example, varies significantly by state and city of residence, in part due to varying income eligibility requirements for the AIDS Drug Assistance Program (ADAP) under Title II of the CARE Act and in part due to the varying resource allocation decisions made by localities. Substantial state variation also occurs in the types of drugs covered and number of prescriptions allowed (Morin et al., 2002). Budget shortfalls can also lead to further restrictions in the ADAP program, such as enrollment caps or benefits limitations, as they did in June 2003.

Finding: A significant proportion of HIV-infected adults do not receive medical care on a regular basis, and many of those not receiving care are in the early stages of the disease.

As a locally controlled, discretionary program that relies on annual appropriations by Congress, CARE Act programs cannot ensure continuity of care from year to year, nor can they ensure that all eligible individuals infected with HIV will receive a minimum basic set of services, thus leading to access issues within the program. In addition, while the community planning process for CARE Act Title I funds has provided important community input into how funds are allocated at the local level, the current process has resulted in funding allocation decisions that have not reflected the greatest areas of need. Perhaps the clearest evidence of this is that the advent of highly effective HIV therapies has produced no meaningful shift of Title I funds to primary care and medications. In part, this is due to significant variability in data sources and measures (and the quality of those data sources and measures) used to describe severity of need for the Title I Supplemental Application (IOM, 2003). Furthermore, current program data collection activities do not support accountability or evaluation. It is currently impossible to make national estimates of the number of clients served by the program or the types of services received because programs do not provide unduplicated counts of clients and the services they receive. As a result, it is difficult to appropriately evaluate the prioritizing of services and allocation of funds within the programs that are so important to providing access to care. There are also lingering conflict of interest concerns about local planning councils because many of their members are service providers who receive CARE Act funds.

CONCLUSIONS

After examining the current direction of the epidemic, the advances in treatment, and the status of the current system of financing and delivery of HIV care, the Committee reached a number of conclusions.



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