previous chapters ensure access to the standard of care for HIV? Does the system promote delivery of high-quality services? Does the system facilitate efficiency and ensure accountability? Based on the data presented in previous chapters, the Committee offers the following observations and conclusions.

While the third decade of HIV/AIDS offers unprecedented technological and clinical advances in its treatment and epidemiological management, the structural barriers in the financing and delivery of care have undermined the effective application of these advances. As discussed in preceding chapters of this report, effective HIV/AIDS management results in (1) people with HIV/AIDS experiencing substantial reductions in mortality and disability, (2) people with HIV/AIDS experiencing improved quality of life, and (3) with continued HIV prevention, the rates of new infection declining significantly, protecting the health of the public. As a clinical and scientific matter, the improvement in the individual health of those with HIV/AIDS and the protection of the public’s health are inextricably linked.

The link between individual health and the protection of the public’s health is reflected in three overarching clinical and epidemiological realities. First, with sustained comprehensive treatment, mortality from the disease can be reduced significantly, with commensurate reductions in disability and health care costs. Second, receiving sustained comprehensive treatment can help to prevent transmission of HIV to others because drug therapies reduce viral load, thus potentially rendering the individual less infectious (Vernazza et al., 1999; Staszewski et al., 1999; Barroso et al., 2000). Yet there is some evidence that receiving HAART can cause an increase in unsafe behaviors, thus emphasizing the importance of prevention counseling as a routine part of clinical care (Katz et al., 2002). Third, people who receive drug therapies on a nonsustained or intermittent basis are more likely to develop and transmit resistant strains of HIV, creating substantial new risks for individuals and the community at large.

The Committee finds that the current system of HIV/AIDS care is characterized by substantial financial and structural barriers to critical elements of care, including HAART, and by interruptions in care and drug therapies that pose serious risks to both individual and community health. These barriers include limited access to private insurance and constrained eligibility for public programs with benefit packages that vary from state to state. The result is continued preventable death and disability and little decline in the rate of new infections each year (CDC, 2002).

Based on its analysis of the trends in HIV infection, demographics of the disease, treatment advances, and the current systems of financing and delivering care, the Committee concludes the following:

Conclusion 1: Current public financing strategies for HIV care have provided care and extended the lives of many low-income individuals.

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