co-morbid conditions among people living with HIV/AIDS. Most importantly, the course of the illness has changed. Individuals with HIV are living longer and require care appropriate for a chronic illness rather than for an acute terminal illness.

The shift from acute-care needs to chronic-care needs has not been adequately accounted for by changes in the HIV care delivery system. Initially, the HIV care system developed in response to AIDS, the final stage of HIV infection. In the early days of the epidemic, little could be done for an individual ill with AIDS except to treat opportunistic infections and cancers as aggressively as possible and provide palliative care to ease suffering. As a result, hospitals and community groups were the backbone of a care system that relied heavily on inpatient and end-of-life care rather than on continuous primary medical care and drug treatment. The development of HAART allows for the suppression of the virus, which can prevent or delay the consequences of AIDS. That therapy, consisting of a number of prescription drugs, is delivered primarily in outpatient settings and requires access to high-quality primary care. In addition to HAART, many individuals require a variety of other services, including substance abuse and mental health treatment, case management, and prevention services. The care delivery system, and the financing that supports it, has struggled to adapt to the shift in the locus of service delivery and to integrate HIV care among numerous and multidisciplinary providers.

In assessing the current system, the Committee identifies the current standard of care for HIV and then assesses the extent to which the current financing and delivery system allow individuals with HIV to receive such care. The Committee’s assessment leads to several conclusions. First, although current public financing strategies for HIV care have provided care to, and extended the lives of many low-income individuals, significant disparities remain in assuring access to the standard of care for HIV across geographic and demographic populations. As a result, many individuals have no access or limited access to the standard of care for HIV. Second, certain characteristics of the system (e.g., fragmentation of coverage, multiple funding sources with different eligibility requirements, and significant variations in the type of HIV services offered) do not allow for comprehensive and sustained access to quality HIV care. In many respects, this system, conceived in the early epidemic, is inadequate to meet current needs. Third, the current federal–state partnership for financing HIV care is unresponsive to the fact that HIV/AIDS is a national epidemic with consequences that spill across state borders. Finally, the Committee concludes that the large federal investment in HIV care presents a strong incentive and opportunity to finance and deliver care more effectively.

The Committee’s principal recommendation to address system deficiencies is the establishment of a new federal program for financing HIV



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