In 1993, the National Research Council’s Panel on Monitoring the Social Impact of the AIDS Epidemic noted that “instead of spreading out to the broad American population, as was once feared, HIV is concentrating in pools of persons who are also caught in the ‘synergism of plagues’,” a situation in which “poverty, poor health and lack of health care, inadequate education, joblessness, hopelessness, and social disintegration converge” (NRC, 1993, p. 7). This trend has not reversed in the nearly 10 years since that report was released. HIV has continued its march into the most vulnerable populations in society: the uninsured, racial/ethnic minorities, those with substance use disorders and mental illness, homeless persons, and unsupervised youth (Karon et al., 2001; Levi and Hidalgo, 2001). These are the populations that publicly funded care is intended to help—individuals without financial, social, or personal resources upon which to draw in the event of a catastrophic illness such as HIV. In a move to offer these resources, in 1990 Congress enacted the CARE Act to provide safety net funds for health and supportive services for individuals living with AIDS and HIV infection who have either no or inadequate insurance.
The complex needs of the HIV population require provision of supportive services to overcome barriers to receiving primary care, including case management, housing, food, transportation, and mental health and substance abuse treatment. The greatest disparities in receiving care are manifest in these vulnerable populations, and providing access to HIV care clinicians is only part of what is needed (Shapiro et al., 1999).
This section discusses the demographic shifts of the epidemic and the co-morbidities faced by vulnerable populations that affect access to care, adherence to medications, and continuity of care. Mental health and drug dependence disorders and the effects of poverty disproportionately affect these groups and present challenges to them in meeting life’s basic necessities, such as adequate food, housing, and health care. These populations are characterized further by being in transition between settings, for example, from the community, to the criminal justice system, to substance abuse and mental health facilities, and at times to homeless shelters. This complicates ensuring continuity of care for these individuals and requires communication and coordination between these settings. Finally, while the primary care setting is a focus for care provision, the delay between the time of a vulnerable patient’s test results and entry into care can be long and retention in care can be difficult. Vulnerable patients need assistance that prepares them for entering and staying in primary care as well as assistance with navigating the health care system.