trimethoprim--sulfamethoxazole-drug-combination and Meningitis--Cryptococcal

Understanding the costs associated with health care delivery strategies is essential for planning. There are few data on health service resources used by patients and their associated costs within antiretroviral (ART) programmes in Africa.. The study was nested within a large trial, which evaluated screening for cryptococcal meningitis and tuberculosis and a short initial period of home-based adherence support for patients initiating ART with advanced HIV disease in Tanzania and Zambia. The economic evaluation was done in Tanzania alone. We estimated costs of providing routine ART services from the health service provider's perspective using a micro-costing approach. Incremental costs for the different novel components of service delivery were also estimated. All costs were converted into US dollars (US$) and based on 2012 prices.. Of 870 individuals enrolled in Tanzania, 434 were enrolled in the intervention arm and 436 in the standard care/control arm. Overall, the median (IQR) age and CD4 cell count at enrolment were 38 [31, 44] years and 52 [20, 89] cells/mm3, respectively. The mean per patient costs over the first three months and over a one year period of follow up following ART initiation in the standard care arm were US$ 107 (95%CI 101-112) and US$ 265 (95%CI 254-275) respectively. ART drugs, clinic visits and hospital admission constituted 50%, 19%, and 19% of the total cost per patient year, while diagnostic tests and non-ART drugs (co-trimoxazole) accounted for 10% and 2% of total per patient year costs. The incremental costs of the intervention to the health service over the first three months was US$ 59 (p<0.001; 95%CI 52-67) and over a one year period was US$ 67(p<0.001; 95%CI 50-83). This is equivalent to an increase of 55% (95%CI 51%-59%) in the mean cost of care over the first three months, and 25% (95%CI 20%-30%) increase over one year of follow up.

Topics: Adult; Anti-HIV Agents; Antiretroviral Therapy, Highly Active; CD4 Lymphocyte Count; Delivery of Health Care; Disease Progression; Female; Health Care Costs; Health Resources; HIV Infections; Humans; Male; Meningitis, Cryptococcal; Public Health Systems Research; Tanzania; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary; Zambia

Patients with HIV are at risk of both primary and secondary haematological disorders. We report two cases of patients with HIV and cryptococcal meningitis who developed severe haemolytic anaemia, thrombocytopenia, renal failure and lactic acidosis while on treatment with amphotericin B and co-trimoxazole.

Topics: Acidosis, Lactic; Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Anemia, Hemolytic; Antifungal Agents; Cryptococcus neoformans; Drug Therapy, Combination; Female; Humans; Male; Meningitis, Cryptococcal; Renal Insufficiency; Thrombocytopenia; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Dr. Bernard Bihari, an AIDS specialist practicing in New York City, and other members of the Community Programs for Clinical Research on AIDS (CPCRA), have determined that some of the Public Health Services's recommendations for preventing opportunistic infections do not match the standards of care that the CPCRA developed nearly five years ago. The basic treatments provided by Bihari include using 1) TMP-SMZ and fluconazole to prevent, respectively, Pneumocystis carinii pneumonia (PCP) and cryptococcal meningitis in patients with CD4 counts below 200; 2) using high-dose acyclovir to prevent cytomegalovirus disease when the CD4 counts drop below 150; and 3) using clarithromycin and ethambutol to prevent Mycobacterium avium complex when CD4 counts drop below 100. This protocol has kept many patients from developing these opportunistic infections. Bihari notes that while the Centers for Disease Control and Prevention (CDC) recommendations are based on FDA-approved treatments and large clinical trials, private practitioners do not necessarily have to follow them.

Topics: AIDS-Related Opportunistic Infections; CD4 Lymphocyte Count; Clarithromycin; Cytomegalovirus Infections; Ethambutol; Humans; Meningitis, Cryptococcal; Mycobacterium avium-intracellulare Infection; New York City; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination