Furthermore, design aspects of the two federal programs that provide services to HIV-infected people—Medicaid and CARE Act—allow for a tremendous amount of variability in the benefits an HIV-infected person can receive. Benefits in one area often fall well below those considered standard in others. The federal–state partnership embodied in the Medicaid program, in particular, allows states to respond to the epidemic in significantly different ways that may not be the most efficient or effective in light of a nationwide epidemic. HIV-infected individuals living in one state may not be eligible for Medicaid services in another state because of differences in income thresholds, or they may receive fewer or more services because the benefit packages vary in each state (e.g., limitations on prescriptions drugs, or coverage of case management and hospice services). Life-saving drugs may be available only intermittently, and providers may not be allowed to use critically important laboratory tests needed to evaluate HIV treatment. Disparities and variations in access to care are the signs of a system that does not equitably meet the needs of the HIV-infected population.
The advent of HAART changed the goal of therapy to near-complete suppression of the virus in order to maintain immune system function and overall health while simultaneously preventing the emergence of drug resistance, an outcome that had not been possible previously (CDC, 1998). Today, when appropriately treated, HIV can be managed as a serious chronic illness. Appropriate treatment requires early and continuous access to HAART, which is expensive, and the ability to support adherence to a sometimes complex drug regimen.
Yet, studies have shown that two years after HAART became the standard of care only half of those in care were receiving it (Cunningham et al., 1999). Other studies have also provided evidence that minorities, women,