Care of HIV-infected adults at Baragwanath Hospital, Soweto
Part I. Clinical management and costs of outpatient care
Objective. To provide a detailed breakdown of clinical presentations and management of outpatients with HIV. and associated costs, in order to inform clinical practice, health service planning and projections of the costs of HIV care in South Africa
Setting. The outpatient department of a public sector, academic hospital in Soweto, South Africa
Design. A retrospective, descriptive study using a record review and a combination of direct and step-down costing of health service costs (1992 prices).
Patients. All 179 patients with HIV seen at the outpatient department between 1989 and 1992.
Results. The average age at presentation was 30 years for men and 29 years for women. The most common clinical presentations at first viSIT were lymphadenopathy, weight loss, peripheraJ neuropathy and tuberculosis. Many patients, however, were asymptomatic. Analysis of clinical presentations, investigations and drugs used indicated that at least 80% of patients could have been managed at primary care leveL The average cost per consultation was R112.03. Costs per patient and per visit increased with stage of disease. Most of the costs arose from variable costs, which are influenced by clinical management decisions. Laboratory investigations (30%), staff (21 %) and drugs (22%), especially for fungal, viral and tuberculosis infection, were the major contributors to costs.
Conclusions. Given projected HIV infection rates and the associated, potentially enormous costs of care revealed by this study, clinicians and health service planners must identify and implement cost-effective approaches to investigating, treating and meeting other health care needs of HIV-infected people. Treatment of people with HIV at primary care outpatient services seems both possible and potentially more cost-effective than hospital-level care in South Africa Emphasis should be placed on building primary level capacity to take on this role effectively. Further studies are required to identify the costeffectiveness, not only of treating HIV-related conditions, but also of treating other diseases if just and adequately infonned decisions about rationing of care are required in view of resource constraints.