Life Care Planning Considerations for the HIV/AIDS Patient (III)

Life Care Planning for the HIV/AIDS Patient – Classification (I)

Clinical Management of HIV Infection Objectives of Clinical Therapy (II)

The approval in 1996 of several antiretroviral drugs and tests for quantifying viral load trans­formed the care of HIV patients. Case management strategies in the past primarily addressed cost-effective treatment of the primary disease for a relatively short time horizon. The new pri­mary disease treatment protocols have significantly slowed the progression of HIV infection and prolonged survival in many patients. The extension of life span has broadened case management guidelines for the HIV-infected patient in scope, direction, and responsibilities. One new facet of case management is the psychosocial adaptations of living long-term with HIV/AIDS. This not only includes the psychological health of HIV-positive persons and their families, caregivers, and health-related professionals, but also the immense financial and job market accommodations that are required.

Life care planning for the individual living with AIDS or symptomatic HIV can cover a wide array of needs. To be as inclusive as possible in outlining the potential areas of needs, a checklist may prove helpful. The following checklist is for planning purposes. In the interest of space, not every possible concern has been detailed. However, this checklist will guide the interested party in the systematic thought process needed to comprehensively consider the need areas (Kitchen, 1995).

Life Care Planning: Needs Checklist for the HIV/AIDS Patient

Physical impairment/considerations:

Hemiplegia Loss of balance Loss of strength Paralysis Coordination

Fatigue (extreme in some cases)

Weakness

Clumsiness

Ataxia

Reduced functional capacity Pain

Visual acuity

Physical stamina and endurance

Loss of bowel control

Arthralgia

Arthritis

Fibromyalgia

Cognitive impairment/neuropsychological considerations:

Depression

Dementia

Intellectual impairment

Inattention

Forgetfulness

Reduced concentration

Expressive/receptive speech

Aphasia

Dysarthria

Adjustment disorder

Apathy

Disorientation

Social isolation

Delirium

Manic disorder

Psychotic disorder

Anxiety disorder

Adjustment disorder

Respiratory considerations:

Bacterial infection

Lymphoma

Fungi

Respiratory therapy, Peripheral neuropathy, Pap test,

Mycobacteria Pneumocystis Kaposi’s sarcoma Viral infections Tuberculosis

Gastrointestinal considerations:

Abdominal pain

Painful elimination

Hepatomegaly

Cholecystitis

Colitis

Enteritis

Megacolon/colon perforations Pancreatitis Intestinal obstruction Mucosal biopsy

Neurological considerations:

Meningitis

Focal CNS lesions

Encephalitis

Headache

Myelopathy

Cranial nerve palsies

Seizures

Peripheral neuropathy Demyelinating neuropathy

General health considerations:

Diarrhea

Painful elimination Apathy Anorexia Dysphagia

Poor intake (painful mouth/throat) Medication reaction/interaction Adverse drug reactions Chronic pain Esophageal disease Fever

Malnutrition Weight loss Malabsorption Wasting syndrome

Candida (oral/esophageal/vaginal)

Sleep disorder

Hematologic considerations:

Anemia

Leukemia

Bone marrow disorders

Leukopenia

Thrombocytopenia

Cardiovascular considerations:

Pericarditis

Pulmonary hypertension Myocardial involvement Vascular abnormalities Arrhythmias

Venous thrombosis and pulmonary embolism

Endocrinologic considerations:

Hypothalamic-pituitary

Adrenal

Glucocorticoid hormones (Cortisol)

Mineralocorticoid hormone deficiency (renal sodium wasting, hypotension, hypokalemia, and metabolic acidosis)

Thyroid

Gonad

Pancreas

Mineral homeostasis Lipid metabolism Wasting syndrome

Renal considerations:

Fluid imbalance Electrolyte imbalance Acid—base disturbance Acute tubular necrosis Metabolic acidosis HIV-associated nephropathy Hemolytic uremic syndrome Dialysis

Dermatologic considerations:

Infections

Shingles

Herpes virus infection Hairy leukoplakia Neoplastic disease Seborrheic dermatitis Hypersensitivity rashes

Oral considerations:

Candidiasis Gingivitis Periodontitis Herpes simplex Herpes zoster Bacterial lesions Cytomegalovirus ulcers Hairy leukoplakia Warts

Neoplastic disease:

Kaposi’s sarcoma

Lymphoma

Carcinoma

Recurrent aphthous ulcers

Life Care Planning: Recommendations Checklist

Allied health evaluations:

Physical therapy Occupational therapy Speech therapy Respiratory therapy Recreational therapy Psychology Neuropsychology Vocational/educational Financial planning Seating/mobility Adaptive driving

Medical (evaluations and follow-up):

Physiatry

General medicine

Dental

Podiatry

Oncology

Dermatology

Neurology Rheumatology Anesthesiology (pain control)

Nutritional

Gynecological/obstetrics

Psychiatry

Gastroenterology

Urological

Plastic/reconstruction

Pulmonary

Cardiology

Ophthalmology

Diagnostics, such as TB testing, MRI, CT scans, Pap smear, etc. (see list in the following) Routine preventative immunizations (i.e., pneumonia vaccine, hepatitis B)

Laboratory testing (Bartlett, 2001):

HIV serology CBC

CD4 count

Quantitative plasma HIV RNA

Chemistry profile, including renal function and liver function tests Toxoplasma serology (immunoglobulin G, or IgG)

Chest X-ray PPD

STD screen; syphilis and Chlamydia urine screen (women)

Baseline fasting lipid profile and glucose in all candidates for HAART therapy Hepatitis screen: HAV and HBV (to determine candidates for vaccine), HCV (in all injection drug users), and active hepatitis screen by determination of transaminase levels Pap smear (if none in the past year)

Optional tests:

CMV serology HAV antibody Varicella antibody

G6PD (sometimes done at baseline in those with high risk—African Americans and men of Mediterranean heritage)

Sequential tests:

HIV RNA plasma levels: baseline confirmatory test at 2 to 4 weeks, then every 3 months if stable, or more frequently with initiation of antiretroviral therapy or change in therapy CD4 count: baseline and then every 3 to 6 months +/— confirmatory test if outlier results PPD: annual in high-risk patients with persistently negative results RPR: annual syphilis test in sexually active patients Pap smear: baseline and 6 months, then annually if negative CBC: baseline and every 3 to 6 months (as a component of CD4 count)

Therapeutic drug monitoring:

AZT-CBC every 3 months or more frequently ddC, ddI , d4T—peripheral neuropathy

Nevirapine—liver function tests, especially during first 6 weeks

Protease inhibitors +/— NNRTI—fasting lipid profile at baseline and in 3 to 6 months; subse­quent frequency depends on risks and test results Fasting levels necessary for triglycerides that are used to determine LDL; should be done after 8- to 12-hour fast

Therapeutic modalities:

Physical therapy

Occupational therapy

Speech therapy

Respiratory therapy

Recreational therapy

Therapy/counseling (group, individual)

Career guidance/counseling Staff training Family counseling Family education Patient education

Driver’s education (with adaptations)

Legal/financial counseling Spiritual support/counseling Caregiver support Case management Leisure pursuits

Equipment considerations:

Mobility equipment (wheelchairs/scooters, etc., manual/power)

Equipment repairs/maintenance

Emergency call equipment (Wander guard/cell phone, Call Alert, other safety systems)

Home furnishings (to conserve physical energy)

Lift recliner Accessible setting Mobile stools Reachers

Environmental control devices/maintenance and repair

Ramping

Stair glide

Elevator

Hospital bed/mattress

Special-size linens/blankets

Washer/dryer (for excess laundry requirements)

Feeding pumps (parenteral/enteral feeding)

Scale

Handheld shower Shower bench Handrails

Medical equipment:

Suction machine Apnea monitor Oxygen concentrator Liquid oxygen Ventilator Humidifier

Miscellaneous supplies (medical):

Catheters

Feeding bags

Suction catheters

Syringes

Diapers

Bed pads

Gloves

Creams/powders

Gauze/tapes

Masks

Thermometers Blood pressure monitors Garbage bags Wipes Paper towels Antibacterial soaps

Architectural renovations/medical retrofitting:

Barrier-free design Grab bars in bathroom Temperature guards Call system

Orthotics:

As prescribed

Orthopedic equipment:

(For strength maintenance and mobility)

Walkers

Parallel bars

Canes Crutches Bath seat

Aids for independent function:

Built-up plates/utensils One-handed equipment Voice-activated computer/software Adaptive clothing

Infection control devices:

Sharps/needle/contaminant storage and destruction Decontaminant cleaners

Medications:

Antiretrovirals Protease inhibitors Palliative care Pain treatment Oral IV

Feeding supplements Dietary supplements Vitamin therapy

Attendant/nursing care:

Respite care Caregiver support Hospice care Home health aide Driver

Nursing care

Home maintenance (interior/exterior)

Surgical/aggressive intervention:

Ports for total parenteral nutrition (TPN) access

Plastic surgical repairs

Pain control devices (implanted)

Surgical treatment of complications Tumor removal

Complications:

Hospital care Clinic care Secondary infections

Falls

Accidents

Medical complications (myriad) Financial

Costs of Care

There is one certainty when considering the costs of care for the HIV/AIDS patient: there is no way to predict the costs of care with certainty. In this author’s opinion, the medical manage­ment of the HIV/AIDS patient cannot be projected beyond the near future because the course of the disease and complications vary widely between patients. New treatment therapeutics and regimens, which are continuously being introduced to the treatment protocol, can change the treatment plan repeatedly. Although one can become knowledgeable about the most frequently encountered complications and the range of care and associated costs, with current research it is not possible to state within a reasonable degree of rehabilitation probability the frequency of occurrence, the severity of occurrence, the duration of a complication, or its best treatment strat­egy at some future time. Therefore, a practical way to predict a treatment course, project its costs, and feel comfortable that adequate services and funding have been identified may not exist. This effectively limits the amount of information for quantifying the costs of treatments that can be provided in a life care plan. The following tables present the costs of the choices for various anti­retroviral therapies (ARTs) used as primary treatments of HIV infection. Table 15.1 summarizes annual costs for nucleoside analog medicines. Annual costs for nonnucleoside compounds are shown in Table 15.2. Protease inhibitor drug costs are summarized in Table 15.3. The new drug classes of entry inhibitors and integrase enzyme inhibitors annual costs are presented in Table 15.4. The costs of interventions for some of the more common OIs are summarized in Table 15.5, while Table 15.6 presents some other customary health care expenses. Also refer to Table 15.7 for ARV costs presented within a composite cost of care study.

More extensive primary disease therapies used over lengthier periods of time and the concomi­tant extension in life expectancy for the HIV patient that has occurred over the past decade have increased costs of care significantly compared to life care plans prepared 10 years ago. In addition to the costs for treating the primary HIV infection, common complications in HIV disease man­agement must be considered in projecting the costs of care. The most common complication of HIV disease is the occurrence of OIs, which can substantially influence the total sphere of costs. Improved prophylaxes and treatment protocols for more OIs result in the prescribing of more drugs over the course of the disease, which also raises the costs of care.

Opportunistic infection management can be a major expenditure, especially when one factors in the ongoing prophylactic treatment after the initial acute infection has subsided or when the patient’s condition indicates prophylaxis be commenced. For example, the routine use of Diflucan for persons with CD4+ counts of less than 100 would cost almost $100,000 for each major infection prevented. Another example to consider is the medication for CMV infections. Oral Ganciclovir as a prophylaxis of CMV disease reduced the rate of CMV disease by nearly 50%; however, oral Ganciclovir costs approximately up to $20,000 per year. At higher CD4+ counts, health care costs are principally due to primary disease therapy and typically not OI management. The primary treatment therapy remains the most expensive cost consideration, however; costs for prophylaxis and treating complications increase as the CD4+ counts decrease. Table 15.5 presents the costs of agents recommended for prophylaxis or treatment of the more frequently encountered OIs among adults with HIV.

 Antiretroviral Therapy: Nucleoside Analogs (Reverse Transcriptase Inhibitors)

Name

Cost/yeara

Zidovudine, ZDV (Retrovir)/AZT

$4,340.18

Didanosine, ddI (Videx)

$3,686.85

Zalcitabine, ddC (Hivid)

$3,013.89

Stavudine, d4T (Zerit)

$4,061.28

Lamivudine, 3TC (Epivir)

$3,818.75

Combivir (Zidovudine/lamivudine)

$7,940.61

Abacavir (Ziagen)

$4,930.75

Trizivir (Ziagen/Retrovir/Epivir)

$12,895.71

Tenofovir (Viread)b

$5,198.00

Emtricitabine (Emtriva)

$3,625.56

Truvada (emtricitabine/tenofovir)

$9,683.45

Emzicomc (Epivir/Ziagen)

$10,151.88

Atripla (Sustiva/ Viread/Emtriva)

$13,800.00

Source: Stine, G. J., AIDS Update. New York: McGraw-Hill, 2008. With permission.

Note: Nucleoside analog reverse transcriptase inhibitors (NRTIs) are potent in combination with other drugs; used alone, they lead to HIV resistance, ZDV (AZT), d4T, 3TC, and abacavir penetrate the blood-brain barrier. Common side effects: lactic acidosis. Seven new nucle­oside analogs are in some phase of testing in the United States.c

a Cost is based on average prescription prices found in Jacksonville, FL, pharmacies, 2006. b Tenovir is the first nucleotide analog approved for HIV treatment. It blocks HIV replication simi­lar to the nucleoside analogs. c Prevents the viral proteins from assembling into the HIV capsid that houses viral RNA, enzymes, etc.

The medical management of the HIV/AIDS patient is not limited to primary disease treatment and control of OIs. Other health care resources such as consultations with specialists, tests, par­ticular procedures, and health care facility usage are regularly employed to monitor and manage the course of the disease and its complications. Table 15.6 presents some health care resource costs. The costs are presented in 2003 dollars as econometrically updated from the originally reported 1995 dollars (Gable et al., 1996). The 1995 dollar costs were revised to represent 2003 dollar costs based on the cumulative increase in the medical care component of the U.S. Department of Labor’s Consumer Price Index, 1995 (annual) versus June 2003.

These tables do not present home care costs such as attendants or nursing services that the patient may periodically require. The cost of attendant or skilled nursing care will vary by the severity and duration of the specific episode of the complication. In early disease stages the patient may only need outpatient treatment, while in later stages the patient may require intermittent hospitalization or home-based attendant care with visiting skilled nursing. Eventually disease pro­gression may necessitate skilled nursing care and perhaps home-based hospice care.

 Antiretroviral Therapy: Nonnucleoside Compounds (Nonnucleoside Reverse Transcriptase Inhibitors)

Name

Cost/Year*

Nevirapine (Viramune)

$4,395.36

Delavirdine (Rescriptor)

$3,842.13

Efavireuz (Sustiva, Stocrin)

$5,258.69

Source: Stine, G. J., AIDS Update. New York: McGraw-Hill, 2008. With permission.

Note: Non-nucleoside analog reverse transcriptase inhibitors (NNRTIs) may interact with other Cytochrome p450-preceed drugs: protease inhibitors, oral contraceptives, etc. NNRTIs have a mixed ability to penetrate the blood-brain barrier. Common side effect: mild rash. Some doctors build up drug doses slowly to avoid rash; the other worry is that dose building increases risk of drug resistance.

a Cost is based on average prescription prices found in Jacksonville, FL, pharmacies, 2006.

When computing the potential cost of attendant care services, it is important to include vol­unteer or nonpaid hours in the total costs of care. It is common for the patient’s family, significant other, spouse, or other volunteers to provide health care services when sufficient funding to acquire paid help is lacking. Particularly in determining costs of care in the life care planning (forensic) arena, these volunteer hours must be accounted for in the total cost of care. In other words, the ser­vices that a spouse, friend, or volunteer provide have a value. The proper method to assess the value of such services is to determine what it would cost to replace these services in the labor market. These service-related costs are typically obtained by contacting a home health agency to evaluate the level of care required based on the home health regulations in a specific state.

This discussion of costs also leads to a consideration of the availability of funding for the proper treatment of early intervention and prophylaxis for OIs. As is typical in the general population, funded health care has been proven to reduce overall costs of health care since preventative steps can be taken that reduce actual costs per incidence of medical need. That is true in the HIV/AIDS population as well. If funding is not available for primary disease medications or for preventative treatment of OIs, costs can escalate due to complications and OIs, resulting in more hospital stays and a foreshortened life expectancy.

Other considerations in providing care for the HIV patient include social services, palliative treatment (i.e., pain management), psychological support, and home health requirements. Home health requirements can include services provided and arranged through an agency (home health agency), private home health hires, friends, family services, community or church volunteers, and local service programs. A central aspect of home health care is providing a stable environment in which adherence to the treatment regimen can be maintained to avoid the possibility of viral resistance even if directly observed therapy becomes necessary.

The economic impact on the individual through loss of work productivity, quality of life, self­esteem, and will to live merits consideration in assessing the costs of living with HIV infection. Services must be provided to empower the HIV/AIDS individual in all spheres of life.

The first report of annual health care expenditure per HIV+ patient in the United States was published by Chen et al. (2006). Their study, “Distribution of health care expenditures for HIV-infected patients,” was conducted in the University of Alabama at Birmingham outpatient

 Antiretroviral Therapy: Protease Inhibitors

Name Cost/Yeaia
Saquinavir mesylate (Invirase) $5,233.39
Ritonavir (Norvir) $9,001.32
Indinavir (Crixivan) $6,310.46
Nelfinavir (Viracept) $8,641.23
Saquinavir (Fortovase) $2,954.93
Amprenavir (Agenerase) $4,372.71
Kaletra (Lopinavir/Novir) $8,040.05
Atazanavir (Reyataz) $9,959.88
Fosamprenavir (Lexiva) $7,800.00
Tipranavir (Aptivus)c $3,340.68
Darunavir (Prezista) $9,125.00

Source: Stine, G. J., AIDS Update. New York: McGraw-Hill, 2008. With permission.

 

Note: Protease Inhibitors (PIs) are very potent and may interact with other drugs using cyto­chrome p450 metabolic pathways. Potentially life-threatening if taken with Seldane, Hismanal, Propulsid, Halcion, or Versed. Avoid rifabutin, Nizoral, rifampin. Poor absorption may affect potency. Common side effects: liver toxicity, hypoglycemia, flatulence, bloating, lipodystrophy (fat distribution). Seven new protease inhibitors are now in some phase of testing in the United States. In addition, there are at least 28 other antiretroviral drugs being investigated.

a Cost is based on average prescription prices found in Jacksonville, FL, pharmacies, 2006. c Prevents the viral proteins from assembling into the HIV capsid that houses viral RNA, enzymes, etc.

clinic. The annual health care costs are reported as total cost, ARV medication, non-ARV medi­cation, hospital cost, other outpatient costs, and physician/clinic costs. The results are summa­rized in Table 15.7.

Viatical Settlements

A unique financial resource, a viatical settlement, is available to individuals who are HIV+. This process, which is called viatification, allows individuals to sell their life insurance policy for cash. A viatical settlement provides a valuable financial resource to help patients pay for the cost of hos­pitalization, treatment, home care, or other expenses, including day-to-day living expenses. The proceeds of a viatical settlement can facilitate options the patient might not otherwise have had, such as noninsured or experimental medical treatments, and can restore the patient’s control over the conduct of daily life.

Viatical settlement is not a new concept. The term comes from the Latin viaticum, meaning “provision for a journey.” Viatica were the supplies that Roman soldiers were given in preparation for their journeys into battle (presumably journeys from which they might not return). In essence,

 Antiretroviral Therapy: Entry Inhibitors and Integrase Enzyme Inhibitors

Name Cost/Yeara
Entry Inhibitors  
T-20 (Enfuvirtide, Fuzeon) $20,000 (WAC)d
Maravirocc (Selzentry)e $13,200
Integrase Inhibitors  
Raltegravir (MK 0158)e $12,133.08

Source: Stine, G. J., AIDS Update. New York: McGraw-Hill, 2008. With permission.

 

Note: Entry inhibitors bar HIV from entering immune cells.

Integrase inhibitors prevent HIV DNA from entering human DNA. All lettered notes for Tables 15.1-15.4 are summarized below:

a Cost is based on average prescription prices found in Jacksonville, FL, pharmacies, 2006. b Tenovir is the first nucleotide analog approved for HIV treatment. It blocks HIV replication simi­lar to the nucleoside analogs. c Prevents the viral proteins from assembling into the HIV capsid that houses viral RNA, enzymes, etc.

d Atazanavir is the first once-a-day PI for use with other anti-HIV drugs. Fuzeon, on launch day (USA) 2003, cash and carry price was $2200/month or $26,400/year. In 2006 the price was $2335/ month or $28,020/year. Wholesale acquisition cost (WAC) was $20,000. In May 2003, of the 142 largest insurers, 94% agreed to cover Fuzeon, as have Medicaid program in 48 states.

There are now drugs that interfere with at least nine different mechanisms in the process by which HIV attaches itself to specific cell types, enters them, enters the cells’ DNA, makes copies of itself, and exits the cell. e Maraviroc is the second FDA entry inhibitor drug, but the first CCR5 coreceptor inhibitor. Raltegravir is the first FDA HIV integrase enzyme inhibitor drug. Both drugs will be used in salvage patient therapy, that is, patients resistant to current antiretroviral therapy.

a viaticum was the provision a soldier needed for the closing phase of his life. The analogy is that a person wishing to viaticate is preparing for the closing phase of life.

Initially, the viatical settlement industry was comprised of an informal network of small insur­ance settlement companies serving primarily the AIDS community. Many insurance settlement providers are active in the field today, and the process has expanded to include persons with other life-threatening illnesses such as cancer or Alzheimer’s disease. In fact, in this author’s experience, the selling of an insurance policy no longer requires any justification. Any person can sell any policy and use the proceeds as desired, even to take a vacation.

Viatical settlements are available in all 50 states. There are no restrictions on how the funds may be used, which restores some control to the patient for making decisions as personally deemed necessary. All types of insurance policies, including term, whole life, universal life, or group (employer paid) policies, may be sold. Policy values of just $10,000 to well over $1 million have been sold as viatical settlements. The viatification process is initiated with a relatively simple application and usually takes 3 to 6 weeks to complete. Some viatical investment companies will offer to buy the policy directly; others will seek offers to purchase from other funding sources. For cautions, see www.sec .gov/answers/viaticalsettle.htm. Also, the National Association of Insurance Commissioners posts a link of companies including those deemed unsuitable. For example, see

 Wholesale Acquisition Costs of Agents Recommended for Preventing Opportunistic Infections among Adults Infected with HIV

Pathogen

Drug/Vaccine

Dose

Estimated Annual Cost/Patient US$

Pneumocystis

carinii

Trimethoprim-

sulfamethoxazole

160/800 mg daily

135

  Dapsone 100 mg daily

72

 

Aerosolized pentamidine

300 mg every a.m.

1185

  Atovaquone 1500 mg daily

11,627

Mycobacterium avium complex Clarithromycin 500 mg twice daily

2843

  Azithromycin 1200 mg weekly

3862

  Rifabutin 300 mg daily

3352

Cytomegalovirus Ganciclovir (oral)

1000 mg 3 times/day

17,794

  Ganciclovir implant (lasts 6-9 months)  

5000

  Ganciclovir (IV) 5 mg/kg of body weight daily

13,093

  Foscamet (IV) 90-120 mg/kg of body weight daily

27,770-37,027

  Cidofovir (IV)

375 mg every other week

20,904

 

Fomivirsen (intravitreal)

1 vial every 4 weeks

12,000

  Valganciclovir 900 mg daily

21,582

Mycobacterium TB Isoniazid 300 mg daily

23/9 months of therapy

  Rifampin 600 mg daily

294/2 months

  Pyrazinamide 1500 mg daily

194/2 months

Fungi Fluconazole 200 mg daily

4603

 

Itraconazole capsule

200 mg daily

5340

 

Itraconazole solution

200 mg daily

5673

  Ketoconazole 200 mg daily

1230

Herpes simplex virus Acyclovir 400 mg 2 times/day

1384

  Famciclovir 500 mg 2 times/day

5311

  Valacyclovir 500 mg 2 times/day

2538

Toxoplasma gondii Pyrimethamine 50 mg weekly

49

  Leucovorin 25 mg weekly

888

  Sulfadiazine 500 mg 4 times/day

1490

 

Pathogen

Drug/Vaccine

Dose

Estimated Annual Cost/Patient US$
Streptococcus

pneumoniae

23-valent pneumococcal vaccine One 0.5-ml dose intramuscularly

13

Influenza virus Inactivated trivalent influenza vaccine One 0.5-ml dose intramuscularly

3

Hepatitis A virus

Hepatitis A vaccine

Two 1.0-ml doses intramuscularly

124

Hepatitis B virus Recombinant hepatitis B vaccine Three 10- to 20-jg doses intramuscularly

70

Bacterial infections Granulocyte-colony- stimulating factor (IV) 300 |jg 3 times/week

29,406

Varicella-zoster

virus

Varicella-zoster immune globulin Five 6.25-ml vials

562

 

Source: Wholesale acquisition costs of agents recommended for preventing opportunistic infec­tions among adults infected with human immunodeficiency virus, Drug Topics Red Book, Medical Economics, Montvale, NJ, 2000. With permission; as noted in CDC-MMWR Recommendations and Reports, June 14, 2002/51(RR08), 1-46; Guidelines for Preventing Opportunistic Infections among HIV-Infected Persons—2002; Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America.

www.insurance .ca .gov/0100-consumers/0030-licensee-info/0040-viatical-settlements/viatical-

settlement-companies.cfm#top.

The value of the insurance policy (the amount paid to the policy owner) is determined by several factors, including prevailing interest rates, premium obligations, and projected life expec­tancy. The National Association of Insurance Commissioners (NAIC) has established pric­ing guidelines. Viators (patients) generally receive between 30% and 80% of the face value of the insurance policy. Generally, the longer the life expectancy, the less the viatical settlement

 Cost of HIV+/AIDS: Health Care Resource Use Costs

Resource Use Unit of Treatment Cost per Unit ($)
Amikacin levels Tests

201

Barium swallow Procedure

312

Blood chemistries Test

47

Blood culture Test

235

Blood gas Test

79

Bone marrow biopsy Procedure, physician, laboratory tests

1158

Bone marrow Test

287

Resource Use Unit of Treatment Cost per Unit ($)
Bone marrow and culture (MAC) Test

634

Brain biopsy Procedure, hospital (3 days), laboratory tests, physician

15,576

Bronchoscope Procedure

2181

Catheter placement Procedure

3116

CD4+ cell count Test

211

Chest radiograph Test

156

Colonoscopy (biopsy) Procedure

720

Complete blood count test Test

3

Consultation (oncologist) Visit

232

Cryptococcal antigen titer Test

89

CT scan/CAT Procedure

935

CT scan (noncontrast) Procedure

467

CT chest, abdomen, head Procedure, contrast material

2804

Dermatologic biopsy Procedure

391

Detached retina Treatment, hospitalization

4673

Dilantin level Test

70

Electroencephalogram Test

779

Endoscopy (biopsy) Procedure

779

Emergency room visit Visit

391

Foscarnet administration induction Treatment

9615

Foscarnet administration maintenance Treatment

1561

Foscarnet induction monitoring Test/cycle

760

Foscarnet maintenance monitoring Test/cycle

913

Ganciclovir administration induction Treatment

6255

Ganciclovir administration maintenance Treatment

1444

Ganciclovir induction monitoring Test/cycle

140

Ganciclovir maintenance Test/cycle

278

Home (drug) administration Visit

156

Home care Visit

350

 

 

Resource Use Unit of Treatment Cost per Unit ($)
Hospital physician visit Visit

195

Hospitalization Day

1544

Intensive care unit Day

3087

Induced sputum Procedure

547

Indwelling catheter Procedure

3087

Infected catheter Treatment and replacement

3739

Intralesional injections Procedure

156

Lipase and triglycerides Test

55

Lumbar puncture Procedure, laboratory tests

733

Lumbar puncture Associated tests

342

Lymphoma biopsy Procedure, hospital (1 day), physician, laboratory tests

3894

Magnesium test Test

31

Magnetic resonance imaging Procedure

1869

Office visit (physician) Visit

79

Ophthalmology examination Test

312

Ophthalmology examination (follow-up) Test

235

PPD skin test Test

15

Pulmonary function test Test

71

Radiation therapy, 2 to 3 weeks  

17,133

Serum amylase Test

24

Specialized test battery Tests

1558

Sputum smear and culture sensitivities Test

326

Toxoplasmosis titer Test

55

TPN TPN material and home infusion charges (9 days)

577

TPN laboratory work Test

125

Transfusion Each

779

Wasting syndrome diagnostic workup Clinical tests

3116

 

Source: Gable, C. et al., Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 12, 413-420, 1996. With permission.

Notes: 2003 dollars econometrically updated from 1995 dollars; CT = computerized tomography.

Mean Annual Expenditure per Patient by Cost Component and CD4+ Cell Count Category for 635 Patients from the University of Alabama at Birmingham HIV Outpatient Clinic

CD4 Cell

Count

Category

No. of Patients Total

Cost

Antiretroviral

Medication

Non-ARV

Medication

Hospital

Costs

Other

Outpatient

Costsa

Physician/

Clinic

Costs

<50

cells/|jl

62

$36,352

(100)

$10,855 (30) $14,882 (41) $8353 (23) $1909 (6) $533 (1)
50-199

cells/jl

99

$23,864

(100)

$11,862 (50) $6685 (28) $3369 (14) $1416 (6) $532 (2)
200-349

cells/jl

143

$18,274

(100)

$11,935 (65) $3452 (19) $1186 (7) $1365 (7) $336 (2)
>350

cells/jl

331

$13,885

(100)

$9407 (68) $1855 (13) $1408 (10) $930 (7) $285 (2)
All

635

$18,640

(100)

$10,500 (56) $4240 (23) $2342 (13) $1199 (6) $359 (2)

 

Source: Chen et al., Clinical Infectious Diseases, 42, 1003-1010, 2006. With permission.

Notes: Cost per patient per year (% of total cost) by category.

a Other outpatient costs include outpatient radiological examination, laboratory tests, proce­dures, and home health care.

company is likely to pay for that individual’s policy because the company must assume respon­sibility for maintaining the policy for a longer period of time. The proceeds from a viatical settlement may, however, impact certain means-based entitlement programs such as Medicaid. Furthermore, under current law, the proceeds from a viatical settlement are taxable as income for federal tax purposes. However, several states have adopted or are considering specific regulations or provisions, which may include the following:

■     State and city tax-free treatment of viatical settlement proceeds to encourage the use of these settlements

■     Prevention of the brokering of life insurance policies to individual investors who are looking for speculative returns without due regard for the policy owner’s welfare

■     Requiring viatical companies to maintain a minimum level of capital or surety bond to fund the purchase of life insurance policies as part of the viatical settlement process to help ensure that companies can fund settlements and to prevent the involvement of viatical settlement companies that may put people at financial risk

■     Requiring licenses and other strictly enforced reporting mechanisms for viatical settlement companies and limiting licenses to companies with well-established operations (Editor’s note: The Viatical Association of America identified in previous editions is not longer active.)

Case Management: A Critical Component

Case management of individuals with HIV/AIDS is vitally important—not only in managing the case from a direct economic standpoint, but also from managing the case from an early inter­vention/prevention standpoint. It is imperative that case managers keep themselves informed on the scope of knowledge available on HIV/AIDS, on new treatment modalities and their uses, on resistance issues, and on side effects. In addition, the case manager must be able to communicate effectively with physicians and to address nutritional issues, adherence of patients to therapy, financial issues, and psychological issues such as loss of identify and self-esteem.

Because the field is changing rapidly, the effective case manager will subscribe to professional journals that are devoted to the subject, for example, the Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology (www.jaids .com), and learn to browse the Internet efficiently. Suggested websites include national health hotlines, government agencies, and professional organizations; private-sector AIDS services, information, and advocacy groups; AIDS lobby/ watchdog groups; and other AIDS-related information sources. Information from the Centers for Disease Control and Prevention (CDC) is also available on the Internet.

When case managing HIV/AIDS clients, the health professional should encourage patients to become self-advocates. This will empower the person with HIV/AIDS to become involved with the treatment of the disease, rather than being a victim of the disease. Delays in treatment are not only costly, but also life threatening. Some suggested activities for both the case management professional and the patient are as follows:

■    Join the local AIDS organization, the county AIDS consortium, and the state board.

■    Attend conferences on AIDS, arming oneself with information to share.

■     Call local health departments or HIV/AIDS organizations for information.

■    Seek out pharmacists who have taken the time to become familiar with the new treatment modalities.

■     Become involved in local support groups.

There are a multitude of state and federal programs that can be of assistance if one is willing to invest the time and energy to become involved and informed. These include AIDS hotline numbers (national and state level), government health agencies and professional societies, private-sector services and advocacy groups, AIDS lobby/advocacy/watchdog groups, other AIDS- related information sources, patient assistance programs made available through pharmaceutical companies, and pharmaceutical information.

Conclusion

The AIDS epidemic continues to present unrelenting challenges to the medical profession. While medical science has made progress in reducing the frequency and duration of complications, improving quality of life of those affected and extending survival, finding an absolute cure or preventative vaccination remains elusive. The progression of this disease is unpredictable, which presents significant obstacles to the life care planner, since, unlike most diseases, complications and the course of the illness cannot be accurately anticipated. The life care plan will rely heavily on the recommendations of the individual’s physician and relevant research. The life care planner who chooses to specialize in the HIV/AIDS arena must be aware of the myriad complications and remain contemporaneous with evolving HIV/AIDS medical research. Accordingly, the life care planner must also be committed to regularly updating the plan based on the client’s ever-changing circumstances and emerging information.

Jean-Paul Marat

Many tips are based on recent research, while others were known in ancient times. But they have all been proven to be effective. So keep this website close at hand and make the advice it offers a part of your daily life.

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