largely because modes and standards of care change relatively quickly. Prediction of (and therefore planning for) specific quantities and types of clinical services and facilities can be extraordinarily difficult because of the rapidly changing nature of HIV clinical care.

One example of the evolution of HIV care is the changing need for inpatient hospital beds. Consider cryptococcal meningitis, a fungal infection of the central nervous system, which eventually attacks 10 to 15 percent of AIDS patients (non-HIV-infected people also occasionally contract the disease). Until recently, HIV-infected people with cryptococcal meningitis required several weeks of intravenous therapy with a relatively toxic drug, amphotericin B, followed by twice-weekly amphotericin B maintenance therapy for the rest of their lives. They constituted a substantial fraction of AIDS patients requiring hospital or nursing-home beds or intensive at-home therapy. Then, in the winter of 1990, a new oral antifungal drug, fluconazole, was licensed. It is equal to amphotericin B, at least for maintenance therapy; many patients who would formerly have required elaborate intravenous therapy (often in an institution) now take one pill a day at home.

Another challenge for the provision of direct services is the complexity of the disease. HIV disease attacks virtually every organ system of the body. The U.S. health care system has long been criticized for its failure to provide comprehensive, coordinated primary care and for too great a reliance on specialists and subspecialists. It is precisely such comprehensive, primary care that is necessary to cope with a disease that is chronic and disabling and that stubbornly refuses to be limited to any single organ system. In many ways, then, the calls for adequate ongoing medical care for HIV-infected persons reflect and reinforce other current demands for an overall reordering of staffing and reimbursement priorities in American health care.

The transmissibility of HIV poses another challenge to health care providers. Not only does the fear of acquiring HIV infection imperil recruitment and retention of health care professionals to work with HIV-infected patients, it also has the potential to drive a wedge between providers and their patients.

Organization of HIV/AIDS Care

A recurring question in the delivery of health care for people with HIV disease and AIDS involves how care ought to be organized and in what setting it might best be delivered. Various goals—increased survival, patient satisfaction, efficiency, economy, or quality care—may call for differing arrangements for delivering care. Optimal care for HIV disease may be difficult to accommodate within the extant organizational and reimbursement



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