being examined. The project information presented in succeeding sections represents both published and unpublished data. The more qualitative information is based largely on case studies; the quantitative information clearly is limited by its focus on program clients rather than on the experience of a broad cross section of persons with HIV disease in each city. Nonetheless, because this data source contains specific, detailed information relevant to the access barriers that confront those with HIV disease, it is useful as an illustrative device.
Equitable access to health care services has been a major focus of health services research in the United States for four decades (Ginzberg, 1990). Research in the past two decades has emphasized factors associated with the rising costs of health care; now, as a result of growth in the number of uninsured over the past decade, access to care has once again emerged as a central topic in health services research. This section reviews the various barriers to use of services confronting persons with HIV disease. In keeping with the model proposed by the IOM committee, barriers have been classified as financial, structural, personal, and attitudinal. Each is defined in relation to the special issues facing persons with HIV disease.
Financial barriers to access to health care services include insurance coverage, provider reimbursement rates, and lack of investment in resources designated for the treatment of HIV disease. Other financial barriers can also be noted, such as out-of-pocket expenses for patients, the high cost of treatment, and the substantial indirect costs of the disease to the patient and society. These barriers are either covered under one of the topics mentioned above or are beyond the scope of this paper.
The absence of insurance coverage is a barrier to health care services regardless of a person's medical problems. In the case of HIV disease, however, the poverty and/or limited work history and savings of the population at risk, as well as the increasingly prolonged nature of the disease, mean that those infected are likely to endure limited access over a long period of time. Because the absence of private compared with public insurance may have a different, and potentially sequential, impact on the person with HIV disease, these two issues are treated separately.