Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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Appendix E: Towards an Understanding of Meeting HIV-Infected Substance Users
Appendix E: Towards an Understanding of Meeting HIV-Infected Substance Users
Pages 313-339
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. 1Paper prepared for the Committee on Public Financing and Delivery of HIV Care, Institute of Medicine, October 28, 2002.
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314 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE Looking back, it is perhaps unfortunate that the first major drug abuserelated policy initiative advocated by the now mobilized "AIDS community" was syringe exchange. While of incontrovertible effectiveness in reducing the transmission of HIV and other blood borne infections among injecting drug users (see, for example, Jones and Vlahov, 1998)
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APPENDIX E 315 IDENTIFICATION OF THE AFFECTED POPULATION Difference conceptualizations of the problems of HIV infection and substance abuse at the national level have resulted in no integration of data about HIV and substance use. As a result, gaining an accurate picture of the scope and nature of substance abuse among those with HIV is difficult.
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316 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE Policy, 2001; SAMSHA, 2001a) and is further complicated by overlapping issues, such as lack of access to welfare and health insurance benefits, unemployment, lack of education, and poverty (SAMSHA, 1998, 2001a, 2001b, 2001d; Tobias et al., 2002)
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. HEALTH CARE NEEDS AND BARRIERS FACING HIV-INFECTED SUBSTANCE USERS Needs HIV-infected substance users have multiple and complex needs that require services from a variety of sources.
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Barriers HIV-infected substance users often face a health and social services system that stigmatizes them and erects multiple barriers to providing the care they require. As a consequence, their patterns of health care utilization and the quality and continuity of care they receive are far from optimal.
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. Chronic drug users are less likely to have a regular source of health care and are more likely than non-drug users to utilize emergency room and inpatient care (Markson et al., 1998; Laine et al., 2001; Welch and Morse, 2001)
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320 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE time that would be required to address their substance use, mental health, and health care needs (Weiss, Kluger et al., 2000)
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. Substance users' attitudes Like providers' attitudes about substance users, substance users' attitudes about health care providers and the health care system may also
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322 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE impact the quality of their care. For example, some HIV-positive substance users, responding to long-standing community distrust of health care providers and/or individual negative experiences, may refuse prescriptions for HIV medications or modify the prescription regimen recommended by their primary care provider (Mantell and Cassidy, 2001)
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APPENDIX E 323 users' multiple needs. Moreover, it is difficult to find staff who are knowledgeable about substance use, HIV, and mental health (Tobias et al., 2002)
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324 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE abuse agencies paid for 31 percent and SAMSHA substance abuse block grants paid for 29 percent of treatment services. Other state agencies contributed 5 percent, county and local agencies 9 percent, other sources 18 percent, and other federal government agencies 7 percent, including Medicaid, Medicare, the Department of Veterans Administration, and the Department of Justice (NASADAD, 1999)
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APPENDIX E 325 Medicaid Federal Medicaid dollars cover only 7 percent of substance abuse treatment expenditures. There are no substance abuse treatment services included in the federally mandated Medicaid benefit package, and while states may opt to add significantly to that, (expensive)
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326 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE including HIV care, substance abuse treatment, and mental health services (Gourevitch, 1996)
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APPENDIX E 327 Urban areas also struggle with treatment shortages. For example, in New York traditional drug treatment serves only approximately 42,000 of the state's estimated 555,000 substance users.
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328 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE Overall, an estimated $12.6 billion is spent on substance abuse treatment from public and private sources (SAMSHA, 2000)
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, but Title II also funds home and community-based health care, health insurance continuation, and medical and support services. Medical and support services can be allocated by the state directly and/or through HIV care consortia that plan and deliver services.
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330 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE abuse treatment and counseling" category, which includes substance abuse treatment as well as supportive services. These numbers, however, do not reflect spending on services used by substance users that fall under other prioritized categories (e.g., mental health, case management, or primary medical care)
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Barriers at the provider and client level impede substance users' receipt of optimal health care. Current planning for the substance abuse and HIV treatment systems do not, generally, address these issues.
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They also contain program elements, such as housing, transportation services, case management, services for women with children, legal assistance, and benefits advocacy that help substance users to better access the health care system and to avoid penalties for their substance use. Broad models also focus on outreach to substance users at risk for HIV to engage them into care.
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Through its outreach component, PROTOTYPES links with communities at high risk for HIV and links substance-using individuals to a broad range of health, substance abuse, and mental health care and necessary social services. By focusing specifically on providing services to women and their children, PROTOTYPES is able to eradicate one of the major barriers to care for this population.
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334 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE treatment, and harm reduction and are actively focused on providing care in communities of high need. By developing programs around a core set of medical and substance abuse treatment services, they are able to address substance abuse and HIV in one setting from a multidisciplinary perspective.
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. "Helping the urban poor stay with antiretroviral HIV drug therapy." Am J Public Health 90(5)
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municipalities." American Journal of Public Health 88(1)
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. "Does access to health care impact survival time after diagnosis of AIDS?
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Boston, Health and Disability Working Group, Boston University School of Public Health. Tobias, C., M
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APPENDIX E 339 Westmoreland, T
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