BOSTON – Comprehensive HIV care in the United States has resulted in a dramatic reduction in AIDS-related morbidity and mortality, but the future of that care is clouded by uncertainties surrounding health care reform and financing, HIV specialists said at the annual meeting of the Infectious Diseases Society of America.
While they applaud expanded access to care, members of the HIV Medicine Association of the IDSA and the Ryan White Medical Providers Coalition expressed concern that the quality of care for HIV-positive patients could suffer if that care was moved out of Ryan White clinics and into Medicaid-based community health centers without clinical expertise in HIV, said Dr. Joel Gallant from the division of infectious diseases at Johns Hopkins University, Baltimore.
Dr. Joel Gallant
"The multidisciplinary integrated care provided by these clinics has really been critical to their success, and they have become models of high-quality health care for underserved people and for the concept of the medical home. Unfortunately, this model is now in jeopardy, in part because of the current economic climate and in part because of the potential successes of health care reform," he said at a briefing discussing the groups’ joint policy statement on the essential components of effective HIV care.
The Ryan White program, established by Congress in 1990, is the third largest funder of HIV care in the United States, after Medicare and Medicaid. According to the Kaiser Family Foundation, the program serves more than 500,000 people with HIV each year, and pays for the care of people with limited or no insurance or other financial resources.
In their policy statement, the authors optimistically state that President Obama’s health care reform plan "provides an unprecedented opportunity to improve access to HIV care and develop more sustainable funding streams that can be used to expand access to the effective HIV care model developed by the Ryan White program."
But if such change is to succeed – and it’s a very big "if" – Dr. Gallant and colleagues acknowledged that it "will require Medicaid, Medicare, and private insurers to adopt delivery systems and risk-adjusted payment mechanisms that support access to effective HIV care."
The authors say that whatever shape health care takes in the future, the elements required for effective HIV care include access to:
• Routine HIV testing.
• Early diagnosis.
• Care provided by an expert in HIV.
• Subspecialists with HIV experience.
• HIV medications.
• Support for adherence to treatment and health care.
• Access to social work services, substance abuse treatment, and mental health services.
"Weakening of this model by fragmenting care, decreasing access to essential services or decreasing provider expertise could really have devastating consequences to infected individuals and to society as a whole," Dr. Gallant said.
"[The HIV care] model is now in jeopardy, in part because of the current economic climate and in part because of the potential successes of health care reform."
He noted that although HIV medications are expensive, they are life-saving, highly cost-effective, and prevent illness, disability, hospitalization, and death when properly used.
"In addition, now we know that successful HIV treatment prevents transmission. In the recently published HPTN 052 study, treating the affected partner in a sero-discordant partner reduced transmission to the uninfected partner by 96%, so providing quality HIV care to HIV-infected is really critical to our efforts to reduce the size of the epidemic in this country," he added (N. Engl. J. Med. 2011;365:493-505).
The Ryan White model also has broader application to the treatment of other chronic conditions, commented coauthor Dr. Mari Kitahata from the department of medicine at the University of Washington, Seattle.
"A key component is coordination of care, and a care coordinator could be a qualified nurse, case manager or social worker responsible for communicating and coordinating with other providers, as well as bringing access to services throughout the continuum. Medication management is an essential component of primary care, as it is in other chronic diseases," she said.
The policy statement was developed by a joint working group of the HIV Medicine Association’s board of directors and the Ryan White Medical Providers Coalition with support from HIV Medicine Association staff.
Dr. Gallant disclosed that he has received honoraria or consulting fees from Bristol-Myers Squibb, Merck, Janssen Therapeutics, RAPID Pharmaceuticals and Gilead Sciences, and payment for review activities from Gilead and Sangamo Biosciences. Dr. Kitahata disclosed no potential conflicts of interest.