Making fair decisions about financing care for persons with AIDS

An estimated 40 percent of the nation's 55,000 persons with acquired immunodeficiency syndrome (AIDS) have received care under the Medicaid Program, which is administered by the Health Care Financing Administration (HCFA) and funded jointly by the Federal Government and the States. In fiscal year 1988, Medicaid will spend between $700 and $750 million for AIDS care and treatment. Medicaid spending on AIDS is likely to reach $2.4 billion by fiscal year 1992, an estimate that does not include costs of treatment with zidovudine (AZT). Four policy principles are proposed for meeting this new cost burden in a way that is fair, responsive, efficient, and in harmony with our current joint public-private system of health care financing. The four guidelines are to (a) treat AIDS as any other serious disease, without the creation of a disease-specific entitlement program; (b) bring AIDS treatment financing into the mainstream of the health care financing system, making it a shared responsibility and promoting initiatives such as high-risk insurance pools: (c) give States the flexibility to meet local needs, including Medicaid home care and community-based care services waivers; (d) encourage health care professionals to meet their obligation to care for AIDS patients.     

Perceptions of the use of complementary therapy and Siddha medicine among rural patients with HIV/AIDS: a case study from India

Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine, such as Ayurveda and Siddha. These forms of traditional medicine are currently used by up to two‐thirds of its population to help meet primary healthcare needs, particularly in rural areas. Gandeepam is one of the pioneering Siddha clinics in rural Tamil Nadu that is specialized in providing palliative care to HIV/AIDS patients with effective treatment. This article examines and critically discusses the perceptions of patients regarding the efficacy of Siddha treatment and their motivation in using this form of treatment. The issues of gender equality in the access of HIV/AIDS treatment as well as the possible challenges in complementing allopathic and traditional/complementary health sectors in research and policy are also discussed. The article concludes by emphasizing the importance of complementing allopathic treatment with traditional medicine for short‐term symptoms and some opportunistic diseases present among HIV/AIDS patients. Copyright © 2012 John Wiley & Sons, Ltd.     

Low-cost generic drugs under the President's Emergency Plan for AIDS Relief drove down treatment cost; more are needed

The President's Emergency Plan for AIDS Relief (PEPFAR) was originally authorized in 2003 with the goal of supporting HIV prevention, treatment, and care within fifteen focus countries in the developing world. By September 2011 nearly 13 million people around the world were receiving HIV/AIDS-related care through PEPFAR, and 3.9 million were receiving antiretroviral treatment. However, in the early years of the program, access to antiretroviral drugs was hampered by the lack of a licensing process that the US government recognized for generic versions of these medications. Ultimately, the obstacle to approval of generic antiretroviral drugs was removed, which led to PEPFAR's considerable success at making these treatments widely available. This article outlines PEPFAR's evolving use of generic antiretroviral drugs to treat HIV in the developing world, highlights ongoing initiatives to increase access to generic antiretrovirals, and points to the need for mechanisms that will speed up the approval of new generic drugs. The striking decline in antiretroviral treatment costs, from $1,100 per person annually in 2004 to $335 per person annually in 2012, is due to the availability of effective generic antiretrovirals. Given growing resistance to existing drugs and the planned expansion of treatment to millions more people, access to newer generations of generic antiretrovirals will have to be expedited.     

President seeks 3 percent increase in AIDS funding for '98

President Clinton's spending proposals for 1998 include increased funding for AIDS research, care, and treatment, as well as initiatives to help people return to work if their multidrug therapy is effective. Some AIDS advocates are still disappointed with this funding level and predict that there will be a shortage of funds available to provide adequate services to HIV/AIDS patients. Advocates also expressed concern over reduced Medicaid spending since many AIDS patients rely completely on Medicaid for health care. The spending proposal keeps Federal funding for the network of State AIDS drug assistance programs at $167 million despite the demand for multidrug treatments. The budget includes $634 million for AIDS-related programs at the Centers for Disease Control and Prevention (CDC) and $1.54 billion for AIDS-related research directed through the National Institutes of Health (NIH) Office of AIDS Research. The total cost of AIDS care, research, and prevention reaches nearly $8.9 billion. Funding proposals for each agency and allocations for the Ryan White CARE Act are outlined.     

ADAP funding seen as insufficient; increases sought

Federal and State lawmakers are being asked to appropriate an additional $244.9 million this fiscal year and next to meet the growing demand for medicine through AIDS drug assistance programs (ADAPs). The ADAP Working Group revealed preliminary data indicating a widening gap between existing funding and projected needs of people with HIV who lack private insurance. A $66.9 million shortfall is expected in the current fiscal year. The projected spending needs for 1997 and 1998 are based on a survey of a pharmacoeconomic model that includes the rate of growth in applications to State ADAPs. The model takes into account future prescribing practices, assuming greater use of combination therapy using two nucleoside analogues and a protease inhibitor. Four States do not currently cover protease inhibitors and ten have capped access to new drugs. Despite rising costs for ADAPs, expenses could become even greater if people are denied access to medication.     

Health and federal budgetary effects of increasing access to antiretroviral medications for HIV by expanding Medicaid

OBJECTIVES. This study modeled the health and federal fiscal effects of expanding Medicaid for HIV-infected people to improve access to highly active antiretroviral therapy. METHODS: A disease state model of the US HIV epidemic, with and without Medicaid expansion, was used. Eligibility required a CD4 cell count less than 500/mm3 or viral load greater than 10,000, absent or inadequate medication insurance, and annual income less than $10,000. Two benefits were modeled, "full" and "limited" (medications, outpatient care). Federal spending for Medicaid, Medicare, AIDS Drug Assistance Program, Supplemental Security Income, and Social Security Disability Insurance were assessed. RESULTS: An estimated 38,000 individuals would enroll in a Medicaid HIV expansion. Over 5 years, expansion would prevent an estimated 13,000 AIDS diagnoses and 2600 deaths and add 5,816 years of life. Net federal costs for all programs are $739 million (full benefits) and $480 million (limited benefits); for Medicaid alone, the costs are $1.43 and $1.17 billion, respectively. Results were sensitive to awareness of serostatus, highly active antiretroviral therapy cost, and participation rate. Strategies for federal cost neutrality include Medicaid HIV drug price reductions as low as 9% and private insurance buy-ins. CONCLUSIONS: Expansion of the Medicaid eligibility to increase access to antiretroviral therapy would have substantial health benefits at affordable costs.     

The role of public health in providing primary care for the medically underserved

Strategies designed to meet the health care needs of Americans should include the issues of access as well as financing. And primary care and clinical preventive services should receive as much national attention as acute care and long-term care. The public health system at the Federal, State, and local levels with its mandate to assure conditions in which people can be healthy must also be incorporated into the national debate. Publicly funded infrastructures for delivering primary health care have become a significant element of assuring access at the community level. This paper examines the expanding role of public health in assuring access to the delivery of primary health care and clinical preventive services to vulnerable populations within the larger issue of who should have access to care and how it should be made available. Special attention is paid to the part played by the Health Resources and Services Administration (HRSA) of the Public Health Service, which, in the Federal fiscal year that began on October 1, 1989, administered some $1.8 billion worth of programs for health care of targeted populations and for the support of training in the health professions.     

Human rights is a US problem, too: the case of women and HIV.

Overall, US AIDS incidence and mortality have shown significant declines since 1996, probably because of new antiviral therapies. For women, however, these benefits have been much less pronounced than for men. At the heart of women's HIV risk is gender-based discrimination, which keeps women, and especially women of color, poor and dependent. Although human rights issues are often linked with AIDS issues abroad, in the US they receive insufficient attention in our response to women's HIV risk. Advocacy from public health professionals is needed to overcome the longstanding paternalistic attitudes of federal agencies toward women and to change the paradigm of women's HIV/AIDS prevention and care. Examples of unjust and punitive social policies that may affect women's HIV risk include the 1996 welfare policy legislation, drug treatment policies for women, and women's access to medical research and technology. The overriding public health response to AIDS consists of behavioral interventions aimed at the individual. But this approach will not successfully address the issues of women with AIDS until efforts are made to eliminate society's unjust and unhealthy laws, policies, and practicles.     

Hospital cost for patients with HIV infection in a university hospital in The Netherlands

Precise data on the utilization of health care facilities by HIV infected patients are generally not available. Nor are there data on the related cost, effectiveness and efficiency of the treatment provided. This is due mainly to the lack of a suitable method for recording demographic, medical and financial data on individual patients in hospitals. For this reason we have been developing a system of data collection, which provides a detailed cost record of each patient. The application of this system for 52 patients with HIV infection treated in a university hospital over a two-year period showed that for a patient with AIDS the mean cost of inpatient and outpatient hospital services was $19,507 per person-year. For patients with HIV infections other than AIDS the mean costs ranged from $1,769 for CDC III patients to $2,064 for CDC II patients (expressed in 1987 US dollars). Continued operation of the registration system will make it possible to analyze the causal background of costs as well as the cost-effectiveness of the treatment.     

中国艾滋病抗病毒治疗药品采购供应现状分析

目的分析我国艾滋病抗病毒治疗药品采购供应现状,为改善抗病毒药品可及性提出相应建议。方法回顾有关历史及现状,结合艾滋病抗病毒治疗特点,总结艾滋病抗病毒药品采购供应工作的特点及现存问题。结果艾滋病抗病毒治疗具有长期性、复杂性和不可预期性,药品种类及生产商均有限,各类药品短期需求量存在不确定性,药品采购的可选择范围也较小。目前我国艾滋病抗病毒药品采购供应存在采购环节多、周期长,药品品种变更可能影响病人服药依从性等问题,不能满足艾滋病治疗现况需求。结论建立高效的药品供应协调机制,缩短采购周期;改进招标方式,延长招标覆盖时间,体现政府采购导向作用;建立药品储备,应对药品紧急需求。     

States' responses to Title II of the Ryan White CARE Act.

Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 provides formula-based grants to States to help them improve the quality, availability, and organization of health care and support services for people with human immunodeficiency virus (HIV) infection. This article reviews State expenditures during the first year of CARE Act funding (April 1991-March 1992) within the context of Title II guidelines and the federally funded grant programs that preceded and helped shape Title II. The authors also discuss future challenges that require development of resources, the assessment of program impact, and the evaluation of the quality and appropriateness of HIV-related services. Ninety-one percent of the $77.5 million awarded to States during fiscal year 1991 went for the provision of medical and support services through HIV care consortia, drug reimbursement programs, home and community-based care programs, and health insurance initiatives. The remaining monies were used for planning, evaluation, and program administration. Forty States allocated $38.9 million for the establishment of HIV care consortia to assess service needs and to develop comprehensive continuums of health and support services in the areas most affected by HIV disease. Fifty States allocated an additional $28.3 million for the continuation or expansion of FDA-approved drug therapies for low-income people with HIV infection. Twenty-five States allocated $2.2 million for the provision of home- and community-based health services, and 16 States allocated $1.3 million for programs that help low-income people with HIV infection to purchase or maintain health insurance coverage.     

Integrating HIV Prevention Activities into the HIV Medical Care Setting: A Report from the NYC HIV Centers Consortium

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues. Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, USA; Crystal is with the AIDS Research Group, Rutgers the State University of New Jersey, USA; Absalon is with the Center for Infectious Disease Epidemiologic Research, Mailman School of Public Health, Columbia University, USA; Klein and Agins are with the New York State Department of Health, AIDS Institute, USA; Remien is with the HIV Center for Clinical and Behavioral Studies, Columbia University and the NY State Psychiatric Institute, USA. An erratum to this article can be found at     

HIV/AIDS and long-term care: A state perspective

Long-term care services for people with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) were fostered in New York State by passage of HIV-specific regulations that set program standards and authorized reimbursement rates sufficient to support these standards. A rapid expansion of HIV-specific capacity has occurred. Demographic and selected clinical characteristics of the populations in AIDS residential health care facilities and AIDS adult day health care programs in New York State are presented. Aspects of the service models for these two program types that have changed to meet new needs are discussed. Ms. Chorost is from the Chronic Care Section, Division of HIV Health Care, AIDS Institute; Dr. Chesnut is from the Information Systems Office of the AIDS Institute.     

Health Care Services for men who have sex with men in different Australian states and territories since the emergence of HIV

The purpose of this article is to describe sexual health services available in Australia across the different states and territories for gay men and men who have sex with men (MSM) and their utilisation. An assessment of services available in different states is made, then the evidence about how MSM and people living with HIV/AIDS access health care in Australia is presented. This demonstrates that the number and location of sexual health services has changed over time. It also demonstrates that services available differ by state and territory. The availability of non-occupational post-exposure prophylaxis for HIV infection has been different in each state and territory, as has its utilisation. The majority of care for sexual health-related issues and for MSM and people living with HIV/AIDS is delivered in general practice settings in Australia, with hospital outpatient settings, including sexual health clinics, utilised commonly.     

Stronger health systems for more effective HIV/AIDS prevention and care

Of the 42 million living with HIV/AIDS world-wide some 90% live in developing countries. The international community acknowledges the devastating impact of HIV/AIDS on development and over the past few years resources to control HIV/AIDS have increased considerably. We argue that strengthening of health systems is a necessary prerequisite for improving the prevention of HIV infection and the care of HIV-infected persons. Sexual behaviour change requires a multidisciplinary approach, but health services play a crucial role in detection and treatment of other sexually transmitted infections; HIV counselling and testing; prevention of mother-to-child transmission of HIV; and care of HIV-infected patients. Increasing access to antiretroviral treatment especially poses formidable challenges to health authorities in developing countries. Additional resources for the prevention of HIV-infection and the care of HIV-infected persons may not have the desired impact if health systems in developing countries are not strengthened. Further, any activity in the area of HIV/AIDS prevention and care, carried out within health services, can have a positive ripple effect on other health care activities and vice versa. This interactive effect needs to be acknowledged and built on.     

The Unchecked HIV/AIDS Crisis in Mississippi

While the population of the southern United States is only 37% of the country’s total, this region is experiencing 50% of new HIV diagnoses and 46% of new AIDS diagnoses. Specifically, Mississippi has the highest rates of new infection, the most AIDS deaths, the greatest number of people living with HIV/AIDS, and the fewest resources. Mississippi has the highest death rate in the country: 32.9 per 1,000. A Mississippian with HIV/AIDS is almost twice as likely to die as the average American with the virus (SHARP Report, 2010). Compounding the problem are government policy issues, such as disproportionate program funding; socio-economic issues, such as widespread poverty, housing insecurity, and the lack of access to care; and cultural issues, such as homophobia and social stigma. These factors are reflected in this study which examines the needs of people living with HIV/AIDS in a southern, rural county of Mississippi. From a representative sample of 218 HIV positive individuals, researchers identified the levels of need for housing, transportation, medical care, mental health care, substance abuse treatment, and education. The author discusses the reciprocal influences of these needs and HIV, the need for policy changes at the state and federal levels, and the need for resources that both support people living with HIV/AIDS and curb the rate of new infections.     

Settlement caps long fight over tainted clotting products

A Federal judge approved a settlement that will award $640 million to a group of hemophiliacs who contracted HIV from contaminated blood-clotting products nearly 20 years ago. Each of 6,200 hemophiliacs or surviving family members will receive $100,000. The agreement covers hemophiliacs who contracted HIV from clotting products between 1978 and 1985, and spouses, cohabitating partners, and offspring who became infected as a result. The most significant ruling in this four-year-long case was an order by the 7th U.S. Circuit Court of Appeals that forbade U.S. District Judge John Grady to force pharmaceutical companies to defend themselves in a single class action. Rather than having to defend themselves against hundreds of individual claims, the companies offered to settle for the $640 million. The four drug companies and the Federal government reached a separate agreement. Under the deal, the companies will reimburse the Federal health care insurance programs nearly $12.2 million for patient care. This absolves the hemophiliacs from repaying the government for the cost of publicly-funded medical care.