The Alfred is one of 3 treatment sites that make up the Australian AIDS Cohort comprising 50% of AIDS patients in Australia, and which enables important epidemiological analysis of the AIDS epidemic to be undertaken. In the 12 months to June 1997, a total of 20 clinical trials were conducted, with 267 patients participating. In the following 12 months, a further 17 clinical trials, involving 198 patients, were conducted. Over the 2 year time period, a similar number of patients were enrolled in antiretroviral therapy studies, but trials for prophylaxis and management of opportunistic infections were reduced due to the inability to recruit patients because of the improved immunological status of patients generally. New technologies involving HIV resistance assays, quantitative measurement of CMV and pulse field gel electrophoresis have resulted in clinical practice more accurately measuring the efficacy of new treatments and plot the spread of infections of public health importance.

Importantly, the nature of the research undertaken has been both informed by and informed clinical practice, and contributed to the knowledge of the disease and its treatment. A total of 268 publications by members of the Clinical Research Department were completed in the 2 years to June 1998, of which 106 related directly to patient clinical management. The association of The Alfred with Monash University Departments, together with the proposed relocation of the MacFarlane Burnet Centre for Medical Research is expected to further expand its research capabilities.

The Alfred Infectious Diseases Service provides teaching for Monash University medical students in years 3,4,6 and 5, as well as HIV education programs for Melbourne University students from St Vincents' and Austin clinical schools and Monash University Law students. It also provides periodic post-graduate training of basic trainees in Internal Medicine, advanced trainees in Infectious Diseases, Microbiology for FRCPA, Diploma of Pharmacy and Diploma of Venereology. Training of overseas students from Egypt and Japan has also been provided. A regular program of in-service education has also been established for all health care professionals involved in the care of patients with infectious diseases.

The acute inpatient service is based in the 34-bed inpatient care facility in Ward 7 West at The Alfred. The facility was purpose-built following the closure of Fairfield, and opened in 1997. While the ward is primarily for HIV/AIDS patients, other patients may also be admitted, particularly those with infectious diseases. Similarly, HIV/AIDS patients may also be admitted to other wards at The Alfred, depending on the nature of the condition being treated and the availability of beds. Ward 7 West has 19 single rooms with en-suite facilities, with 4 of these rooms being negatively ventilated. A direct ward admission policy for high volume GPs and consultants has been established, and there is also the ability to "fast-track" patients from emergency departments and outpatients. A satellite pharmacy is located adjacent to the acute ward, servicing both inpatients and the ambulatory services.

The continuing and palliative care service is comprised of The Victorian AIDS Palliative Care Consultancy and the 15 bed inpatient Continuing Care Unit in Ward 3A. These services also work in conjunction with the general palliative care service at The Alfred. The Consultancy is funded separately by DHS, and comprises a part-time palliative care physician, palliative care nurse and part-time grief counselor.

The facilities of Ward 3A have been the subject of considerable criticism by many of those consulted in the course of the review. A new purpose-built palliative and continuing care facility is currently in the planning stages, and is due for completion in January 2000.

The table below illustrates the level of inpatient activity at The Alfred for the 3 years ending June 1998, including patients treated under the HIV contract and the Health Services Agreement, the latter of which is external to the contract for the transfer of patients from Fairfield Hospital.

The level of inpatient activity at The Alfred has declined significantly over the past 2 years under both the HIV contract and the existing Health Services Agreement. While not evident from the table, the analysis undertaken by The Alfred indicates that the reduction has been almost exclusively due to a reduction in HIV day patients. HIV-related multi-day admissions have reduced at a lesser rate, although there has been a significant reduction in the average length of stay for multi-day inpatients. In addition, 25% of the Alfred Hospital at Home activity during this period was provided to HIV/AIDS patients, consistent with the evolution of HIV care.

The level of activity for continuing care has also declined significantly over the two years, although there has been a dramatic increase in the length of stay for these patients.

The changes in inpatient activity are reflective of the dramatic change that has occurred nationally and internationally in the treatment of HIV/AIDS over the past several years. The success of antiretroviral therapy has resulted in a significant reduction in the number of AIDS-related deaths and hence the demand for continuing/palliative care, more HIV patients being treated in the community rather than in hospital, and a reduction in opportunistic infections and hence acute inpatient episodes. These have undoubtedly been the major factors influencing the inpatient activity levels at The Alfred, and the reduction in this activity should be seen as reflecting current models of service delivery, rather than a failure to provide the required level of care.

In regard to continuing care, the reduction has also been affected by the serious concerns about the current palliative care ward at The Alfred among consumers. A considerable number of consumers, as well as a number of community-based providers, consulted during the review expressed their concern and disappointment with these facilities, and their strong opposition to using them. Staff at The Alfred acknowledged this problem, and were anxious to improve their facilities and services. The proposed development of the new Continuing Care Unit at The Alfred may assist in reducing these concerns, but there will be a need to promote the new facility among consumers and service providers.

A dedicated outpatient facility for HIV/AIDS patients is located adjacent to the other outpatient clinics at The Alfred, with 10 clinics per week, including a Saturday morning clinic. Consideration is also being given to conducting an evening clinic to cater for those patients in employment. A day care facility is located adjacent to the acute care ward in Ward 7 West.

The Alfred also operates an ambulatory care service at the Melbourne Sexual Health Centre (MSHC). Offering an outpatient clinic and day care facilities, the service originally operated for 5 days per week. However, due to a range of factors, the service has contracted to one and a half days per week. There has been some criticism of this service, and its future must be in doubt. The Alfred should review the continued operation of this service, and consider alternative approaches to the provision of these services. It should be noted that other services provided at MSHC were highly regarded by a significant number of consumers and other stakeholders consulted during the course of the review.

A Hospital in the Home program (The Alfred at Home) was originally established for HIV/AIDS patients at The Alfred, and continues to offer acute follow-up for patients once they return home. Referrals to this service continue to increase, predominantly from referrals of other units to the Infectious Diseases physician managing the program.

Outpatient occasions of service are below the level identified in the Service Agreement. Again this is seen to be a product of the emergence of community-based care, together with the establishment and growth of several GP clinics in the area which provide services to a considerable number of HIV/AIDS patients. These clinics are now providing services that traditionally would have been provided at outpatient clinics.

The Alfred's approach to care reflects a multi-disciplinary approach including medical services, primary nursing, social work, nutrition services, physiotherapy, occupational therapy and pharmacy services. Other ID services offered include an HIV Coordinator, the Access Information Centre and the recent appointment of a full-time Health Educator.

Submissions and presentations by representatives from each of these groups to the consultants in the course of the review indicated that the planning and delivery of a wide range of allied health services specific to the needs of HIV/AIDS patients are provided, with a high level of professional proficiency. Comments from consumer representatives and community-based providers were generally highly complimentary of these services and the professionalism of those engaged in patient care.