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HIV/AIDS Care in the Third Decade: Opportunities and Challenges in the Changing Epidemic

The year 2001 marked the beginning of the third decade of the AIDS epidemic. In just over 20 years, HIV/AIDS had changed the landscape of medicine, public health, and health care in the United States and the world. The rapid changes in treatments, however, threaten to out-pace the design of the health care delivery system for individuals with HIV and AIDS. In 1996, the introduction of effective new antiretroviral therapies changed the clinical course and outcome of this illness. Until the introduction of highly active antiretroviral therapy (HAART), AIDS was associated with an inevitable functional deterioration and death. Acute illness brought people into the care system, clinical care occurred in a hospital setting with intense outpatient follow-up, and prevention was focused on those at risk of becoming infected.

The third decade of the HIV/AIDS epidemic offers a remarkable opportunity to extend the productive years of life of people living with HIV/AIDS (PLWH/A). The challenge will be to restructure the public health care financing and delivery system so that uninsured and underinsured PLWH/A have access to appropriate treatments without disparity, to offer the comprehensive set of services required to promote adherence to their medications to individuals affected by co-morbid conditions, and to prevent new infections by making prevention a routine part of care.

In the United States, 816,149 AIDS cases and 467,910 AIDS-related deaths have been reported as of December 2001 (CDC, 2002a). It is estimated that approximately 40,000 people in this country are newly infected with HIV each year, and the disease remains an imminent and serious



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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White 2 HIV/AIDS Care in the Third Decade: Opportunities and Challenges in the Changing Epidemic The year 2001 marked the beginning of the third decade of the AIDS epidemic. In just over 20 years, HIV/AIDS had changed the landscape of medicine, public health, and health care in the United States and the world. The rapid changes in treatments, however, threaten to out-pace the design of the health care delivery system for individuals with HIV and AIDS. In 1996, the introduction of effective new antiretroviral therapies changed the clinical course and outcome of this illness. Until the introduction of highly active antiretroviral therapy (HAART), AIDS was associated with an inevitable functional deterioration and death. Acute illness brought people into the care system, clinical care occurred in a hospital setting with intense outpatient follow-up, and prevention was focused on those at risk of becoming infected. The third decade of the HIV/AIDS epidemic offers a remarkable opportunity to extend the productive years of life of people living with HIV/AIDS (PLWH/A). The challenge will be to restructure the public health care financing and delivery system so that uninsured and underinsured PLWH/A have access to appropriate treatments without disparity, to offer the comprehensive set of services required to promote adherence to their medications to individuals affected by co-morbid conditions, and to prevent new infections by making prevention a routine part of care. In the United States, 816,149 AIDS cases and 467,910 AIDS-related deaths have been reported as of December 2001 (CDC, 2002a). It is estimated that approximately 40,000 people in this country are newly infected with HIV each year, and the disease remains an imminent and serious

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White threat to public health (Karon et al., 2001). Globally, the picture is starker. The Centers for Disease Control and Prevention (CDC) estimates that the number of people living with HIV/AIDS worldwide is 40 million, and that during 2001 the world’s death toll from AIDS reached 3 million (CDC, 2002a). Although the epidemic had slowed until recently in most of the developed world, the National Intelligence Council (2002) predicts that by 2010 the numbers of those infected with the virus could reach 75 million in Nigeria, Ethiopia, Russia, India, and China alone (NIC, 2002). In 2002, the United Nations Population Division lowered its estimate of the world’s population for 2050 by 400 million people, largely because of the effect of HIV/AIDS (United Nations, 2003). If the epidemic has maintained a staggering pace, so too has the fight against it. Scientific discovery has resulted in a rapid gain in knowledge about the disease, dissemination of prevention and treatment information, and changes in expectation and outcomes. The first widely distributed reports of the disease occurred in 1981 and concerned homosexual men (CDC, 1981). Over the next two years, at-risk populations were further defined to include injection drug users, individuals with hemophilia and others who had received blood products, and Haitians; universal precautions for health care workers and other professionals whose work put them in contact with blood and other bodily fluids had been published; and the virus that caused the disease had been identified (CDC, 1982a,b,c,d,e, 1983; Barre-Sinoussi et al., 1983). Advances in knowledge and treatment options continued throughout the eighties and early nineties, and by 1996 combination antiretroviral therapy became (and remains) the standard of care for those infected with HIV. The impact of HAART was dramatic—the number of deaths from AIDS fell by 43 percent between 1995 and 1997 (Figure 2-1) (CDC, 2002a). In all, it took only 15 years from the first noted incidence of this new disease to the development of therapies that can be effective against it. The rapid pace of the development of new technology to fight the disease continues. In January 2003 the Food and Drug Administration (FDA) announced the expansion of availability of a rapid HIV test, which returns results in a matter of minutes rather than days or weeks. The FDA approved the expansion in the hopes that combining administration and results of the test into one clinic visit would increase the numbers of people seeking the test and entering the care system if testing positive (FDA, 2003a). In March 2003, the first in a new class of drugs called fusion inhibitors was granted accelerated approval, expanding the options of those for whom other treatments have failed (FDA, 2003b). This promising evolution of treatment does not, however, mean that the HIV epidemic is over or that it soon will be. The decrease in deaths brought about by new treatments, coupled with the steady number of new

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White FIGURE 2-1 Numbers of AIDS cases diagnosed and AIDS deaths reported, 1987 through 2001. SOURCE: CDC, 2002a. infections, indicates that more people than ever are living with HIV and AIDS (CDC, 2002a). As a consequence, the population at risk for transmitting the disease—those already infected—continues to grow (Figure 2-2). In 2003, CDC released preliminary data showing an increase in the number of AIDS cases reported in 2002 over 2001 (CDC, 2003). Though the increase was small (2.2 percent), it was the first since 1993 and could be an early warning that the system is missing opportunities to prevent those with HIV infection from progressing to AIDS. The loss of these opportunities, both for treatment to prevent disease progression and for intervention to reduce risky behaviors and promote prevention, occurs when infected individuals remain outside the care system, and eventually results in a greater burden to the system. Furthermore, those newly infected with HIV are more likely than in the past to be poor, members of a racial/ethnic minority group, and uninsured or publicly insured (Levi and Hidalgo, 2001). Those groups that traditionally have been at high risk, such as men who have sex with men (MSMs) and injection drug users (IDUs), have been joined by the seriously mentally ill, women of color, and the homeless. The third decade of the HIV/AIDS epidemic presents great opportunities and challenges for care providers and policy makers. Treating this deadly disease effectively is now possible for many individuals. But treatment regimens can be complex and expensive. The epidemic also continues its entrenchment in vulnerable populations suffering from co-morbid con-

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White FIGURE 2-2 People living with AIDS as a proportion of cumulative AIDS cases. SOURCE: CDC, 2002a. ditions that can complicate their seeking and obtaining care. The ability of new therapies to slow the disease, both at an individual and a population level, is determined both by their availability to those who need them and the ability of recipients to follow complex regimens. Even then, it is possible that the treatment will fail and drug resistance will develop. Given the continuing shifts in the epidemic, the care system’s ability to provide treatment in a timely manner to save lives, avert disability, and prevent the spread of the disease is increasingly challenged. This, in turn, challenges policy makers at all levels to ensure that programs meant to support the care system do so in a way that facilitates the mission of that system. The following sections discuss the changing elements of the epidemic that require consideration in a restructured HIV care delivery system: the effect of HAART on the course of the disease, as well as the risk of toxicities and resistance with HAART; the central role of adherence to therapy; the changing demographics of the epidemic and the challenges they present; and the increasing incidence of both medical and social co-morbid conditions among PLWH/A. To provide the background for these discussions, however, it is necessary to understand the natural history of the individual HIV infection.

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White THE NATURAL HISTORY OF INDIVIDUAL HIV INFECTION HIV is believed to have entered human populations from chimpanzees in Africa in the first half of the 20th century. Comparisons with closely related viruses in chimpanzees show that this crossover was likely made on multiple occasions (Korber et al., 2000; Hahn et al., 2000). In the United States, there is evidence the virus was present as early as 1977, though its long latency period rendered it invisible (Gottlieb, 2001). The course of HIV disease varies by individual and is not fully predictable, and the full effects of current antiretroviral management on the natural history of the disease remain uncertain. Still, the scientific and medical communities have learned a great deal in the past 20 years, and the natural history of HIV infection is now better understood (Polk et al., 1987; Mellors et al., 1996, 1997; Vlahov et al., 1998; Pezzotti et al., 1999). This understanding is important to the care system because it indicates when care will be needed and which services will be necessary and appropriate at each point in the disease process. Initial/Primary HIV Infection The majority of newly infected individuals develop what is known as primary HIV infection or acute retroviral syndrome. Acutely infected persons are symptomatic, often sufficiently so to seek medical care. These symptoms—fever, rash, fatigue, generalized lymphadenopathy, and nausea among others—are flu-like and appear within days to several weeks of the moment of infection. Primary HIV infection usually resolves in a matter of weeks and is not life threatening. Because the symptoms are characteristic of infection by less serious viruses, the opportunity to identify HIV infection is often missed at this stage (Quinn, 1997; Kahn and Walker, 1998). During the symptomatic phase of acute infection, virus replication is unchecked by the immune system. Individuals in this disease stage are highly infectious. This is of great importance from a public health perspective because unsafe behavior in this phase may readily lead to transmission. It is estimated that more than half of all HIV infections may be transmitted during this stage of infection (Schacker et al., 1998). Therefore, increasing the identification of HIV during this silent phase of the disease and providing prevention counseling to infected individuals are key strategies for managing the progression of the epidemic. Asymptomatic HIV Infection After full antibody reaction to HIV infection is established (typically within three to six months), the infection is said to be in the “chronic” or

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White “established” stage (Fauci, 1993; Levy, 1993; Pantaleo et al., 1993). Symptoms of acute infection have resolved by this point. The term “asymptomatic HIV infection” applies to this phase when the person is unaware of any symptoms of infection. This phase may last for 1 to 10 or more years, even without antiretroviral therapy (Haynes et al., 1996). During this period, however, the virus is still actively replicating and the infected individual may unknowingly transmit the virus. Also, the infection is gradually changing the individual’s complex immune system, most notably by causing a reduction in the number of CD4+ T-lymphocytes (CD4 cells) in the peripheral circulation.1 Even though there are no clinical manifestations of the disease, the immune system begins to deteriorate (Pantaleo et al., 1993). As the CD4 cell count begins to decline, individuals who are asymptomatic, or have nonacute conditions such as chronic fatigue, may meet the established treatment guidelines criteria to receive HAART. The challenge with many HIV-infected individuals in this stage who are focused on more immediate needs, such as housing and employment, is to engage them in treatment and promote retention in care and adherence to therapy. Eventually, the CD4 cell count falls from above 500 cells/ml, the threshold of a normally functioning immune system, to 200 cells/ml, an indicator of severe immune suppression, and can fall even lower. This drop in the CD4 cell count is significant because it increases the risk of serious and potentially fatal opportunistic infections or cancers (Polk et al., 1987; Mellors et al., 1996, 1997; Vlahov et al., 1998; Pezzotti et al., 1999). Antiretroviral therapy applied during the asymptomatic phase of disease can raise CD4 cell counts predictably and durably, preventing or delaying the stage of life-threatening immune deficiency commonly referred to as AIDS (Detels et al., 1998). Symptomatic HIV Disease/AIDS Advances in treatment have changed the ways in which the clinical stages of HIV disease are viewed. The difference between asymptomatic and symptomatic HIV disease is less obvious than the terms imply. With progressive immune depletion—perhaps especially if the plasma viral load2 1   CD4+ T-lymphocytes or CD4 cells are a type of white blood cell responsible for signaling other cells in the immune system to perform their specific functions, providing protection against viral, fungal, and protozoal infections. These cells are HIV’s preferred targets, and their destruction is the primary cause of immunodeficiency. A decrease in CD4 cells is the best known risk indicator for developing opportunistic infections; thus, an individual’s CD4 cell count is an important measure of disease progression (HIV/AIDS Treatment Information Service, 1999). 2   Viral load, also known as viral burden, is the amount of HIV circulating in an individual’s blood. The amount of virus in the blood is related to the overall health of the infected

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White is very high—patients may begin to note fatigue and malaise. Minor infections such as oral candidiasis are seen frequently and the risk of more serious complications rises as the CD4 cell count falls below 200 cells/ml. Some of these infections, notably Pneumocystis carinii pneumonia, can be prevented with prophylactic antibiotics, while others cannot (CDC, 2002a). Along with antiretrovirals, these prophylactic antibiotics, as well as certain vaccines that can prevent complicating infections, are essential components of medications that must be provided to maintain the health of the individual infected with HIV (USPHS/IDSA, 2001). Death from HIV Disease Prior to the availability of current effective antiretroviral therapy, development of AIDS and death were predictable outcomes among HIV-infected patients (Polk et al., 1987; Mellors et al., 1997; Vlahov et al., 1998; Pezzotti et al., 1999). Death usually followed several months of progressive debilitation, wasting, and often, dementia. Many suffered blindness from cytomegalovirus retinitis or endured intractable diarrhea. Today, the pattern is more complex and not as predictable (Pezzotti et al., 1999). Antiretroviral therapies can continue at least partially to suppress viral replication and to maintain some integrity of the immune system. Although HAART options can be exhausted, and some individuals still die of AIDS, it is increasingly likely that the cause of death for an HIV-infected person will be tuberculosis or hepatitis C virus (CDC, 1999, 2002b). EFFECT OF HAART ON HIV PROGRESSION AND CARE The impact of antiretroviral therapy on the outcome of HIV infection is one of the most dramatic developments in medical history. Therapies for treating HIV have come so far that it is possible to forget the bleak outlook of the early to mid-eighties, when the best that medical technology could offer was palliative care that only delayed death for a short time. Once a retrovirus was established as the cause of the disease, researchers were able to focus their efforts on blocking the replication of the virus in the body. In 1986, the National Institutes of Health (NIH) organized the AIDS Clinical Trials Group (ACTG), which has studied dozens of therapies and continues to do so today. The findings from this research group provide the foundation of the current guidelines for antiretroviral therapy (Sepkowitz, 2001).     individual—the higher the viral load, the sicker the patient. Measuring viral load is an important part of gauging a treatment regimen’s effectiveness (HIV/AIDS Treatment Information Service, 1999).

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White In 1987, AZT became the first drug approved for the treatment of AIDS based on the interim results of a randomized clinical trial. Its introduction raised the hopes of the HIV-positive community. In 1989, however, the results from the completed ACTG trial showed that AZT could slow disease progression, but did not impact survival rates (Volberding et al., 1990; Sepkowitz, 2001; Bartlett et al, 2001). Subsequently, the results of the Concorde trial in Europe showed that long-term disease progression rates were also unaffected by AZT (Seligmann et al., 1994). Seven years would pass before breakthrough research on viral load measurements and the efficacy of triple-drug therapy was first reported (Bartlett et al., 2001). A longitudinal study on viral load as an indicator of disease stage revealed that by monitoring the amount of the virus present in the plasma, therapeutic benefit of drug therapy could be assessed in days or weeks rather than the months required by monitoring CD4 cell counts (Mellors et al., 1996). The results of a trial of triple-drug therapy were equally exciting and some believed that eradication of the virus was close at hand (Bartlett et al., 2001). Unfortunately, that was not the case, but morbidity and mortality did decrease sharply after the introduction of HAART therapy (Figure 2-3) (Palella et al., 1998; Detels et al., 1998; Chiasson et al., 1999). By 1998, the number of individuals receiving HAART therapy had risen dramatically, FIGURE 2-3 Mortality and frequency of use of combination antiretroviral therapy including a protease inhibitor among HIV-infected patients with fewer than 100 CD4 cells per cubic millimeter, according to calendar quarter, from January 1994 through June 1997. SOURCE: Palella et al., 1998, Copyright 1998, Massachusetts Medical Society. All rights reserved.

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White and the number of deaths had fallen just as dramatically (Palella et al., 1998). Even those with severely weakened immune systems (indicated by a CD4 cell count of less than 50 cells/ml) had significantly fewer opportunistic illnesses when taking potent drug regimens (Miller et al., 2000). The results to date in clinical practice remain impressive. In fact, it is no longer possible to give an evidence-based estimate of the median survival of those with HIV disease who are treated with appropriate drugs because not enough time has elapsed. Opportunistic infections, previously common, are now less so (USPHS/IDSA, 2001). Opportunistic malignancies—especially Kaposi’s sarcoma and non-Hodgkins lymphoma of the central nervous system—have all but disappeared in those receiving effective antiretroviral therapy (Jacobson et al., 1999; Pezzotti et al., 1999). The success of HAART is tempered by its challenges, however. All antiretroviral medications carry the risk of side effects and adverse reactions, ranging from transient nausea and headache to serious or even fatal metabolic disorders (Montessori et al., 2004; Nolan, 2003). These adverse reactions can force a change in drug regimen and limit future treatment options (Ledergerber et al., 1999; Lucas et al., 1999). In addition, chronic conditions that develop as a result of the medications, such as diabetes and heart disease, must be treated along with the HIV infection in the long term (Carr et al., 1999). To promote the adoption of the new therapies as quickly as possible, NIH sponsored a Panel to Define Principles of HIV Therapy (Box 2-1) that released its first report in 1998. Among other things the principles stressed the importance of individualized care, adherence to treatment regimens, and continuous monitoring and contact with the care system (CDC, 1998a). Current Treatment Guidelines The U.S. Department of Health and Human Services’ (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents generally recommend HAART when the CD4 cell count falls below 350, although for individuals with CD4 cell counts of 200 to 349 other factors are considered. These include the individual’s willingness and ability to begin therapy, current state of immunodeficiency and risk of progression, and the potential for adverse reactions and side effects. Combination regimens of three drugs are most commonly used, and one-drug regimens (monotherapy) are never recommended (DHHS, 2004). The goal of therapy is durable suppression of HIV replication so that measured levels in the peripheral blood fall below the sensitivity levels of assays, usually below 50 HIV copies/ml. Therapy is monitored to follow the expected rise in CD4 cell counts and the fall in plasma viral load. All patients also require laboratory and clinical assessment for disease or drug-related toxicity (DHHS, 2004). For individuals who do not respond as

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White BOX 2-1 Principles of Therapy of HIV Infection Ongoing HIV replication leads to immune system damage and progression to AIDS. HIV infection is always harmful, and true long-term survival free of clinically significant immune dysfunction is unusual. Plasma HIV RNA levels indicate the magnitude of HIV replication and its associated rate of CD4+ T cell destruction, whereas CD4+ T cell counts indicate the extent of HIV-induced immune damage already suffered. Regular, periodic measurement of plasma HIV RNA levels and CD4+ T cell counts is necessary to determine the risk for disease progression in an HIV-infected person and to determine when to initiate or modify antiretroviral treatment regimens. As rates of disease progression differ among HIV-infected persons, treatment decisions should be individualized by level of risk indicated by plasma HIV RNA levels and CD4+ T cell counts. The use of potent combination antiretroviral therapy to suppress HIV replication to below the levels of detection of sensitive plasma HIV RNA assays limits the potential for selection of antiretroviral-resistant HIV variants, the major factor limiting the ability of antiretroviral drugs to inhibit virus replication and delay disease progression. Therefore, maximum achievable suppression of HIV replication should be the goal of therapy. The most effective means to accomplish durable suppression of HIV replication is the simultaneous initiation of combinations of effective anti-HIV drugs with which the patient has not been treated previously and that are not cross-resistant with antiretroviral agents with which the patient has been treated previously. Each of the antiretroviral drugs used in combination therapy regimens should always be used according to optimum schedules and dosages. The available effective antiretroviral drugs are limited in number and mechanism of action, and cross-resistance between specific drugs has been documented. Therefore, any change in antiretroviral therapy increases future therapeutic constraints. Women should receive optimal antiretroviral therapy regardless of pregnancy status. The same principles of antiretroviral therapy apply to HIV-infected children, adolescents, and adults, although the treatment of HIV-infected children involves unique pharmacologic, virologic, and immunologic considerations. Persons identified during acute primary HIV infection should be treated with combination antiretroviral therapy to suppress virus replication to levels below the limit of detection of sensitive plasma HIV RNA assays. HIV-infected persons, even those whose viral loads are below detectable limits, should be considered infectious. Therefore, they should be counseled to avoid sexual and drug-use behaviors that are associated with either transmission or acquisition of HIV and other infectious pathogens. SOURCE: CDC, 1998a.

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White expected to HAART, assays of genetic mutations associated with antiretroviral resistance are also commonly used, and some studies suggest an improved outcome if drug doses are adjusted for measured serum drug concentrations (DHHS, 2004). In many patients, antiretroviral therapy fails to fully suppress the virus either immediately or after a period of success. In this event, altering some or all of the drugs in the prescribed regimen may be required (DHHS, 2004). Adherence The central challenge of HAART is adherence, or the ability of an individual to consistently follow the prescribed treatment regimen. Adherence is crucial in the treatment of any illness; however, its importance is magnified in the treatment of HIV for two reasons. First, fully successful suppression of the virus in the blood requires very high levels of adherence. Second, poor adherence can contribute to the development of drug-resistant strains of the virus, which can then be transmitted to others. This results in reduced treatment effectiveness and options in those individuals who have never been treated for HIV before and thus constitutes a public health threat. The factors that influence an individual’s ability to adhere to HAART include the regimen itself, an individual’s personal characteristics, and the social environment of the patient (Ickovics and Meisler, 1997; Catz et al., 2000; Stone, 2002; Gebo et al., 2003). The ability to fully adhere to a treatment regimen for any illness is almost never complete; in general, 80 percent compliance is considered adherent (Piliero and Colagreco, 2003; Rabkin and Chesney, 1999). Although rates of compliance of those with HIV on HAART are generally higher than those of individuals with other chronic illnesses, HAART requires unprecedented adherence of more than 90 percent to receive optimal benefit (Harrigan et al., 2003; Garcia de Olalla et al., 2002; Bangsberg et al., 2001; McNabb et al., 2001; Paterson et al., 2000). While adherence levels in clinical trials have been high, results in the clinical setting have not been as successful (Escobar et al., 2003). A number of studies using multiple methods to measure adherence in various settings and populations have indicated that patients’ adherence to HAART averages 70 to 80 percent. Significantly, the studies show that few individuals are able to achieve the adherence levels required to receive the maximum benefit from the medication (Golin et al., 2002; Liu et al., 2001; Bangsberg et al., 2000). The inability of large numbers of patients to achieve the high levels of adherence required for complete viral suppression underscores the need to develop and provide appropriate adherence support as a routine part of HIV care. The second factor that must be considered in any discussion of adherence is its role in the development of drug resistance. Drug resistance can

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White their treatment at the clinic, 50 percent had a documented history of sexual abuse, and 82 percent had a history of substance use (Pao et al., 2000). Undocumented and Legal Immigrants Undocumented workers and other immigrants also face barriers to accessing and maintaining continuity of care for HIV. These individuals are especially vulnerable to the barriers presented by language difference, lack of cultural competency, and lack of insurance or other means to pay for care. In a pilot study of undocumented immigrants in southern California, less than 8 percent of the sample accessed nonemergency health care, and high-risk behavior or HIV (although no HIV testing was done) suggested that this population requires closer attention for HIV-related services (Loue and Oppenheim, 1994). Although considerable attention has been paid to immigrants with tuberculosis in the previous decade, HIV infection identification and treatment have not received an equal amount of attention (Weis et al., 2001). A summary of a needs assessment of recent migrants into a Texas county indicated that migration was associated with knowledge barriers for all types of services. Results also showed that recent immigration was a significant predictor of failure to receive government-administered basic services such as food services, but was not a significant predictor of failure to receive community-based organization-administered “specialized” services targeted specifically to HIV-positive individuals (Montoya et al., 1998). This indicates that there are programs and interventions that can reach this population. Incarcerated Populations A study conducted by Hammett et al. (2002) used data from 1997 to estimate that up to one-fourth of the people living with HIV in this country pass through a correctional facility each year. A recent assessment of voluntary counseling, testing, and referral (VCTR) in 48 correctional facilities throughout the country resulted in an HIV prevalence of 3.4 percent (Sabin et al., 2001). In one study, 85 percent of HIV infection in prison was associated with injection drug use prior to incarceration (Vlahov et al., 1989). Transmission of HIV infection in prison is rare (Brewer et al., 1988; Horsburgh et al., 1990). Although screening and prevention is not the focus, VCTR illustrates that contact with the correctional health care system can give public health professionals an opportunity to diagnose HIV and provide therapy to a population that might prove difficult to reach otherwise (Hammett et al., 2002; Sabin et al., 2001; Rich et al., 2001). Because the majority of persons who enter a correctional facility will eventually return to their communities, the manner in which correctional

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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White health services deal with the HIV-infected individual has important implications to the overall care of the HIV-infected population. Routine HIV testing is well accepted as a procedure offered to incoming prison inmates. Combination antiretroviral therapy has been associated with a reduction in mortality in prisons. A link between community HIV specialists and correctional health care providers is an important partnership for ensuring that HIV-infected patients have optimal care both inside prison and after release (Spaulding et al., 2002). CONCLUSION The current environment of HIV care is both more hopeful and more complex than it was 20 years ago. The early HIV care system was designed—consciously or not—to manage patients who entered with symptomatic, advanced disease and who died after several years of increasingly untreatable opportunistic diseases. A substantial portion of this time was spent in acute care hospitals and involved use of cumbersome, expensive, and invasive therapies. This model of care no longer applies. The changes in the treated natural history of HIV infection from an acute to a chronic disease model and the shift in populations most affected must be considered when crafting policies for the public financing and delivery of HIV care. The public care system must take advantage of the opportunities offered by effective treatments such as HAART while working to meet the challenges of the new epidemic. Findings: Despite remarkable advances in the treatment of HIV, the epidemic remains a threat to public health. Access to HAART is the cornerstone of HIV care. Without it, individuals face increased illness, disability, and death. Nearly complete adherence to the prescribed HAART regimen is crucial for both optimal treatment benefit and the prevention of drug resistance. The demographics of the HIV epidemic are shifting into populations that are highly vulnerable in terms of having access to care, continuity of care, and adherence to treatment, such as racial and ethnic minorities, low-income women, individuals who are mentally ill or have substance abuse disorders, and homeless individuals.

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