Estimated cost per HIV infection diagnosed through routine HIV testing offered in acute general medical admission units and general practice settings in England

OBJECTIVES:

Following national guidelines to expand HIV testing in high-prevalence areas in England, a number of pilot studies were conducted in acute general medical admission units (ACUs) and general practices (GPs) to assess the feasibility and acceptability of testing in these settings. The aim of this study was to estimate the cost per HIV infection diagnosed through routine HIV testing in these settings.

METHODS:

Resource use data from four 2009/2010 Department of Health pilot studies (two ACUs; two GPs) were analysed. Data from the pilots were validated and supplemented with information from other sources. We constructed possible scenarios to estimate the cost per test carried out through expanded HIV testing in ACUs and GPs, and the cost per diagnosis.

RESULTS:

In the pilots, cost per test ranged from £8.55 to £13.50, and offer time and patient uptake were 2 minutes and 90% in ACUs, and 5 minutes and 60% in GPs, respectively. In scenario analyses we fixed offer time, diagnostic test cost and uptake rate at 2 minutes, £6 and 80% for ACUs, and 5 minutes, £9.60 and 40% for GPs, respectively. The cost per new HIV diagnosis at a positivity of 2/1000 tests conducted was £3230 in ACUs and £7930 in GPs for tests performed by a Band 3 staff member, and £5940 in ACUs and £18 800 in GPs for tests performed by either hospital consultants or GPs.

CONCLUSIONS:

Expanded HIV testing may be more cost-efficient in ACUs than in GPs as a consequence of a shorter offer time, higher patient uptake, higher HIV positivity and lower diagnostic test costs. As cost per new HIV diagnosis reduces at higher HIV positivity, expanded HIV testing should be promoted in high HIV prevalence areas.

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By:  Ong KJ1, Thornton AC2, Fisher M3, Hutt R4, Nicholson S5, Palfreeman A6, Perry N3, Stedman-Bryce G7, Wilkinson P5, Delpech V1, Nardone A1.

• 1Centre for Infectious Disease Surveillance and Control, Public Health England, UK.
• 2Department of Infection and Population Health, University College London, London, UK.
• 3Brighton and Sussex University Hospital, Brighton, UK.
• 4NHS South East London, Public Health Lewisham, London, UK.
• 5Brighton and Hove City Council, Brighton, UK.
• 6University Hospitals Leicester, Leicester, UK.
• 7Pamoja Consulting, Brighton, UK. 
• HIV Med. 2016 Apr;17(4):247-54. doi: 10.1111/hiv.12293. Epub 2015 Sep 23.

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Economic & Health Implications from Earlier Detection of HIV Infection in the United Kingdom

Purpose: 

To model the budget and survival impact of implementing interventions to increase the proportion of HIV infections detected early in a given UK population.

Patients and methods: 

A Microsoft Excel decision model was designed to generate a set of outcomes for a defined population. Survival was modeled on the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study extrapolated to a 5-year horizon as a constant hazard. Hazard rates were specific to age, sex, and whether detection was early or late. The primary outcomes for each year up to 5 years were: annual costs, numbers of infected cases, hospital admissions, and surviving cases. Three locations in the UK were chosen to model outcomes across a range of HIV prevalence areas: Lambeth, Southwark, and Lewisham (LSL), Greater Manchester Cluster (GMC), and Kent and Medway (K&M).

Results: 

In LSL, the projected cumulative cost savings over 5 years were £3,210,206 or £5,290,206 when including the value of the 104 life-years saved. Savings were insensitive to transmission rates, but sensitive in direct proportion to the percentage shift from late to early detection. In GMC, savings were in a similar proportion to LSL, but the magnitude was smaller, as a consequence of the lower base-case HIV prevalence. In K&M, with a smaller population and lower HIV prevalence than GMC, savings were commensurately smaller (£733,202 cumulatively over 5 years).

Conclusion: 

The results strengthen the rationale for implementing increased testing in high prevalence areas. However, in areas of low prevalence, it is unlikely that costs will be returned over a 5-year period.

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By:  Vladimir Zah,^1,2 Mondher Toumi¹

¹Ecole Doctoral Interdisciplinaire Sciences-Santé (EDISS), University of Lyon, Lyon, France; ²ZRx Outcomes Research Inc., Mississauga, Canada

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East London's Homeless: A Retrospective Review of an Eye Clinic for Homeless People

BACKGROUND:

There is very little published work on the visual needs of homeless people. This paper is the first study to investigate the visual needs of homeless people in the UK. Although similar work has been done in other countries, this study is unique because the United Kingdom is the only country with a National Health Service which provides free healthcare at the point of access. This study analysed the refractive status of the sample used, determined the demographics of homeless people seeking eye care and established if there is a need for community eye health with access to free spectacle correction in East London.

METHODS:

This retrospective case study analysed the clinical records of 1,141 homeless people using the Vision Care for Homeless People services at one of their clinics in East London. All eye examinations were carried out by qualified optometrists and, where appropriate, spectacles were dispensed to patients. Data captured included age, gender, ethnicity and refractive error. Results were analysed using two-sample t-tests with Excel and Minitab.

RESULTS:

Demographics of age, gender and ethnicity are described. Spherical equivalents (SE) were calculated from prescription data available for 841 clinic users. Emmetropia was defined as SE-0.50DS to +1DS, myopia as SE < -0.50DS, and hyperopia as SE > +1DS. The majority of clinic users were male (79.2 %, n = 923). Approximately 80 % (n = 583) of clinic users were white, 10 % (n = 72) were 'black', 4 % (n = 29) 'Asian' and the remaining 5.6 % (n = 40) were of 'mixed ethnicity' and 'other' groups. The mean age of females attending the clinic was significantly lower than that of males (45.9 years, SD = 13.8 vs' 48.4 years, SD = 11.8) when analysed using a two-sample t-test (t (317) = 2.44, p = 0.02). One third of service users were aged between 50-59 years. Myopia and hyperopia prevalence rates were 37.0 % and 21.0 % respectively. A total of 34.8 % of homeless people were found to have uncorrected refractive error, and required spectacle correction.

CONCLUSIONS:

This study has identified a high proportion of uncorrected refractive error in this sample and therefore a need for regular eye examinations and provision of refractive correction for homeless people.

Below:  Number of eye examinations each year at VCHP

Below:  Spherical equivalent for right and left eyes for all in the sample

Full article at:   http://goo.gl/qEV1JO

By:  D'Ath PJ1, Keywood LJ2, Styles EC3, Wilson CM4.

• 1Division of Optometry and Visual Science, School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB, UK. penny.dath@gmail.com.
• 2Division of Optometry and Visual Science, School of Health Sciences, City University London, Northampton Square, London, EC1V 0HB, UK.
• 3Vision Care for Homeless People, c/o Crisis Skylight, 66 Commercial Street, London, E1 6LT, UK.
• 4Department of Ophthalmology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
• BMC Health Serv Res. 2016 Feb 16;16(1):54. doi: 10.1186/s12913-016-1295-8. 

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The Epidemiology of Self-Harm in a UK-Wide Primary Care Patient Cohort, 2001–2013

BACKGROUND:

Most of the research conducted on people who harm themselves has been undertaken in secondary healthcare settings. Little is known about the frequency of self-harm in primary care patient populations. This is the first study to describe the epidemiology of self-harm presentations to primary care using broadly representative national data from across the United Kingdom (UK).

METHODS:

Using the Clinical Practice Research Datalink (CPRD), we calculated directly standardised rates of incidence and annual presentation during 2001-2013. Rates were compared by gender and age and across the nations of the UK, and also by degree of socioeconomic deprivation measured ecologically at general practice level.

RESULTS:

We found significantly elevated rates in females vs. males for incidence (rate ratio - RR, 1.45, 95 % confidence interval - CI, 1.42-1.47) and for annual presentation (RR 1.56, CI 1.54-1.58). An increasing trend over time in incidence was apparent for males (P < 0.001) but not females (P = 0.08), and both genders exhibited rising temporal trends in presentation rates (P < 0.001). We observed a decreasing gradient of risk with increasing age and markedly elevated risk for females in the youngest age group (aged 15-24 years vs. all other females: RR 3.75, CI 3.67-3.83). Increasing presentation rates over time were observed for males across all age bands (P < 0.001). We found higher rates when comparing Northern Ireland, Scotland, and Wales with England, and increasing rates of presentation over time for all four nations. We also observed higher rates with increasing levels of deprivation - most vs. least deprived male patients: RR 2.17, CI 2.10-2.25.

CONCLUSIONS:

Incorporating data from primary care yields a more comprehensive quantification of the health burden of self-harm. These novel findings may be useful in informing public health programmes and the targeting of high-risk groups toward the ultimate goal of lowering risk of self-harm repetition and premature death in this population.

Below: Overall incidence and annual presentation rates. a Incidence. b Annual presentation rates

Full article at:  http://goo.gl/xfGSjq

By:  Carr MJ1, Ashcroft DM2,3, Kontopantelis E4,5, Awenat Y6, Cooper J7, Chew-Graham C8,9, Kapur N7, Webb RT7.

• 1Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK. matthew.carr@manchester.ac.uk.
• 2Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK.
• 3NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester, UK.
• 4Centre for Health Informatics, Institute of Population Health, University of Manchester, UK, Manchester, UK.
• 5NIHR School for Primary Care Research, University of Manchester, Manchester, UK.
• 6School of Psychological Sciences, University of Manchester, Manchester, UK.
• 7Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK.
• 8Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
• 9Manchester Mental Health and Social Care Trust, Manchester, UK. 
• BMC Psychiatry. 2016 Feb 29;16(1):53. doi: 10.1186/s12888-016-0753-5.

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Prisoners with Intellectual Disabilities & Detention Status. Findings from a UK Cross Sectional Study of Prisons

The purpose of this study was to compare social and environmental historical and contextual risk factors between prisoners with intellectual disabilities and those without intellectual disabilities, and to investigate whether prisoners with intellectual disabilities were more likely to be placed on remand in prison (awaiting trial or sentencing) compared to those without intellectual disabilities, after controlling for socio-demographic factors such as age, gender, ethnicity, accommodation status and nature of offences. 

In this study, we carried out a secondary analysis of data from the 1997 Prison survey, which included 131 prisons in England and Wales. A fixed sampling fraction was used to obtain a representative sample of prisoners. 

A total of 3563 prisoners were approached and 3142 (88%) prisoners gave informed consent to be interviewed. Of these, 170 were identified as having intellectual disabilities using the Quick Test. Prisoners with intellectual disabilities were more likely to have lived in institutions or taken into local authority care and more likely to live in temporary accommodation. They were less likely to have had a paid job or any educational qualifications and more likely to perceive a lack of social support. Prisoners with intellectual disabilities were more likely to be placed on remand and were less likely to be sentenced, even after controlling for socio-demographic factors and nature of offence. 

This study suggests that prisons should be more pro-active at identifying people with intellectual disabilities and ensuring that their needs are met, including appropriate access to bail and court diversion schemes.

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By:  Ali A1, Ghosh S2, Strydom A3, Hassiotis A4.

• 1Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: afia.ali@ucl.ac.uk.
• 2Violence Prevention Research Unit, Wolfson Institute of Preventive Medicine, Queen Mary University of London, William Harvey House, 61 Bartholomew Close, London EC1A 7BE, UK. Electronic address: s.ghosh@qmul.ac.uk.
• 3Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: a.strydom@ucl.ac.uk.
• 4Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK. Electronic address: a.hassiotis@ucl.ac.uk. 
• Res Dev Disabil. 2016 Feb 24;53-54:189-197. doi: 10.1016/j.ridd.2016.02.004.

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Mixing Drink and Drugs: ‘Underclass’ Politics, the Recovery Agenda and the Partial Convergence of English Alcohol and Drugs Policy

Highlights

• The criminal law upholds a ‘great regulatory divide’ separating the licit trade in alcohol from the illicit trade in substances classified as either class A, B or C under the Misuse of Drugs Act 1971. This article, however, makes explicit comparison of recent policy developments used to govern alcohol and illicit drugs in England.
• Consideration of the idea of a convergence between policies governing alcohol and illicit drugs in England through the lens of the recovery agenda.
• Analysing the relevance of Berridge's long term historical argument to policies enacted by UK governments over the last 20 years, which pays specific attention to the re-emergence of abstinence in both alcohol and drugs policy.
• Examining whether the relevant policies of the New Labour Government (1997-2010) and the Coalition Government (2010-2015) to question whether the dividing line of the criminal law necessarily means that all public policies relating to alcohol are distinct in form and unrelated in practice from those which affect illicit drugs.

Abstract

Alcohol policy and illicit drugs policy are typically presented as separate and different in academic discussion. This is understandable, to a degree, as the criminal law upholds a ‘great regulatory divide’ ( Seddon, 2010 : 56) separating the licit trade in alcohol from the illicit trade in substances classified as either class A, B or C under the Misuse of Drugs Act 1971. 

This paper takes a different stance. In doing so, it draws upon Berridge's (2013) argument that policies governing various psychoactive substances have been converging since the mid-twentieth century and seeks to elaborate it using recent developments relating to the control and regulation of drugs and alcohol in the broader areas of criminal justice and welfare reform. Significantly, the article examines how recent policy directions relating to both drugs and alcohol in England have, under the aegis of the ‘recovery agenda’, been connected to a broader behavioural politics oriented towards the actions and lifestyles of an apparently problematic subgroup of the population or ‘underclass’. 

The paper thus concludes that, although the great regulatory divide remains intact, an underclass politics is contributing towards the greater alignment of illicit drugs and alcohol policies, especially in regards to the respective significance of abstinence (or abstinence-based ‘recovery’).

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By:  Mark Monaghan, Henry Yeomans

School of Sociology and Social Policy, University of Leeds, UK

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Face Recognition by Metropolitan Police Super-Recognisers

Face recognition is used to prove identity across a wide variety of settings. Despite this, research consistently shows that people are typically rather poor at matching faces to photos. Some professional groups, such as police and passport officers, have been shown to perform just as poorly as the general public on standard tests of face recognition. However, face recognition skills are subject to wide individual variation, with some people showing exceptional ability—a group that has come to be known as ‘super-recognisers’. 

The Metropolitan Police Force (London) recruits ‘super-recognisers’ from within its ranks, for deployment on various identification tasks. Here we test four working super-recognisers from within this police force, and ask whether they are really able to perform at levels above control groups. We consistently find that the police ‘super-recognisers’ perform at well above normal levels on tests of unfamiliar and familiar face matching, with degraded as well as high quality images. 

Recruiting employees with high levels of skill in these areas, and allocating them to relevant tasks, is an efficient way to overcome some of the known difficulties associated with unfamiliar face recognition.

Below:  Example trials from the Glasgow Face Matching Test (GFMT)

Below:  Example trials from the PLT

Full article at:   http://goo.gl/ulnA7p

By:  David J. Robertson, Eilidh Noyes, Andrew J. Dowsett, Rob Jenkins, A. Mike Burton 

Department of Psychology, University of York, York, United Kingdom

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Factors Associated with Access to Care and Healthcare Utilization in the Homeless Population of England

BACKGROUND:

People experiencing homelessness are known to have complex health needs, which are often compounded by poor access to healthcare. This study investigates the individual-level factors associated with access to care and healthcare utilization among homeless people in England.

METHODS:

A cross-sectional sample of 2505 homeless people from 19 areas of England was used to investigate associations with access to care and healthcare utilization.

RESULTS:

Rough sleepers were much less likely to be registered with a general practitioner (GP) (odds ratio (OR) 0.45, 95% confidence interval (CI) 0.30-0.66) than single homeless in accommodation (reference group) or the hidden homeless (OR 1.48, 95% CI 0.88-2.50). Those who had recently been refused registration by a GP or dentist also had lower odds of being admitted to hospital (OR 0.67, 95% CI 0.49-0.91) or using an ambulance (OR 0.73, 95% CI 0.54-0.99).

CONCLUSIONS:

The most vulnerable homeless people face the greatest barriers to utilizing healthcare. Rough sleepers have particularly low rates of GP registration and this appears to have a knock-on effect on admission to hospital. Improving primary care access for the homeless population could ensure that some of the most vulnerable people in society are able to access vital hospital services which they are currently missing out on.

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By:  Elwell-Sutton T1, Fok J2, Albanese F3, Mathie H3, Holland R1.

• 1Norwich Medical School, University of East Anglia, Norwich, UK.
• 2Department of Public Health, Essex County Council, Chelmsford, UK.
• 3Homeless Link, London, UK. 
• J Public Health (Oxf). 2016 Feb 18. pii: fdw008.

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Medicated Sex in Britain: Evidence from the Third National Survey of Sexual Attitudes and Lifestyles

Key messages

• Ever use of medication to assist sexual performance is reasonably common in Britain, more so in men than women.
• It is associated with using other drugs, higher levels of sexual activity and unsafe sex in both women and men.
• In men, associations with high-risk behaviour persist after adjusting for same-sex behaviour, suggesting the association with high-risk is not restricted to those practicing same-sex sex.
• In men without erectile difficulties, medication use is associated with higher levels of sexual activity and also low interest in sex. This paradox is perhaps explained by low sexual confidence.
• Because medication is increasingly easy to access without prescription, there is a need for better professional and patient education on this phenomenon.

Objectives

To describe the prevalence of medication use to assist sexual performance in Britain and to identify associated factors.

Methods

Cross-sectional probability sample, undertaken in 2010–2012, of 15 162 people aged 16–74 years, resident in Britain, of whom, 5617 men and 8095 women reported sexual experience (ever) and 4817 men were sexually-active (reported sex in the last year).

Results

Ever use of medication to assist sexual performance (medicated sex) was more commonly reported by men than women (12.9% (95% CI 11.9% to 13.9%) vs 1.9% (95% CI 1.7% to 2.3%)) and associated with older age in men and younger age in women. It was associated with reporting smoking, and use of alcohol and recreational drugs, as well as unsafe sex (≥2 partners and no condom use in the last year) in both men and women. Among men, the proportion reporting medicated sex in the last year was higher among those reporting erectile difficulties (ED) than those not doing so (28.4% (95% CI 24.4% to 32.8%) vs 4.1% (95% CI 3.4% to 4.9%)). In all men, medicated sex was associated with more frequent sexual activity, meeting a partner on the internet, unsafe sex and recent sexually transmitted infections diagnosis; associations that persisted after adjusting for same-sex behaviour and ED. However, there were significant interactions with reporting ED, indicating that among men with ED, medicated sex is not associated with same-sex behaviour and ever use of recreational drugs.

Conclusions

A substantial minority of people in Britain report medicated sex, and the association between medicated sex and risky sexual behaviour is not confined to high-risk groups.

Full article at:  http://goo.gl/XZYd9Y

By:  Kirstin R Mitchell,1 Philip Prah,2 Catherine H Mercer,2 Jessica Datta,1 Clare Tanton,2 Wendy Macdowall,1 Andrew J Copas,2 Soazig Clifton,2 Pam Sonnenberg,2 Nigel Field,2 Anne M Johnson,2 and Kaye Wellings1

¹Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK

²Research Department of Infection and Population Health, University College London, London, UK

Correspondence to Dr Kirstin Mitchell, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK; Email: ku.ca.mthsl@llehctim.nitsrik

AMJ and KW are joint senior authors.

Sex Transm Infect. 2016 Feb; 92(1): 32–38., Published online 2015 Jun 19. doi:  10.1136/sextrans-2015-052094

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Is Treatment for Alcohol Use Disorder Associated with Reductions in Criminal Offending? A National Data Linkage Cohort Study in England

BACKGROUND:

This is the first English national study of change in criminal offending following treatment for alcohol use disorder (AUD).

METHODS:

All adults treated for AUD by all publicly funded treatment services during April 2008-March 2009 (n=53,017), with data linked to the Police National Computer (April 2006-November 2011). Pre-treatment offender sub-populations were identified by Latent Profile Analysis. The outcome measure was the count of recordable criminal offences during two-year follow-up after admission. A mixed-effects, Poisson regression modelled outcome, adjusting for demographics and clinical information, the latent classes, and treatment exposure covariates.

RESULTS:

Twenty-two percent of the cohort committed one or more offences in the two years pre-treatment (n=11,742; crude rate, 221.5 offenders per 1000). During follow-up, the number of offenders and offences fell by 23.5% and 24.0%, respectively (crude rate, 69.4 offenders per 1000). During follow-up, a lower number of offences was associated with: completing treatment (adjusted incident rate ratio [IRR] 0.82; 95% confidence interval [CI] 0.79-0.85); receiving inpatient detoxification (IRR 0.84; CI 0.80-0.89); or community pharmacological therapy (IRR 0.89; CI 0.84-0.96). Reconviction was reduced in the sub-population characterised by driving offences (n=1,140; 11.7%), but was relatively high amongst acquisitive (n=768; 58.3% reconvicted) and violent offending sub-populations (n=602; 77.6% reconvicted).

CONCLUSIONS:

Reduced offending was associated with successful completion of AUD treatment and receiving inpatient and pharmacological therapy, but not enrolment in psychological and residential interventions. Treatment services (particularly those providing psychological therapy and residential care) should be alert to offending, especially violent and acquisitive crime, and enhance crime reduction interventions.

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By:  Willey H1, Eastwood B2, Gee IL3, Marsden J4.

• 1Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, United Kingdom.
• 2Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, United Kingdom; Institute of Psychiatry, Psychology and Neuroscience, King's College London,United Kingdom.
• 3Centre for Public Health, Liverpool John Moores University, United Kingdom.
• 4Alcohol, Drug and Tobacco Division, Health and Wellbeing Directorate, Public Health England, United Kingdom; Institute of Psychiatry, Psychology and Neuroscience, King's College London,United Kingdom. Electronic address: john.marsden@kcl.ac.uk. 
• Drug Alcohol Depend. 2016 Jan 29. pii: S0376-8716(16)00048-X. doi: 10.1016/j.drugalcdep.2016.01.020. 

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