Document 0357
 DOCN  M9590357
 TI    The economics of prophylactic therapy.
 DT    9509
 AU    Pinching AJ; Department of Immunology, Medical College of Saint
       Bartholomew's; Hospital, West Smithfield, London, UK.
 SO    Annu Conf Australas Soc HIV Med. 1994 Nov 3-6;6:136 (unnumbered
       abstract). Unique Identifier : AIDSLINE ASHM6/95291742
 AB    The AIDS patient, with profound and progressive cell-mediated
       immunodeficiency, presents a prospect of substantial morbidity and
       mortality due to severe opportunist infections. The clinical goal is to
       minimise HIV replication to ameliorate the rate at which immune defences
       are eroded and to maximise immune and other defences against these
       infections. This should have the effect of improving both quality and
       quantity of life. The use of prophylaxis against specific opportunist
       organisms is one means of improving outlook. Prophylaxis should focus on
       the commoner organisms to maximise the personal relevance of the
       approach and to minimise the risk of toxicity and multiplicity of
       agents. In increasingly cost-conscious health care systems, economic
       considerations are also important, and the costs of caring for AIDS
       patients are notably high. Direct costs largely result from the
       intensive inpatient care required, together with the expensive
       investigation and treatment of the major infections. Indirect costs
       include the loss of productive life in terms of personal employment and
       the cost of invalidity on social security systems. Approaches to reduce
       these costs tend to focus on increased community-based care and to
       improve early recognition and therapy for opportunist disease. The
       judicious use of prophylaxis offers a further means of reducing such
       costs by deferring or preventing those infections that incur greatest
       cost. Pneumocystis carinii prophylaxis is an evident example, where the
       reduced attack rate of this acute infection will greatly reduce
       inpatient costs. Such a high proportion of patients with AIDS will be
       affected that treatment of the whole at-risk population is economically
       as well as clinically justifiable. Mycobacterium avium intracellular
       (MAI) disease presents a somewhat different example. Again, the attack
       rate of this infection in temperate zones is high for people with CD4
       counts below 100. However, the onset of symptomatic MAI disease is
       typically insidious, usually producing many weeks or months of ill
       health before the diagnosis is made. This high and prolonged morbidity
       will incur substantial costs in terms of reduced work productivity and
       increased need for social security support and care. Therapy, while
       reasonably effective, has significant limitations in the long term and
       may take some time to establish its effects. Rifabutin, a relatively
       expensive agent, has been shown to reduce substantially the attack rate
       of symptomatic MAI disease, albeit with little if any effect on
       survival. The deferral or prevention of symptomatic MAI infection by
       this means will therefore reduce the disability resulting from the
       symptoms it produces and hence will reduce the indirect costs, quite
       apart form the desirable aim of improved quality of life. It will also
       reduce the direct costs of investigation and the more costly therapy for
       established MAI disease. The use of this agent is associated with very
       little toxicity and does not appear to induce resistance; it may also
       reduce infection with M tuberculosis. In the widest sense therefore, MAI
       prophylaxis for AIDS patients with very low CD4 counts offers an
       economically as well as a clinically viable.
 DE    AIDS-Related Opportunistic Infections/ECONOMICS/*PREVENTION &  CONTROL
       Cost-Benefit Analysis  England  Human  Mycobacterium
       avium-intracellulare Infection/ECONOMICS/  *PREVENTION & CONTROL
       Rifabutin/*ADMINISTRATION & DOSAGE/ECONOMICS  MEETING ABSTRACT

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