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Public Financing and Delivery of Hiv/Aids Care: Securing the Legacy of Ryan White
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Index
A
Access to care
CARE Act programs, 12–13, 17
case management and, 130–131
current system, 5, 13, 268–269, 271
demographic disparities, 129–130
goals, 6–7, 14–15, 16, 33, 36, 50, 134
HAART, 11–13, 14, 129–130, 136, 181, 218–223
insurance access and, 272–274
mental illness and, 55–56, 252, 258, 259–260, 263
outreach to improve, 304
provider participation in federal programs and, 12, 14, 19, 111, 136, 203
public perception, 27–28
shortcomings of current system, 6, 11–12, 14, 19, 135–136
state-to-state disparities, 11, 14, 75, 110, 112, 113, 114–117, 118, 119–122, 284–290, 291, 292, 300, 326
See also Barriers to care
Accountability, 13, 14, 136
in Centers of Excellence, 171–174
criteria for assessing programs, 142
goals, 15, 134
in Medicare, 146
Acute infection
care trends, 6
clinical features, 40
Adherence to HAART
clinical significance, 5, 9, 46, 47, 63
current rate, 46
determinants of, 46, 47–49
drug resistance and, 9, 46–47
mental illness and, 47, 49, 56–57, 91–93, 254, 256–257, 260
patient–provider relationship and, 47, 49, 163
predictive factors, 49
requirements for success, 9, 46, 162–163
substance abuse and, 59, 91–93, 320–321
AIDS Drug Assistance Program, 109, 299
barriers to access, 13, 118, 145, 300
drug purchases, 20, 125, 204, 270, 306
eligibility, 13, 17, 197
HIV-CCP and, 197–198, 207
purpose, 80, 299
resource allocation, 13, 145, 248, 299
spending, 80, 84, 297–298
AIDS Education and Training Centers, 29, 81, 190, 300
Alternative delivery and financing systems, 195
assessment criteria, 16, 142, 214
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block grant program, 153–157
enhanced or expanded Medicaid, 148–153, 195, 213–214, 230, 231
expanded CARE Act programs, 144–145
goals, 16, 141–142
HAART modeling for evaluation of, 214–216
inputs for modeling, 217–225
Medicare expansion, 145–148, 195
projected enrollment, 224–225
projected utilization, 223–224
prospects, 174–175
range of, 15–16, 141, 142, 213
sensitivity analyses, 234–243
state participation, 142–144
See also HIV Comprehensive Care Program
American Public Health Association, 47
Antiretroviral drugs
access disparities, 129–130
alternative therapies, 46
for children, 90
costs, 20, 21, 204, 270
effectiveness, 42, 43–44
technical evolution, 42–43
See also Highly active antiretroviral therapy
Anxiety disorders
adherence to HIV treatment and, 91
prevalence, 251, 253
risk behavior and, 54–55, 255
Assessment
adherence prediction, 49
depression, 55
insurance status and time of diagnosis, 274
role of primary care, 98
Asymptomatic infection, 40–41
At-risk populations, 37
implications for health care delivery, 50
trends, 9, 10, 38, 50, 63
Automobile restraints, 187
Awareness of HIV status, 156, 181, 218, 226
AZT, 42–43, 269, 299
B
Bailey Boushay House, 333
Balanced Budget Act, 18, 197
Barriers to care
in CARE Act programs, 118–122, 300
conflicting goals among programs, 133–134
coordination among programs and, 127–129, 136, 268, 305–306, 328
cost of care, 132–133
in current system, 6, 14, 19, 27, 133–134, 280–283, 304–307
in Medicaid, 12, 17, 109–114, 132–133, 291–293
in Medicare, 117, 295–297
mental illness, 55–56, 131
in private insurance programs, 107–109, 301, 302–303
provider reimbursement, 19, 111, 325–326
sources of, 129
for substance abusers, 58–59, 313, 318–323, 325–327, 330–332
for women of color, 59
See also Access to care
Bipolar disorder, 251
Block grants
advantages, 154
disadvantages, 155–157
structure, 153–154
substance abuse treatment, 324
C
Cancer, 44
Candidiasis, 42
Capitation rates, 111, 114
CARE Act. See Ryan White CARE Act
Care coordination model of service, 170
Care-seeking behavior
cost of care and, 132
substance abuse and, 58, 94, 319
Case management, 127
benefits, 96, 130–131
CARE Act coverage, 298–299
Centers of Excellence model, 170
definition, 96
delivery models, 96
HAART utilization and, 224
modeling service needs, 223–224
CD4 lymphocyte levels
course of HIV, 41, 42
depression effects, 93–94
HAART guidelines, 44, 89
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CD8 lymphocyte levels, depression effects, 93–94
Center for Substance Abuse Treatment, 324
Centers for Medicare & Medicaid Services, 114, 128–129, 233–234
Centers of Excellence for HIV care
accountability mechanisms, 171–174
existing programs, 168–169
features, 168
functions, 7, 170–171
HIV-CCP demonstration project, 180, 206
reimbursement practice, 168, 169, 171–174, 188
structural models, 169–170
Childcare services, 322
Children and adolescents
CARE Act services, 80–81, 202
HIV transmission at childbirth, 19, 90
HIV treatment, 90–91
Medicaid coverage, 278
mental illness among, 61–62, 252
sexual abuse as HIV risk factor, 255
unsupervised youths, 61–62
Chronic care
clinical model, 162–164
definition of chronic illness, 161
HIV/AIDS requirements, 161–162
implications for health care delivery, 6, 12, 31, 88, 161–164, 165
integrated and coordinated model, 165–168
trends, 6, 12, 63, 88, 100
Colorectal cancer screening, 186–187
Community health centers, 303–304
Co-morbidity
among HIV-infected youth, 61–62
HIV-CCP coverage, 201, 202
infections, 59–60.
See also Opportunistic infection
recommendations for federal care program, 19
social conditions as, 54, 60–63
trends, 5–6, 10, 38–39
types of, 52–54
See also Mental illness;
Substance abuse;
specific disorders
Consolidate Omnibus Reconciliation Act, 109, 302
Coordination among HIV/AIDS programs
need for, 127–129, 268
research needs, 305–306
Coronary angioplasty, 187
Cost effectiveness
current HIV care, 270
HAART, 89, 179, 196
HIV-CCP, 16, 22–23, 24, 179, 180–181, 185–188, 231–232
program evaluation methodology, 185–186, 214
Cost of care
as barrier to care, 132–133
buy-in provisions, 18, 111
care-seeking behavior and, 132
drugs, 19–21, 203–205, 270, 306
enhanced Medicaid program, 234
goals, 134
HAART, 23, 179, 185, 196, 204–206, 223, 269–270
HIV care as portion of all health care spending, 270
HIV-CCP budget, 233–234
inputs for modeling alternative programs, 217–218, 223–224, 234–243
preventive intervention outcomes, 193
private insurance premiums, 107–108, 302
provider reimbursement rates, 111
psychopharmacotherapy, 262
recommendations for federal program, 21
spend-down eligibility in federal programs, 18, 326
subsistence purchases and, 131
substance abuse treatment, 327–328
trends, 276
for uninsured HIV/AIDS patients, 189
Course of disease, 40–42
disease state-transition model, 215
initiation of HAART, 226–227
insurance coverage and, 87
insurance status and time of diagnosis, 274
mental illness effects, 93–94, 257
oral manifestations, 98
D
Data collection
on CARE Act program performance, 13, 14, 122–123, 126–127, 136, 145
current inadequacies, 13, 14, 136
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HAART use and need, 218–223
HIV population characteristics, 218
inputs for modeling alternative programs, 217–225
Medicare, 146
privacy and confidentiality issues, 196
records management in Centers of Excellence, 169–170
on substance abuse, 315–317
Delivery of care
case management services, 96
consideration of substance abusers in policy planning, 314
coordination among programs, 124, 125, 127–129, 268, 305–306, 328
current system, 5–6, 12, 34, 63, 99, 100
demographic factors, 50
financing of care and, 10
functions of system, 167
future challenges, 36, 38–39
goals, 14–15, 16, 33, 36, 88, 133–134, 161, 178
historical development, 87–88
integrated and coordinated model, 165–167
organizational structure, 167–168
primary care, 98–99
prospects for reform, 174–175
shortcomings of current system, 13–14, 107, 134–136, 165, 167, 194–195
system evaluation, 32
trends, 6, 12, 36
See also Alternative delivery and financing systems;
specific programs
Demographic patterns
access disparities, 129–130, 305
geographic distribution, 51–52
implications for service delivery, 50
infection rate, 9–10, 38, 51
insurance access, 272
mental health care utilization, 258
mental illness risk, 251
mortality, 9
trends, 50, 51–52, 63, 194–195, 270, 307
See also Racial/ethnic minorities;
Women
Dental health. See Oral health
Dental Reimbursement Program, 30, 81
Department of Defense, 19, 203, 304
Department of Veterans Affairs, 33, 282–283, 303, 327
drug purchases, 19, 20, 203
Depression
adherence to HIV treatment and, 56–57, 91, 256
HIV progression and, 93–94
identification, 55
immune function and, 257
prevalence, 251, 253
risk behavior and, 54–55, 255
Diabetes, 47, 162
Drug-resistant viral strains
adherence and, 5, 9, 46–47
screening for, 89
trends, 9, 47
Dysthymia, 253
E
Early Treatment for HIV Act, 292
Education and training of health providers
CARE Act programs, 29, 81, 190, 300
care for substance abusers, 321
in Centers of Excellence, 168
Medicaid providers, 111–114
Efficiency of service delivery, 134.
See also Cost effectiveness
Eligibility, 278, 280–283
alternative block grant program, 153–157
asset testing for, 198–199
buy-in provisions, 18
CARE Act, 17, 82, 144–145, 196, 197, 207, 249, 298
criteria for assessing programs, 142
current status, 17
expansion of Medicaid eligibility, 149–153, 217
HIV-CCP, 7, 18, 157–158, 178, 179, 181–182, 190, 196–201, 207, 217, 226
Medicaid, 17, 18, 75–76, 109, 114, 196, 197, 201, 278, 279–290, 291–292, 305, 325
Medicare, 78, 145–146, 147, 294–295, 305
modeling prospective enrollment in alternative programs, 224–225
mortality outcomes, 130
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recommendations for improving access, 18
Social Security Disability Insurance, 294
spend-down provisions, 18, 197–198, 279, 326
substance abuse treatment, 325
Supplemental Security Income, 279, 325
Eligible Metropolitan Areas, 119, 122–123, 246–247, 298–299, 329, 331
Emergency room admission, 59
current utilization, 99
modeling service needs, 223
substance abuser care-seeking behaviors, 319
Entitlement programs, 73, 153, 156, 276
Evidence-based practice, 163
F
Federal Ceiling Price, 20, 21
recommendations for HIV-CCP, 179–180, 203, 205
Federal Employee Health Benefits, 304
Federal programs for HIV/AIDS care, 278, 280–283, 328
barriers to access, 132, 133–134
benefits, 280–283
Centers of Excellence oversight, 174
current spending, 73, 75, 78, 188, 274–277
eligibility, 280–283
financing mechanisms, 73, 100
goals, 8, 133–134
mandatory vs. discretionary spending, 276
origins and development, 8
problems of federal–state partnership, 6, 11, 14, 136
recommendation for new program, 6–7, 16.
See also HIV Comprehensive Care Program
substance abuse treatment in, 95
See also specific programs
Federal Supply Schedule, 20, 21
recommendations for HIV-CCP, 179–180, 203, 205
Fee-for-service care, 12
Financing system
Centers of Excellence, 171–174
community-based services, 304
coordination among programs, 305–306
criteria for assessing programs, 142
current HIV spending, 73, 188, 274–277
current system, 5, 11, 73, 100, 216, 268
delivery system and, 10
federal block grant program, 153–157
geographic variation, 122
goals, 14–15, 16, 178
insurance coverage distribution, 271–274
prevention services, 306–307
problems of federal-state partnership, 6, 11, 14, 136
shortcomings of current system, 6, 11, 14, 134–136, 194–195, 268–269, 304–307
substance abuse services, 323–326, 327–328
See also Alternative delivery and financing systems;
Cost of care;
specific programs
Fusion inhibitors, 37
G
Geographic distribution
CARE Act spending, 122
disease prevalence, 51–52
drug use patterns, 316
uninsured population, 129
Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, 44–46, 89
H
HAART. See Highly active antiretroviral therapy
Health Insurance Portability and Accountability Act, 85–87, 107, 108, 301–303
Health Resources and Services Administration, 7, 165
Hepatitis C, 42, 59–60
Heterosexual transmission trends, 10, 51
Highbridge Woodycrest, 334
Highly active antiretroviral therapy (HAART), 100
access under HIV-CCP, 159, 178–179, 182–183, 217, 226–230
adverse effects, 44
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assessment for, 49
cost-effectiveness, 89, 179, 196
costs, 20–21, 23, 159, 179, 185, 196, 204–206, 223, 269–270
criteria for evaluating alternative delivery and financing systems, 214–215
current access, 11–13, 14, 129–130, 136, 181, 214–215, 218–223, 226
disease status of recipients, 226–227
dosing schedule, 48–49
drug interactions, 127, 320
effectiveness, 5, 8, 31, 37, 43–44, 130, 184–185
implications for care delivery system, 6, 31, 36, 39, 88
income levels of recipients, 222
insurance status of recipients, 181, 222
Medicaid coverage, 77, 217, 230
in pregnancy, 90
requirements for clinical effectiveness, 18
substance abusers and, 320
transmission risk and, 8, 37–38, 135
treatment guidelines, 44–46, 89
viral resistance to, 9
See also Adherence to HAART
High-risk pools, 304
HIV/AIDS Integrated Services Project, 306
HIV/AIDS Mental Health Services Demonstration Program, 95
HIV Comprehensive Care Program, 213
administrative structure, 157, 159
benefit package, 18–19, 157, 158, 179, 186, 201–202, 215–216, 217
Centers of Excellence demonstration project, 180, 206
cost-effectiveness, 22–23, 24, 179, 180–181, 185–188
disadvantages, 159–160
drug purchases, 21, 159, 179–180, 203–206
eligibility, 7, 18, 157–158, 178, 179, 181–182, 190, 196–201, 207, 217, 226
financing, 157, 158–160, 196, 217, 233–234
goals, 6–7
HAART access and use under, 159, 178–179, 182–183, 217, 226–230
inputs for modeling, 217–225
maintenance of effort requirements, 160
morbidity and mortality outcomes, projected, 16, 22, 179, 183–184, 225, 230–231
prevention effect, 192–193
private insurance market effects, 181, 199–200
projected enrollment, 22, 178, 182–183, 190, 217, 224–225, 226
projected service utilization, 217–224
projected spending, 23, 160, 179, 188–189, 233–234
provider payment, 19, 158, 179, 185, 188, 202–203, 217
quality of care goals, 21
rationale, 16, 23–24, 33, 158–159, 179, 193–194, 208–209
recommendation for establishment of, 17, 179, 194–196
Ryan White CARE Act and, 21–22, 160, 180, 189–191, 206–208
state participation, 159–160, 195, 196, 234
Home and community-based services, 223, 303–304
CARE Act coverage, 329
Medicaid coverage, 114, 290–291
Homelessness, 61
Housing Opportunities for Persons with AIDS, 276
I
Immigrant population, 62, 200
Immunophysiology
AIDS, 41–42
chronic stage infection, 40–41
co-morbid disease infection, 60
depression effects, 257
HAART, 44–45
primary infection, 40
tuberculosis risk, 60
Incarcerated populations, 62–63, 200–201, 326
Incidence
current rate, 5, 7–8, 27, 36–37
demographic patterns, 9–10, 38, 307
trends, 9–10, 37–38, 194–195, 307
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L
Low-income population
care delivery system goals, 14–15
challenges for service delivery, 50
crowd-out response to government programs, 181
current estimates, 218, 270
current HIV/AIDS care system, 34
definition, 197
eligibility for federal care programs, 17, 18, 197
eligibility for Medicaid HIV benefits, 109, 111, 279, 290
expansion of eligibility for Medicaid
HIV benefits, 149–153
HAART access among, 222
HIV-CCP eligibility, 179, 181–182, 196, 197–199
infection risk, 38
mental illness risk, 251
poverty level, 181, 196
recommendations for CARE Act programs, 22
social co-morbidities, 54, 60–61
substance abuse treatment access among, 58–59
M
Mammography, 187
Managed care, 117
Centers of Excellence model, 170
Medicaid, 111–113, 293
Medicaid
barriers to access, 12, 17, 109–114, 132–133, 272–273, 291–293, 305
benefits, 76–77, 290–291
capitation rates, 111, 114
case management services, 96
community-based services, 304
coordination with other programs, 128–129
coverage for privately-insured individuals, 199
coverage for working individuals, 109–111, 291–292
current participation, 10, 73, 75, 129, 218, 271, 272, 274, 278–279
definition of “disability,” 279
demographic patterns in HIV care, 272
dental services, 130
drug purchases, 20, 21, 203–204, 270, 293, 306
dual enrollment, 271, 294
eligibility for AIDS/HIV care, 17, 18, 75–76, 109, 114, 149–153, 196, 197, 201, 278, 279–290, 291–292, 305
enhanced or expanded models, 15–16, 141, 148–153, 195, 213–214, 217, 230, 231, 234
managed-care services, 111–113, 293
mental illness treatment, 115
performance evaluation, 32
preventive interventions, 97
primary care services, 98
provider participation and reimbursement, 12, 19, 111, 114, 202–203, 325–326
quality of care, 273–274
role in HIV care system, 7
Section 1115 waivers for HIV care prior to disability, 7, 15, 109, 111, 149–150, 291–292, 305
spending, 75, 274–275, 276, 279, 328
state cost control strategies, 293
state-to-state disparities, 11, 14, 75, 110, 112, 113, 114–117, 284–290, 291, 292, 305
strategies for improving service delivery, 114
structure, 75, 278
substance abuse treatment, 95, 115, 325–326
Medicaid Managed Care Organizations, 205
Medicare
access, 19
barriers to access, 117, 295–297, 305
benefits, 79, 117, 147–148, 295
coverage, 77–78, 293
current enrollment, 10, 73, 78, 129, 218, 271, 272, 293–294, 328
dual enrollment, 271, 294, 296–297
eligibility, 78, 145–146, 147, 294–295, 305
expansion of, to improve care, 141, 145–148, 195
financing sources, 146
prescription drug coverage, 79, 147–148, 294–295, 296–297, 305, 306
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program accountability, 146
project growth in enrollment, 78, 294
provider participation and reimbursement, 12, 19, 111, 146, 203
spending, 78, 274–275, 276, 294, 328
strategies for improving service delivery, 117
utilization patterns, 127–128
Medicare Prescription Drug, Improvement and Modernization Act, 147, 294–295
Medigap policies, 117, 296
Mental illness
access to care, 252, 263
adherence to HIV treatment and, 47, 49, 56–57, 91–93, 254, 256–257, 260
among HIV-infected youth, 61–62
barriers to care, 55–56, 131, 258, 259–260
challenges for service delivery, 50
clinical features, 251
co-morbid substance abuse, 251, 327
disability outcomes, 251, 252
HAART utilization and, 224
HIV-CCP coverage, 201
HIV detection in people with, 55, 258
HIV risk, 54–55, 94, 252–253, 254–256
impact on course of disease, 93–94, 257
implications for HIV treatment, 95, 250, 261–263
Medicaid coverage, 115
modeling service needs, 223–224
mortality, 251–252
pharmacotherapy, 261–262
prevalence, 54, 250, 251, 252–253
severe forms, 252
socioeconomic status and, 251
standard of HIV care, 10, 19
stigmatization and discrimination, 260
trends, 10, 253–254
Montefiore Substance Abuse Treatment Center, 333
Mortality
cause of death in HIV disease, 42
co-morbid depression, 94
course of HIV, 42
current rate, 5, 7–8, 37
demographic patterns, 9, 51
HAART outcomes, 5, 8, 37, 130, 184
HIV-CCP goals, 16
HIV-CCP projected outcomes, 22, 179, 183–184, 230–233
insurance coverage and, 130
mental illness, 251–252
obstacles to greater reduction, 5–6, 12
treatment effectiveness, 43
trends, 8, 42
Multidisciplinary treatment approach, 163–164
N
National health insurance, 33
Natural history. See Course of disease
Nonmedical services, 190
Medicare coverage, 117
modeling service needs, 223
NorthSTAR Behavioral Health Pilot Program, 334
O
Obstetric care, 19, 90, 201, 223
Omnibus Budget Reconciliation Act, 203–204, 279
Opportunistic infection, 42, 89–90
guidelines for prevention and treatment, 90
HAART effectiveness, 44
modeling service needs, 223
types of, 90
Oral health
access to care, 130
CARE Act provisions, 30, 81, 98–99, 190, 202, 299
disease progression, 98
Medicaid services, 130
modeling service needs, 223
primary care, 98
Origins of HIV, 40
P
Panic disorder, 91, 253
Patient–provider relationship
discrimination against client with mental illness, 260
HAART adherence and, 47, 49, 163
substance abusing patients, 321–322
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Pneumonia, 42
Posttraumatic stress disorder, 253, 255
Pregnancy
HAART and, 90
HIV transmission prevention in, 19, 90–91
Prescription drugs
CARE Act coverage, 118, 204
costs, 19–20, 270, 306
goals for federal purchasing, 7
HIV-CCP drug purchases, 21, 159, 179–180, 203–206
Medicaid benefits, 76–77, 113, 203–204, 290, 291, 293, 328
Medicaid spending, 270
Medicare benefits, 79, 117, 147–148, 294–295, 296–297, 305
pharmacy assistance programs, 304
psychotropic medications, 261–262
research and development, 20–21
See also AIDS Drug Assistance Program;
Highly active antiretroviral therapy
Prevalence
CARE Act EMA eligibility, 246–247
childhood sexual abuse, 62, 255
co-morbid disease infection, 60
co-morbid mental illness, 54, 252–253
co-morbid substance abuse, 57–58, 253, 316–317
current estimates, 218, 226
geographic distribution, 51–52
homelessness, 61
mental illness, 54, 250, 251
socioeconomic distribution, 270
trends, 37–38
Preventive interventions
among HIV-positive individuals, 97
antiretroviral therapy, 97
financing, 306–307
HIV-CCP coverage, 201, 202
HIV-CCP effects, 192–193
with mentally ill individuals, 262–263
Primary care
access, 10
advantages of health care delivery in, 98
CARE Act provisions, 98–99, 118, 126
HIV-CCP coverage, 201
Medicaid coverage, 98
role in HIV care system, 98
scope of services, 98
Primary infection, 40
Prisons. See Incarcerated populations
Privacy and confidentiality issues, 196
Private insurance, 33
anti-discrimination protections, 301–302
barriers to care, 107–109, 301, 302–303
CARE Act purchases, 108–109, 302
COBRA extensions, 302
consumer costs, 107–108
coverage over course of disease, 87
crowd-out response to government programs, 181, 199–200
current coverage, 10, 73, 85, 100, 108, 129, 218, 271, 272, 274, 301
demographic patterns in HIV care, 272
denial of service, 108, 301
HIV-CCP eligibility and, 199
Medigap policies, 117, 296
portability protections, 301
regulation, 85–87, 108, 301–302
state-by-state variation in care, 108
PROTOTYPES, 332–333
Public perception and understanding
of HIV/AIDS care, 27–28
stigmatization of HIV-infected persons, 260
Q
Quality-adjusted life years
evaluation of alternative care systems, 22, 215, 216
HIV-CCP goals, 16
HIV-CCP projected outcomes, 22–23, 179, 184–185, 186–188, 231–233
Quality of care
CARE Act programs, 118, 123
current system, 305
goals, 15, 134, 164–165
HIV-CCP goals, 21
insurance access and, 273–274
in managed-care organizations, 111–113
Medicaid providers, 111–114
mental illness and, 260, 262–263
promptness of diagnosis, 274
in rural areas, 99
specialists in HIV care, 113, 114
strategies for improving, 164–165
substance abuse and, 319–320
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R
Racial/ethnic minorities, 38
barriers to care, 59, 129–130, 131, 132–133
CARE Act services, 82, 247, 249
co-morbid disease infection, 60
HIV risk, 9, 38
infection patterns, 51, 307
insurance access and utilization, 272
mental health care utilization, 258
mental illness risk, 251
mortality patterns, 9
substance use in HIV transmission among, 57, 315
Reimbursement
alternative block grant program, 156
carve-out programs, 114, 170
Centers of Excellence, 168, 169, 171–174
criteria for assessing programs, 142
disincentive programs, 173–174
HIV-CCP, 19, 158, 179, 185, 188, 202–203, 217
Medicaid, 12, 14, 19, 114, 132–133, 202–203, 293, 325–326
Medicare, 12, 19, 111, 146, 203
obstacles to access, 12, 14, 19, 132–133, 136, 203, 293
risk-adjusted capitation, 114
state-to-state variation, 326
Research and development in pharmaceutical industry, 20–21
Rivington House, 334
Rural areas, 323
Centers of Excellence in, 173
quality of care in, 12, 99
substance abuse treatment in, 326
Ryan White CARE Act, 7, 11, 28
barriers to care, 12–13, 118–122, 300
benefits, 202, 298–300
case management services, 96
clients, 30, 35, 81–82, 298
coordination with other programs, 124, 125, 128–129
dental program, 30, 81, 98–99, 190, 202, 299
early intervention services, 80, 119, 202, 207–208, 299
education and training centers, 29, 81, 190, 300
effectiveness, 31–32
eligibility, 17, 82, 144–145, 196, 197, 207, 298
Eligible Metropolitan Areas, 119, 122–123, 298–299, 329, 331
emerging communities awards, 249, 299
expansion of, to improve care, 141, 144–145
funding, 118, 145, 297–298, 300, 328
HIV-CCP and, 21–22, 160, 180, 189–191, 206–208
HIV treatment evolution and, 30–31
performance evaluation, 13, 14, 122–123, 126–127, 136, 145
planning bodies, 13, 84–85, 123–127, 144, 329, 331
primary care services, 98–99, 118, 126
private insurance purchases under, 108–109, 302
purpose, 8, 11, 28–30, 50, 79, 268, 297
services and components, 29–30, 80–81, 82–84
spending, 80, 81, 119, 125, 276, 298, 299, 300
state and local administration, 13, 80, 144, 145, 248, 298, 299, 329
state-to-state disparities, 17, 118, 119–122, 144–145, 284–290, 298, 300, 305
substance abuse treatment, 95, 314, 328–331, 334–335
Title I, 13, 29, 80, 82, 84, 85, 96, 119, 123, 125, 145, 190, 207, 246–247, 298–299, 328–330
Title II, 13, 29, 80, 82–84, 96, 108–109, 119, 122, 190, 207, 248–249, 299, 328–330
Title III, 29, 80, 119, 190, 202, 207–208, 299
Title IV, 29, 80–81, 119, 190, 202, 299
See also AIDS Drug Assistance Program
Ryan White Planning Councils and Consortia, 123–127
S
Schizophrenia, 251, 253, 255, 261
Screening
cost-effectiveness, 186–187
for drug-resistant viral strains, 89
HIV detection in people with mental illness, 55, 258
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incarcerated persons, 63
prenatal, 90–91
rapid testing, 37
Sensitivity analysis, 234–243
Settings for care
current utilization, 12, 99, 100
insurance coverage and, 10, 268
for substance abusers, 59, 319–320
trends, 6, 87–88, 165
Sexual abuse
HIV transmission risk and, 255
prevalence, 62, 255
Sexual behavior
HAART and, 135
mental illness and, 54–55, 94, 254–256
prevention of transmission-risk behaviors, 97
prior sexual abuse and, 255
substance use and, in HIV transmission, 315
Sexually transmitted diseases, co-morbid, 59–60
Social co-morbidity, 54, 60–63
Social Security Disability Insurance
eligibility, 294
Medicare eligibility and, 78, 294
spending, 275–276
Social services access, 10
Special Projects of National Significance, 29, 81, 190, 300
Standard of care, 10, 88–89, 100
alternative block grant program, 155–156
criteria for assessing programs, 142
current delivery system, 6
HIV-CCP, 158, 179, 201–202
recommendations for federal program, 18–19
State Children’s Health Insurance Program, 142, 153–154, 155, 200, 201
State governments
alternative block grant program, 153–157
CARE Act administration, 80, 119, 122, 248, 298, 299
drug purchases, 203–204
eligibility for AIDS/HIV care, 17
expansion of Medicaid eligibility, 149–153
health care for incarcerated persons, 200–201
HIV care spending, 276, 279, 328
in HIV-CCP, 17, 157–158, 159–160, 189, 195, 196, 234
inadequacies of current care system, 6, 7
insurance regulation, 108
Medicaid administration, 11, 75, 76–77, 279–290, 291, 328
problems of federal–state partnership, 6, 11, 14, 136
purchase of private insurance by, 108
role in alternative delivery and financing systems, 142–144
substance abuse treatment programs, 323–324
State-to-state variation in services
CARE Act programs, 118, 119–122, 144–145, 284–290, 298, 300, 305
current system, 6, 7, 305
Medicaid programs, 11, 14, 75, 110, 112, 113, 114–117, 284–290, 291, 305
private insurance, 108
reimbursement policies, 326
Stigmatization, 260, 318
Substance abuse
abuser attitudes toward health care, 321–322
among HIV-infected populations, 57–58, 61–62, 253, 316–317
barriers to HIV/AIDS care, 313, 318–323, 330–332
CARE Act provisions, 314, 328–331, 334–335
care-seeking behavior and, 58, 94, 319
challenges for service delivery, 50, 57, 58–59
co-morbid mental illness, 251, 327
considerations in HIV policy planning, 314
current research base, 315–317
current treatment system, 323–332
denial of services based on, 322
effective programs, 331–335
funding for treatment services, 323–326, 327–328
HAART utilization and, 224, 320
hepatitis infection and, 60
HIV-CCP coverage, 201
HIV course and, 91, 93–94
HIV transmission and, 57, 94, 313, 315
Medicaid coverage, 115, 325–326
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modeling service needs, 223–224
patterns, 315–316
provider attitudes, 321
recommendations for federal care program, 19
service needs of HIV-infected substance abusers, 91, 95, 317–318
standard of HIV care, 10, 19
syringe exchange program, 314
treatment adherence and, 47, 49, 59, 91–93, 320–321
treatment capacity, 326–327
treatment for, 322–323
Substance Abuse and Mental Health Services Administration, 95, 315–316, 324
Substance Abuse Prevention and Treatment Block Grants, 95
Supplemental Security Income, 18, 76, 112, 197, 275–276, 279, 305, 325
Syringe exchange program, 314
T
Teaching hospitals, 99
Temporary Assistance for Needy Families, 112
Testing. See Screening
Therapeutic relationship. See Patient–provider relationship
Ticket to Work/Work Incentives Improvement Act, 109–111, 114, 291–292, 305
Transmission, HIV
among injection drug users, 57
HAART therapy and, 8, 37–38, 135
heterosexual, 10, 51
HIV-CCP effects, 192–193
mental illness and, 54–55, 94, 252–253, 254–256
mother-to-child, 90–91
projections, 37–38
stage of disease and risk of, 10, 41,
substance abuse and, 57, 94, 313, 315
See also Incidence;
Preventive interventions
Tuberculosis, 42, 60
U
Underinsured/uninsured population, 33
among individuals with HIV/AIDS, 11, 100, 129, 226, 271, 272, 274
CARE Act coverage, 79, 82, 297
costs of HIV care, 189
demographic patterns, 272
geographic distribution, 129
HAART access and utilization, 181
HIV-CCP projections, 189
infection trends, 38, 50
settings for care, 10, 268
substance abuse treatment access among, 58–59
V
Viral load, 41–42, 43
depression effects, 93–94
W
Women
barriers to care, 59, 322
CARE Act services, 80, 82, 202
depression risk, 251
infection patterns, 9–10, 51
insurance access and utilization, 272
obstetric care, 90
substance use in HIV transmission among, 315
Z
Zidovudine, 90
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