Meeting the needs of people with AIDS: local initiatives and Federal support

The Health Resources and Services Administration (HRSA), one of the seven agencies of the Public Health Service, is working to meet some of the resource and patient service needs engendered by the epidemic of acquired immune deficiency syndrome (AIDS). Those actions derived from, and support the continuation, expansion, and replication of, initiatives at the community and State levels. HRSA is carrying out many of the recommendations of the Intragovernmental Task Force on AIDS Health Care Delivery by enhancing the AIDS training of health care personnel in prevention, diagnosis, and care and by counseling and encouraging the expansion of facilities outside hospitals to care for AIDS patients. The agency, through its pediatric AIDS demonstration projects, is working on models for the care of children with HIV infections. The needs of AIDS patients are being addressed through a drug therapy reimbursement program; demonstration grants to 13 projects to promote coordinated, integrated systems of care in the community; and grants for the development of intermediate and long-term care facilities for patients. Ten regional education and training centers, funded in 1987 and 1988, will increase the supply of health care providers prepared to diagnose and treat persons with HIV infections. Programs will be conducted for several thousand providers over the next 3 years, using such modalities as televised programs and train-the-trainer courses. The centers will also offer support and referral services for providers.     

Improving HIV/AIDS services through palliative care: An HRSA perspective

There has been a dramatic shift of the human immunodeficiency virus/acquired immunodeficiency syndrom (HIV/AIDS) epidemic into poor, marginalized, and minority communities in the US. At the same time, the availability of new highly active antiretroviral treatments has made it possible for a large number of individuals to live for a much longer time with their disease. A net result is that the US is faced with an increasing number of people who are living with HIV/AIDS and are dependent on publicly supported health care services. In this paper, we review the palliative care efforts of the federal agency, the Health Resources and Services Administration (HRSA), responsible for providing Ryan White CARE Act HIV/AIDS care to medically underserved populations. In addition to supporting traditional hospice care, HRSA's HIV/AIDS Bureau has begun a series of initiatives that apply a broader concept of palliative care to its HIV programs in hospital-and community-based settings. Our interest is not to substitute palliation for access to new HIV therapies, such as highly active antiretroviral treatments, but to ensure that our health delivery systems attend to the alleviation of symptoms and suffering along with the provision of antiretroviral and other necessary treatments. HRSA's HIV/AIDS Bureau is organizing a broader provision of palliative care for its clients and actively contributing to improving care for the disenfrachised internationally. The authors are from the HIV/AIDS Bureau, Health Resources and Services Administration, HRSA.     

HIV positive Hispanic/Latinos who delay HIV care: analysis of multilevel care engagement barriers

This article overviews a Health Resources and Services Administration (HRSA) study with a sample population consisting of 470 Hispanic/Latino persons living with HIV/AIDS who received primary HIV/AIDS medical services from one of five HRSA Special Projects of National Significance (SPNS) Border Health demonstration projects. The study purpose was to identify multilevel barriers that affect delayed entry into HIV/AIDS medical care among Hispanic/Latino persons living along the U.S.-Mexico border. Multilevel variables along individual, community/cultural, and structural/systems were assessed relative to delayed care entry. The results of this examination indicate that individual and structural/system-level variables affect delayed care entry, whereas support was not found for community/cultural-level barriers. Study findings inform treatment engagement strategies aimed to decrease HIV disease progression by bringing Hispanic/Latinos into care sooner.     

HIV Positive Hispanic/Latinos Who Delay HIV Care: Analysis of Multilevel Care Engagement Barriers

This article overviews a Health Resources and Services Administration (HRSA) study with a sample population consisting of 470 Hispanic/Latino persons living with HIV/AIDS who received primary HIV/AIDS medical services from one of five HRSA Special Projects of National Significance (SPNS) Border Health demonstration projects. The study purpose was to identify multilevel barriers that affect delayed entry into HIV/AIDS medical care among Hispanic/Latino persons living along the U.S.–Mexico border. Multilevel variables along individual, community/cultural, and structural/systems were assessed relative to delayed care entry. The results of this examination indicate that individual and structural/system-level variables affect delayed care entry, whereas support was not found for community/cultural-level barriers. Study findings inform treatment engagement strategies aimed to decrease HIV disease progression by bringing Hispanic/Latinos into care sooner.     

Human immunodeficiency virus/acquired immunodeficiency syndrome training from a union perspective.

The authors developed a union sponsored 2-day human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) "train the trainer" program for healthcare workers in the San Francisco Bay Area. The program incorporated the "education for action" approach in an effort to respond to the inadequacies in many traditional, institutional trainings. Service Employees International Union (SEIU) and Labor Occupational Health Program (LOHP) conducted the HIV/AIDS "train the trainer" program for approximately 100 healthcare workers in county public hospitals and community health clinics. After completing the program, these workers went back to their healthcare facilities, or community organizations, and led additional classes on HIV/AIDS transmission and prevention for approximately 600 more people. The goal of the program was to empower healthcare workers to: 1) identify the occupational risks associated with exposure to blood and potentially infectious body fluids at the workplace; 2) develop strategies to reduce those risks; 3) discuss their feelings about caring for an HIV/AIDS patient; and, 4) conduct HIV/AIDS workshops at the workplace.     

医护人员对HIV感染者接受态度调查

目的了解某艾滋病高流行地区从事临床工作的医护人员对人类免疫缺陷病毒（HIV）感染者／艾滋病（AIDS）患者（简称PHA）的接受态度及影响因素。方法抽取该市2所市级综合性医院4所乡镇中心卫生院753名医护人员进行自填式问卷调查。结果绝大多数医护人员对HIV感染者／AIDS患者的接受程度处于中等水平。年龄、知识得分、医院级别、医护人员与HIV／AIDS的接触频率与医护人员的接受程度之间有关联。结论在对临床医护人员进行有关减少艾滋病偏见与歧视的培训或倡导工作中，应加强医护人员有关艾滋病临床知识、职业暴露和自我防护等方面的专业培训；加强对综合性医院以及青年医生的教育；加强对HIV／AIDS高频率接触的医护人员的心理咨询。     

Breaking the Glass Ceiling: Increasing the Meaningful Involvement of Women Living With HIV/AIDS (MIWA) in the Design and Delivery of HIV/AIDS Services

The meaningful involvement of women living with HIV/AIDS (MIWA) is a key feature of women-centred HIV care, yet little is known about transforming MIWA from principle to practice. Drawing on focus group data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), we explored HIV-positive women's meaningful involvement in the design and delivery of HIV/AIDS services in British Columbia, Canada. In this article, we highlight the benefits and tensions that emerge as women traverse multiple roles as service users and service providers within their care communities, and the impact this has on their access to care and overall health.     

Co-located Substance Use Treatment and HIV Prevention and Primary Care Services,New York State, 1990–2002: A Model for Effective Service Delivery to a High-Risk Population

The New York State Department of Health (NYSDOH) AIDS Institute (AI) began an initiative in 1990 in collaboration with the Office of Alcoholism and Substance Abuse Services (OASAS) to colocate HIV prevention and clinical services at drug treatment clinics. In 1990, the initiative began funding drug treatment programs to provide HIV counseling, testing, and prevention services. HIV primary care was added the following year. Program implementation and development are described. An analysis is included of HIV counseling and testing data for the period 1990–2002 and quality of care data for five standardized quality measures with comparisons to data from other clinical settings. In the first 13 years of the initiative 168,340 HIV-antibody tests were conducted including 52,562 tests of injection drug users (IDUs) identifying 14,612 HIV-infected persons; the seroprevalence was 8.68%. By the end of 2000, the HIV primary care caseload peaked at 3,815 patients. Quality of primary medical care services among participating drug treatment programs has consistently matched or exceeded that provided in more conventional health care settings such as the hospitals and community health centers that were used as a basis for comparison. Colocating HIV primary care within substance use treatment is an effective strategy for providing accessible high-quality HIV prevention and primary care services. Rothman is with the Bureau of HIV Ambulatory Care, AIDS Institute, New York State Department of Health, Albany, New York, USA; Rudnick and Slifer are with the Substance Abuse Unit, AIDS Institute, New York, NY, USA; Agins is with the Office of the Medical Director, AIDS Institute, New York, NY, USA; Heiner is with the Karl Heiner Statistical Consulting, Ltd., Schenectady, New York, USA; Birkhead is with the AIDS Institute, Albany, New York, USA.     

Tracking working status of HIV/AIDS-trained service providers by means of a training information monitoring system in Ethiopia

Background  

The Federal Ministry of Health of Ethiopia is implementing an ambitious and rapid scale-up of health care services for the prevention, care and treatment of HIV/AIDS in public facilities. With support from the United States President's Emergency Plan for AIDS Relief, 38 830 service providers were trained, from early 2005 until December 2007, in HIV-related topics. Anecdotal evidence suggested high attrition rates of providers, but reliable quantitative data have been limited.     

Reforming American Indian/Alaska Native health care financing: the role of Medicaid

Chronic underfunding of American Indian and Alaska Native (AIAN) health care by the federal government has weakened the capacity of the Indian Health Service, tribal governments, and the urban Indian health delivery system to meet the health care needs of the AIAN population. I describe the current role of Medicaid in financing health care services for American Indians/Alaska Natives and offer 3 suggestions for reforming Medicaid financing of AIAN health care: (1) apply a 100% federal matching rate to the cost of Medicaid services furnished by urban Indian health programs; (2) apply a 100% federal matching rate to the cost of Medicaid services furnished by referral to AIAN patients of hospitals or clinics operated by the Indian Health Service, tribes, tribal organizations, or urban Indian health programs; and (3) exempt AIAN Medicaid beneficiaries who receive services from such hospitals or clinics from state reductions in Medicaid eligibility and benefits.     

A Review of Missed Opportunities for Prenatal HIV Screening in a Nationwide Sample of Health Facilities in the Indian Health Service

To better serve our patients, we sought to identify missed opportunities for prenatal HIV screening across Indian Health Service and potential ways to increase screening. Twenty-seven of 161 Federal or Tribal IHS health facilities were randomly selected. Each facility received a standardized set of commands to identify the charts of prenatal patients who were not screened for HIV according to the national Health Information Technology (HIT) platform. We reviewed 598 records at 27 sites of prenatal patients who were identified as not screened for HIV during their pregnancy. According to on-site chart review, nearly half (267/598, 45%) had been screened for HIV, and a slight majority (331/598, 55%) had not been screened. Among the 331 pregnant women not screened for HIV, about half had no HIV screening despite having had ≥2 prenatal care encounters and no screening exclusions (167/331, 50%). A majority of missed opportunities (118/167, 71%) had prenatal testing for other infectious diseases. Based on these results, the National HIV/AIDS program has encouraged increased bundling of HIV with infectious disease tests in prenatal laboratory panels. Improvements in documentation of HIV screening are expected with the IHS transition to electronic health records.     

Domestic violence screening, policies, and procedures in Indian health service facilities.

BACKGROUND: Research shows that domestic violence against women in the United States is common, and the prevalence of domestic violence is high among Native American women. Victims of domestic violence can benefit from appropriate office intervention and referral. This study examined the effect of administrative and legal requirements on screening for domestic violence in Indian Health Service (IHS) hospitals and clinics. METHODS: A questionnaire was mailed using the total design method to all IHS hospitals and clinics regarding activities related to domestic violence: screening; policies and procedures; presence of committees; staff training; and state and tribal mandatory reporting requirements. RESULTS: The response rate was 65%. Eighty-eight (62%) of 142 facilities screen for domestic violence. A facility was more likely to screen if it had policies and procedures for domestic violence. Ninety-one (64%) of sites had policies and procedures for domestic violence. Less than one half these sites evaluated the use of these policies and procedures. Hospitals were more likely to have policies and procedures than clinics, as were sites administered by the IHS, rather than those administered by tribal contract. Fifty-eight (40.8%) facilities indicated 18 states have mandatory domestic violence reporting requirements. Thirty-three (23.2%) facilities indicated 31 different tribes mandate reporting of domestic violence. Forty-two (29.6%) facilities reported mandatory staff training in at least one topic related to domestic violence in the past year. CONCLUSIONS: Domestic violence policies and procedures promote screening for this important health care problem.     

The role of the primary health care team in the care of people with HIV and AIDS

The model of health care for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) is changing from a primarily hospital-orientated service to a more community-based pattern of care. Despite this, the role of the Primary Health Care Team (PHCT) in HIV and AIDS, care generally remains small. This study, in an area of high prevalence of HIV and AIDS, uses a combination of quantitative and qualitative methods to examine current PHCT involvement in the care of people with HIV and AIDS, attitudes to HIV and AIDS among PHCT members, and views of the PHCT and other key interest groups about future service development. Barriers to greater involvement of the PHCT in HIV and AIDS work are identified, including resources, attitudes, knowledge, and communication between specialist and generic service providers. These are discussed and possible ways of developing the PHCT's role are explored. We conclude that purchasers have a role to play in encouraging a shift of HIV and AIDS work from the secondary sector to the primary sector, both directly through the contracting process and also through an emerging role in facilitating co-operation between providers, which could be extended to enhancing relationships between specialist providers and general practitioners.     

Impact of Title VII training programs on community health center staffing and national health service corps participation

PURPOSE Community health centers (CHCs) are a critical component of the health care safety net. President Bush’s recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. This article examines the association between physicians’ attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP).     

Wellness programmes for persons living with HIV/AIDS: Experiences from Eastern Cape province,South Africa

Abstract

Columbia University's International Centre for AIDS Care and Treatment Programmes (ICAP) supports the establishment of HIV prevention, care and treatment programmes, in resource-limited countries, through the President's Emergency Plan for AIDS Relief. In South Africa (SA), ICAP has collaborated with the Eastern Cape Department of Health since 2004, to support HIV treatment and care programmes at public healthcare facilities in rural and urban areas. Adherence, psychosocial and other supportive services have been combined into Wellness Programmes that have been situated within hospital-based Wellness Centres in two rural regions, and integrated within primary healthcare facilities in a third. This paper reviews components of wellness services for people living with HIV/AIDS including: voluntary counselling and testing, disclosure and prevention, ongoing counselling, health literacy and peer education, community- and home-based care, adherence support, and associated comprehensive care continuums. It also describes local context in which the Wellness Programmes were established. Finally it describes processes, successes and challenges, with programme development, and useful indicators monitored, lessons learned and strategies to strengthen and expand such programmes. Insights provided may inform other efforts to create sustainable systems of interdisciplinary care and accessible psychosocial support for HIV-infected persons within public facilities in resource-constrained settings.     

HIV/AIDS Patients Who Move to Urban Florida Counties Following a Diagnosis of HIV: Predictors and Implications for HIV Prevention

We characterized patients at publicly funded HIV/AIDS patient treatment sites who moved (“migrated”) post-diagnosis of HIV to five urban Florida counties, by geographic, demographic, socioeconomic and risk variables. Each patient who came for services at the sites in a 2–3 week sampling period was asked to complete a brief, self-administered questionnaire. We compared migrant with non-migrant patients to disclose characteristics predictive of migration and help plan for continuity of HIV care, future funding, and HIV prevention. Overall, 25% (range by site, 20%–38%) of the 1,286 patients in the study migrated to the counties from a non-contiguous Florida county, another state, or another country. In a multivariate model comparing interstate migrants with non-migrants, white and Hispanic race/ethnicity, age 9–29 years at first HIV diagnosis compared with older age, increasing education, highest current income and exposure category (men having sex with men and injection drug users) were independently associated with migration (all p < 0.05). In a similar model for international migrants, the independently associated variables included Hispanic ethnicity, education, and younger age at first HIV diagnosis. Although migrating can bring benefits to a patient such as improved access to health care or a new employment opportunity, it is stressful because it can result in changes in a person’s social network, employment, and health care providers. Thus, moving could create unique patient needs concerning medication adherence, risk-taking, and other psychosocial needs. Given the high percentage of migrants in these urban Florida county clinics, these needs should be further examined and addressed. Lieb is with the Florida Department of Health, Bureau of HIV/AIDS, Tallahassee, FL, USA; Trepka is with the Stempel School of Public Health, Florida International University, Miami, FL, USA; Liberti, Cohen, and Romero are with the Florida Department of Health, Tallahassee, FL, USA.     

Health care characteristics of migrant agricultural workers in three north Florida counties

Farm workers, representing 65% of the migrant work force in the St. Johns River basin agricultural area of north Florida, were questioned in 1973–1974 about their own and their families' health status and about their use of professional health care services and facilities. The facilities available for use by this population included 22 physicians in private practice, two hospitals, three public health clinics, and two health clinics operated for migrants. Most contacts made by the migrant farm workers were with the health care professionals in the public facilities, primarily those in the migrant health clinics. The average number of visits made by migrant farm worker heads of households to a physician each year was 3.5 visits. In 1971, the National Health Survey reported an average of 4.9 physician visits for all U.S. citizens. The major factors that affected utilization were the presence of an acute medical condition and the perception of being in poor health. The factors that generally have been thought of as impediments to seeking health care, such as transportation, the presence of children in the household, and a lack of education, were found to be of little import. The acute disease conditions that were most frequently reported by these migrant workers as the reason for their contacts included respiratory illnesses, digestive system problems, injuries, and musculoskeletal problems. The chronic conditions included heart disease and hypertension, musculoskeletal disorders, digestive system problems, and genitourinary problems. Little use was made of dental services, except for tooth extractions.The authors are with the J. Hillis Miller Health Center, University of Florida, Box J-222, Gainesville, Florida 32610. Mrs. Bleiweis is an Assistant in the Department of Community Health and Family Medicine, Dr. Reynolds is Professor and Chairman, and Mr. Butler is an Associate in that department. Dr. Cohen is Professor and Chairman of Clinical Psychology in the Health Center's College of Health Related Professions. This study was supported by Contract PHS-NSA-105-74-42 with the Migrant Health Division, Bureau of Community Health Service, Health Services Administration, of the Public Health Service. The authors gratefully acknowledge the help of Sara Kenaston and Marilyn Uelsmann of the Florida State Division of Family Services and Dr. Ronald Marks of the University of Florida Division of Biostatistics.     

A Case Study Using The Discipline with a Clinical Team

SUMMARY

Health care delivery in hospitals and clinics promotes an interdisciplinary team approach. This article presents the use of The Discipline though the involvements of the chaplain as part of the Infectious Disease team as together they addressed the inherent spirituality of one HIV/AIDS patient. This narrative recounts the unfolding events of the patient's life and describes the use of The Discipline during a very difficult time period for the patient and the staff. The experience can serve as a model for other health care teams who must manage difficult, deteriorating patients.     

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

Background

After many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?

Methods

A 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq's 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.

Results

Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.

Conclusions

There is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.