Slack Russell , Michaels Jonathan
Published: October 2002

Objectives: To investigate whether and to what extent vascular patients are willing to trade expected health outcomes for improvements in non-health benefits, such as the availability of local services, in the provision of peripheral vascular surgery.

Methods: Conjoint analysis was used to elicit patient preferences via a mailed questionnaire. Respondents were asked to consider pairwise descriptions of vascular services described in terms of a number of key attributes and asked to indicate which scenario description they preferred. Multivariate regression analysis was used to estimate the relative importance of the attributes to respondents.

Results: Of the 339 patients invited to participate, 161 (47%) returned a completed questionnaire, although 36 (11%) were found to be internally inconsistent and could not be used, leaving 125 (36%) for analysis. An unexpected problem arose with respect to the design of the conjoint analysis questionnaire. Specifically, three of the attributes in the regression model were found to be collinear. The source of this problem, how it was overcome and how it can be avoided in future studies is discussed. The results of the regression analysis indicated that the patients who responded had a preference for local treatment to the extent that they were willing to incur increased risks of perioperative mortality and amputation to receive treatment at their local hospital. These results are discussed in connection with those from a different study which elicited patient preferences for local treatment using a standard gamble technique.

Conclusions: Policy-makers, when considering the potential benefits of regionalising health care, should seek to elicit the preferences of those patients who will be affected by the reorganisation.
Decision aids: are they worth it? A systematic review
Authors: Estabrooks Carole , Goel Vivek , Thiel Elaine , Pinfold Patricia , Sawka Carol , Williams Ivan
Published: October 2002

Objectives: The field of consumer decision support interventions has grown rapidly in the last 20 years, particularly since the increased formalization of evidence-based decision-making in health care. However, little is known as yet about the effect these decision aids have on relevant outcomes. To identify outcomes influenced by consumer decision aids (CDAs) and the particular effects of CDAs on those outcomes.

Method: Published reports of randomized controlled trials and other designs in English identified from searches of Medline, Cancerlit, CINAHL, PsycINFO, Social Science Abstracts, the Cochrane Library and Current Contents, and from ancestry searches, hand searches and consultation with key informants. Studies were included if consumers were the decision-makers, decisions were real and not hypothetical, the intervention met a strict definition of a CDA and decisions involved treatment or screening. Data on setting, subjects, decision types, decision aid features and outcomes were extracted. The validity of each study included was evaluated by two team members. Summative ratings were calculated and categorized as high, medium and low.

Results: Over 500 titles were initially assessed; 96 study reports were obtained and screened for inclusion. Twenty-two reports representing 20 studies met the inclusion criteria. Eight studies with a low rating were excluded. Results were synthesized from the remaining 12 studies. Published studies of CDAs are increasing although still few in number. Outcomes such as knowledge and decision-making processes are influenced by CDAs but effects on treatment preferences, the actual decision or other outcomes have yet to be clearly established.

Conclusions: Improved outcomes result from the use of CDA in some categories of outcome but insufficient evidence exists yet to support improved outcomes in all categories or to evaluate whether, given the considerable costs of many CDAs, funding for extensive ongoing development and testing can be sustained.
Routine monitoring of performance: what makes health research and development different?
Authors: Croxson Bronwyn , Hanney Stephen , Buxton Martin
Published: October 2002

Increasing attention is being directed to measuring and monitoring the use of health-related R&D funding, partly to justify this expenditure and partly to ensure that R&D effort is directed to achieving the paybacks desired by funders. These paybacks include contributing to knowledge, contributing to R&D capacity, political benefits, benefits to the health service and to patients, and more general economic benefits. This paper addresses the issues that must be considered when designing a routine performance management system for health R&D. Conventional methods of routine performance management are often rendered inappropriate in this context by the intangible and unpredictable outcomes of research, which are heterogeneous across projects and programmes and which can be hard to attribute to particular R&D support. Instead, to be effective in this context, a routine system must combine quantitative and qualitative indicators, utilising information from a number of different sources. The system must achieve acceptable levels (defined by the funder) on each of the following criteria: it must measure those dimensions of payback that are valued by the funder; it must be decision-relevant; it must be consistent with truthful compliance; it must minimise perverse incentives; and it must have acceptable net costs. It is vitally important that the system itself generates a positive payback. We illustrate these issues by outlining a system that might be used to monitor the payback from government-funded R&D.
Twenty-five years of programme budgeting and marginal analysis in the health sector, 1974-1999
Authors: Mitton Craig , Donaldson Cam
Published: October 2002

Objectives: Programme budgeting and marginal analysis (PBMA) is a priority setting framework that has been used over the last 25 years in the health sector. To date, no formal evaluation of this framework has been conducted. The aims of this study were to categorize previous PBMA exercises systematically and determine the impact of PBMA in regional health authorities (RHAs) internationally.

Methods: Thirty authors of grey literature and published papers on PBMA, and an additional six economists with research interests in PBMA, were surveyed with a mailed questionnaire. Previous exercises were categorized and details of the short- and long-term impacts of the framework were obtained. Descriptive statistics and content analysis were used.

Results: The PBMA framework was identified as having been used 78 times in 59 RHAs. For the exercises where longer-term impact was known, the approach was viewed as having had a positive impact, as defined by the setting of priorities or shifting of resources, in 59% of cases and continued to be used in at least 52% of the RHAs. The primary reasons why PBMA was discontinued included personnel changes and lack of internal 'champions'.

Conclusions: Contrary to popular perception, there has been widespread diffusion of PBMA in RHAs internationally and, overall, the impact of this approach has been positive. Although there is general agreement on the validity of the economic principles underlying PBMA, addressing managerial issues would seem to be central to successful implementation in a given region.
Bias measuring bias
Authors: Raine Rosalind
Published: October 2002

The British National Health Service and other publicly funded health systems operate on the principle that health care should be provided solely on the basis of need. Yet the literature abounds with reports of bias in health care use. In order to defend such a charge, two conditions must be met. The first condition is that treatment decisions must be shown to be unfair in that they are not made solely on the basis of need. This paper demonstrates the importance of considering the fair distribution of health care from two, related, perspectives. The first is that people with equal needs should be treated the same (equal use for equal need). This is referred to as the achievement of horizontal equity. The alternative perspective is that people with greater needs should have more treatment than those with lesser needs (unequal use for unequal need). This is referred to as the achievement of vertical equity. Although these perspectives are logically linked, demonstration of equal use for equal need does not necessarily indicate unequal use for unequal need. This is because it cannot be assumed that equal use occurs at every level of need. The second condition that must be met is that clinical judgement must be shown to be influenced by prejudicial notions about patients. Such research is fraught with methodological difficulties, and the charge of biased clinical decision-making is usually made as a result of a process of exclusion. Methods that could be used to examine the extent to which inequalities in health care use are due to bias are described.
Health needs assessment and needs-led health service change: a survey of projects involving public health doctors
Authors: Jordan Joanne , Wright John , Ayres Philip , Hawkings Martin , Thomson Richard , Wilkinson John , Williams Rhys
Published: October 2002

Objectives: To describe the criteria that define an effective health needs assessment and to explore which factors are important for the delivery of effective health needs assessment in the English National Health Service (NHS).

Methods: A postal questionnaire to all public health doctors in an English health region to describe health needs assessment activity, including initiating factors, methods and outcomes. This was followed by semi-structured interviews with public health professionals and others involved in 10 purposively selected needs assessments.

Results: A response rate of 62% identified a total of 102 health needs assessments undertaken between 1993 and 1998. A number of themes emerged as being important in the impact of health needs assessments on policy and planning. These included careful design, methodological rigour, decisive leadership, good communication, involvement and ownership of the work from relevant stakeholders, support from senior decision-makers, appreciation of the political dynamics and engagement with local priorities, availability of resources and, finally, an element of chance. These themes can be categorised broadly into contextual factors and quality or robustness of the work. Our findings suggest that, although methodological and analytical quality are necessary characteristics of effective health needs assessment, they are not sufficient without a favourable political environment.

Conclusion: There appear to be conditions under which needs assessment is more likely to be effective in terms of its influence on policy and planning. However, it is clear that needs assessment does not occupy a central position in health service decision-making, remaining vulnerable to a range of factors over which those responsible for its conduct have little or no control.
The test-retest reliability of the modified Patient Generated Index
Authors: Tully Mary , Cantrill Judith
Published: October 2002

Objectives: The purpose of this study was to determine the test-retest reliability of the recently modified Patient Generated Index (PGI) when used as a self-completed postal questionnaire by older people with arthritis.

Methods: Two sets of postal questionnaires were used, sent two weeks apart, followed by interviews with a theoretically chosen subsample of respondents to both. Reliability for respondents whose health had not changed in the intervening two weeks was assessed using intraclass correlation coefficients. Data from interviews were used to develop theories to select subgroups for analysis.

Results: One thousand one hundred and twenty-nine people over 65 years old with arthritis were surveyed and 53 were selected for interview. The response rates to the two surveys were 78% and 83%, respectively. Complete data for the test-retest analysis were available from 236 (29.2%) respondents. The intraclass correlation coefficient ( ri) was 0.55 [95% confidence interval (CI) 0.43 to 0.64, P < 0.0001]. The most optimistic range for the limits of agreement was 64.66 around the difference between two total PGI scores. The intraclass correlation coefficient decreased considerably if there had been more than six changes to the areas chosen for inclusion on the second occasion ( ri = 0.37, 95% CI 0.01 to 0.65, P < 0.05). Interview data showed that some respondents incorrectly interpreted the scoring instructions, often inconsistently. When their data were excluded, the intraclass correlation coefficient increased to 0.67 (95% CI 0.56 to 0.76, P < 0.0001).

Conclusions: The results indicate that the modified PGI may be sufficiently reliable for within-group comparison of elderly people with arthritis, but not for assessing individual patients. However, it also elicits individual patient concerns and priorities about disease that other questionnaire-based instruments may not identify.
How comprehensive are the basic packages of health services? An international comparison of six health insurance systems
Authors: Polikowski Marc , Santos-Eggimann Brigitte
Published: October 2002

Objectives: Interest in the composition of the health care menu has grown. Its outwardly comprehensive nature is as rhetorical as the slogans of universal access and affordability. This paper summarizes the international part of a report to the Swiss government, in which we explored the basic package of services covered by social health insurance in France, Germany, Israel, Luxembourg, The Netherlands and Switzerland. The aim of the initial report was to check the appropriateness of the Swiss catalogue, with special attention to the risk of unequal access to health care by rationing of effective services. In this paper, we highlight the major differences in service coverage between the countries and address the possible factors explaining those differences.

Methods: The contents of the basic packages of the six countries were compared using data from government ministries and sickness funds.

Results: Coverage is most comprehensive in Germany and Switzerland; these are also the countries with the greatest total health expenditure. Three countries separated nursing care from other types of health care by creating an independent insurance scheme. Some health care benefits are also covered under the heading of social care. High out-of-pocket payments are increasingly used as hidden rationing instruments.

Conclusions: The present comparison highlights the multi-factorial character of the choices made in six countries in order to keep their health care menu within the possibilities offered by available resources.
The impact of managed care and practice size on primary care physicians' perceived ability to refer
Authors: Xu Tom , Rohrer James , Borders Tyrone
Published: October 2002

Objectives: To identify the determinants of primary care physicians' perceived ability to refer patients, to compare perceived ability to refer between solo/two-physician practices and group practices, and to determine the impact of managed care on perceived ability to refer.

Methods: Multivariate analysis using a dataset derived from the Community Tracking Study Physician Survey, 1996-1997. The variables used to explain physicians' perceived ability to refer included physician and practice characteristics as well as aspects of the financial arrangements of managed care. The sample was stratified by practice size. A likelihood ratio test was performed to determine whether there were differences in practice characteristics and managed care financial arrangements that could explain variations in perceived ability to refer between physicians in solo/two-physician and group practices.

Results: Perceived ability to refer did not vary much between physicians in solo/two-physician practices and those in group practices. However, the determinants of perceived ability to refer did vary by practice size. The effects of physicians' characteristics were more pronounced among physicians in group practice, whereas the effects of financial arrangements were significant for physicians in solo/two-physician practices. The most significant determinant of perceived ability to refer was primary care physicians' satisfaction in their communication with specialists.

Conclusion: Group practices are more immune than solo/two-physician practices to external financial arrangements from managed care contracts, possibly through their ability to take advantage of economies of scale and to diversify their sources of funds.