Debate about the best location for and cost of care

There has been a theme running through the conference, and I believe through the UK and Europe about where is the best place to provide HIV care. The Australian concept of the highly trained and experienced General Practitioner or Primary Care physician seems to be missing. This is interesting given the very regulated structure of general practice in the UK. But also perhaps understandable because of the existence of GUM clinics.

Yesterday morning's symposium Making Health Care Resources Count: What is the Optimal Way of Managing HIV? gave a number of perspectives. Andrew Briggs gave an interesting and informative introduction to health economics and particularly focused on the concept of driving cost down while minimising any associated reduction in health benefit. This is basically the exact opposite of introducing new drugs or approaches, which have demonstrable benefits but come with commensurate increases in cost.

This theme was continued by Nathan Clumeck who looked at task shifting to minimise cost without compromising outcomes. I think many of us are familiar with this in the developing country setting. But diminishing health budgets are making the discussion of these issues more prominent in the developed setting. WHO has recently published approaches to task shifting in resource limited settings.

Jens Lungren introduced an additional concept to the cost benefit analysis, that of the additional contributory benefit of prevention and reduced transmission, gained by achieving durable suppressive therapy. In his cost benefit analysis a slightly lower benefit for some patients, might be traded for greater population benefit. For example having more people on adequate suppressive therapy, might have a better cost profile than less people on very high cost suppressive therapy, and some people getting no therapy at all.

Alain Volny-Anne presented an interesting patients' perspective reflecting that decentralised care and community care could mean that people living with HIV now needed to access multiple care providers if they were no longer having all their care needs provided by a specialist HIV facility. He referred to this as the "go away" trend. One of the Australian HIV Community S100 prescribers indicated that in Australia she would be able to provide the majority of that care in the general practice setting.

The outcomes from this session were that prevention is cheaper than treatment, no matter how treatment is delivered. Tasks can be shifted provided that there is adequate training, with supervision and support when required. Nathan Clumeck described a model which involved generalists, physicians assistants, nurses and peers in the delivery of routine care, with second and third line care being restricted to specialist physicians.

Additional Abstracts

Two additional abstracts were presented in this symposium. They related to regimen changes as a way of reducing drug costs in the UK. It has to be recognised that there were abstracts added to the symposium and not papers developed for the symposium. They both suggested considerable cost reductions:

• Hill by switching from brand name co-formulations to generic single drugs multi-pill regimens, and
• Walker by switching from triple-therapy to PI monotherapy

Questions and comments from the floor and subsequent discussions were mixed about the point of even considering these options. It was pointed out that the introduction of generics may result in people having their regimen dictated by their capacity to pay as well as by purchasing and discounting arrangements used by Foundation Trusts negotiating prices.

Two posters on the related themes of where best to provide care:

P139 A comparison or routine and targeted testing strategies Perez et. al. from Spain, Found that routine testing was ALWAYS better in primary care. Targeted testing was lower than routine, testing only 50% of the population. But the best result were found in routine targeted testing in Primary Care.

P160 Late diagnosis among our aging HIV population Mensforth et. al. UK. Found that 27 people over 50 with a HIV indicator condition were not tested for HIV in acute medical unit.