Public Financing and Delivery of HIV/AIDS Care Securing the Legacy of Ryan White (2005) / Chapter Skim
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2 HIV/AIDS Care in the Third Decade: Opportunities and Challenges in the Changing Epidemic
2 HIV/AIDS Care in the Third Decade: Opportunities and Challenges in the Changing Epidemic
Pages 36-72
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From page 36... ...
Until the introduction of highly active antiretroviral therapy (HAART) , AIDS was associated with an inevitable functional deterioration and death.
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. Advances in knowledge and treatment options continued throughout the eighties and early nineties, and by 1996 combination antiretroviral therapy became (and remains)
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From page 38... ...
, it was the first since 1993 and could be an early warning that the system is missing opportunities to prevent those with HIV infection from progressing to AIDS. The loss of these opportunities, both for treatment to prevent disease progression and for intervention to reduce risky behaviors and promote prevention, occurs when infected individuals remain outside the care system, and eventually results in a greater burden to the system.
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From page 39... ...
The following sections discuss the changing elements of the epidemic that require consideration in a restructured HIV care delivery system: the effect of HAART on the course of the disease, as well as the risk of toxicities and resistance with HAART; the central role of adherence to therapy; the changing demographics of the epidemic and the challenges they present; and the increasing incidence of both medical and social co-morbid conditions among PLWH/A. To provide the background for these discussions, however, it is necessary to understand the natural history of the individual HIV infection.
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From page 40... ...
These symptoms -- fever, rash, fatigue, generalized lymphadenopathy, and nausea among others -- are flu-like and appear within days to several weeks of the moment of infection. Primary HIV infection usually resolves in a matter of weeks and is not life threatening.
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The term "asymptomatic HIV infection" applies to this phase when the person is unaware of any symptoms of infection. This phase may last for 1 to 10 or more years, even without antiretroviral therapy (Haynes et al., 1996)
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. EFFECT OF HAART ON HIV PROGRESSION AND CARE The impact of antiretroviral therapy on the outcome of HIV infection is one of the most dramatic developments in medical history.
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40 of per with 30 (% 10 20 Deaths 10 Therapy 0 0 1994 1995 1996 1997 FIGURE 2-3 Mortality and frequency of use of combination antiretroviral therapy including a protease inhibitor among HIV-infected patients with fewer than 100 CD4 cells per cubic millimeter, according to calendar quarter, from January 1994 through June 1997. SOURCE: Palella et al., 1998, Copyright 1998, Massachusetts Medical Society.
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From page 44... ...
. Opportunistic malignancies -- especially Kaposi's sarcoma and non-Hodgkins lymphoma of the central nervous system -- have all but disappeared in those receiving effective antiretroviral therapy (Jacobson et al., 1999; Pezzotti et al., 1999)
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10. Persons identified during acute primary HIV infection should be treated with combination antiretroviral therapy to suppress virus replication to levels below the limit of detection of sensitive plasma HIV RNA assays.
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. The inability of large numbers of patients to achieve the high levels of adherence required for complete viral suppression underscores the need to develop and provide appropriate adherence support as a routine part of HIV care.
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. Among these lessons are that treatment is a collaborative process between patient and provider rather than a directive one from provider to patient, that BOX 2-2 Predictors of Poor Adherence · Poor clinician-patient relationship; · Active drug and alcohol use; · Active mental illness, particularly depression; · Lack of patient education regarding treatment and inability of patients to identify their medications; and · Lack of reliable access to primary medical care or medication.
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From page 48... ...
. Although, as noted earlier, adherence to HIV treatments is generally higher than for other chronic illnesses, these lessons learned over decades of diabetes treatment are applicable because HAART is much less forgiving than any other treatment regimen for any illness.
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. Appropriate adherence support provided as a routine part of HIV care offers the opportunity to get the most out of therapy and helps to reduce the likelihood that drug resistance will develop.
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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.
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4The source of this data, the Kaiser Family Foundation, defines the southern region of the United States as Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia (Kaiser Family Foundation, 2002)
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52 PUBLIC FINANCING AND DELIVERY OF HIV/AIDS CARE PLWA U.S. 100% 90% White 80% 70% 60% 50% 40% Black 30% 20% 10% Hispanic 0% Asian American, Native American, Pacific Islander FIGURE 2-4 Proportion of people living with AIDS (PLWA)
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HIV/AIDS CARE IN THE THIRD DECADE 53 FIGURE 2-5 Cumulative AIDS cases for 1985, 1989, 1997.
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The prevalence of mental illness among those infected with HIV has been estimated to be quite high: about 50 percent of those in HIV care have some form of a comorbid mental illness (Bing et al., 2001)
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. Another study, which focused directly on the barriers to receiving HIV care for individuals whose co-morbid serious mental illness and HIV infection are already known, compared nearly 300 seriously mentally ill and HIV-positive patients in Los Angeles and New York City to patients from the HIV Cost and Services Utilization Study (HCSUS)
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From page 56... ...
The finding that a large percentage of participants were adherent to their drug defied conventional wisdom that individuals with serious mental illness lack the capacity to adhere to a complex dosing schedule. Still, a third of the sample had very poor adherence, a finding that prompted the investigators to suggest further research to identify barriers and inform the development of tailored interventions for those with serious mental illness to achieve greater adherence, and thus greater treatment benefits.
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From page 57... ...
Substance Use Disorders Another serious challenge for HIV care involves individuals with substance use disorders; treating this population requires a range of services, including substance abuse treatment, linked to primary care. Injection drug use in particular was identified early in the epidemic as a route of transmission, and CDC has conducted public health surveillance on the population of injection drug users as a result.
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From page 58... ...
The HIV care system, concerned principally with keeping the HIV-infected individual in contact with the system, can be at odds with the abstinence approach to substance abuse treatment, which expels anyone who does not meet the strict standards of a program (Hsu, 2001)
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From page 59... ...
Substance abuse and mental illness often co-occur with one another as well as HIV, and can be the underlying cause of other conditions that complicate HIV care, such as homelessness. Effective management of the HIV epidemic requires that the issues of substance abuse and mental illness be confronted by providing appropriate treatment to those who need it in care settings that are also equipped to provide HIV care.
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From page 60... ...
Comorbid HIV infection is associated with a more swift progression of HCV-related liver disease and cirrhosis, which may lead to limited tolerance for antiretroviral therapy due to hepatic side effects (Sulkowski et al., 2002; Ostrow, 1999; Greenberg, 1999; CDC, 2002b)
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From page 61... ...
The overlap between homeless populations and populations with substance use disorders or mental illness that was demonstrated in the Philadelphia study also has been observed in multiple other studies (D'Amore et al., 2001; Martens, 2001; Rosenblum et al., 2001; Cheung et al., 2002; Kilbourne et al., 2002)
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From page 62... ...
. In one study, 85 percent of HIV infection in prison was associated with injection drug use prior to incarceration (Vlahov et al., 1989)
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This model of care no longer applies. The changes in the treated natural history of HIV infection from an acute to a chronic disease model and the shift in populations most affected must be considered when crafting policies for the public financing and delivery of HIV care.
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2001. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS.
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2001. Time to initiating highly active antiretroviral therapy among HIV-infected injection drug users.
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1998. Effectiveness of potent antiretroviral therapy on time to AIDS and death in men with known HIV infection durations.
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From page 67... ...
among persons with AIDS in San Francisco, 1996 1999. Journal of Acquired Immune Deficiency Syndromes 28(4)
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1999. Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study.
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2001. Adherence to highly active antiretroviral therapy predicts virologic outcome at an inner-city human immunodeficiency virus clinic.
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Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 20(3)
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. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 17(3)
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From page 72... ...
infection among inmates entering a statewide prison system, 19851987. Journal of Acquired Immune Deficiency Syndromes 2(3)
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