Medicaid home and community-based care waiver programs: providing services to people with AIDS

The authors present the results of a survey demonstrating how Medicaid programs use the home and community-based waiver programs to provide services to people with acquired immunodeficiency syndrome (AIDS) and to other targeted groups. The survey identified a number of waiver services that are effective at meeting the care needs of people with AIDS, such as case management, personal care, respite care, home intravenous therapy, attendant care, hospice, and home-delivered meals. The study demonstrates that in addition to the AIDS-specific waiver program, State Medicaid programs use the home and community-based care waiver programs for the elderly and disabled to provide services to people with AIDS because of their disability status.     

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.     

The invisibility of serodiscordance in care for people with HIV/AIDS

This study seeks to identify and reflect on medical strategies used to ensure the systematic use of condoms for the effectiveness of AIDS prevention, in particular, when patients are involved in serodiscordant marital relationship in that only one of the partners is HIV positive. As analytical tools we used the concepts of thinking styles of epistemology (Fleck), the training process (Good), and therapeutics (Sayd, Camargo Jr. and Almeida). Among the findings of the research stood out an invisibility of the serodiscordant couples, for what turns out to be really important is adherence to treatment, which coincides with adherence to medication (ART).     

The struggle to provide community-based care to low-income people with serious mental illnesses

This paper describes gaps in services for low-income people with serious mental illnesses as reported by mental health professionals and other observers in twelve U.S. communities. According to respondents, service gaps have grown in recent years--especially for uninsured people--as a result of state budget pressures and Medicaid cost containment policies. Growing service gaps contribute to the high prevalence of serious mental illness among the homeless and incarcerated populations, as well as crowding of emergency departments. Some states and communities are aggressively addressing these gaps, although funding for new programs remains scarce.     

Long-term continuum of care for people living with HIV/AIDS

The introduction of highly active antiretroviral therapy (HAART), has created new options for those infected and affected by human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Most HIV-infected persons no longer die within months of diagnosis. There is now a long-term continuum of care that can end in misery or relative comfort. The introduction of palliative care in concert with curative therapies throughout the disease trajectory should be the standard of care for all persons. At the very least, the introduction of palliative care and hospice at the end of life is important to the holistic care of persons living with HIV/AIDS.     

Comprehensive care: building community alliances for care of people with HIV/AIDS

In this article we suggest that optimal care for people livingwith HIV/AIDS calls for a multidisciplinary and multisectoralapproach, which can be achieved with cooperation between thestatutory and non-statutory service systems. AIDS has both directlyand indirectly focused attention on the limitations of the servicesavailable in our communities, including those provided by theprimary and secondary health sector. However, non-statutorycommunity-based organizations have been providing vital servicesof information, counselling and care, relying on a steady streamof unpaid labour. Community control over its health care systemand environment should be encouraged and local authorities shouldacknowledge the resources provided by non-statutory bodies,supporting such groups both morally and financially. Using theHealthy Cities project network as a framework, we recommendestablishing working relationships to enhance service integration.The creation of service alliances is intended to facilitatecontinuity of care by establishing links within local governmentagencies, and the priority of the alliance should be to developa realistic, comprehensive service plan involving all interestedparties.     

Planning health care for people with HIV infection and AIDS.

In recent years planners of health services have been urged to design a comprehensive range of services which are responsive to the needs of people with HIV infection and AIDS and those who might be worried about HIV transmission. Models of care have been tried and tested and pilot services which aim to inform the development of the services scrutinised. Though in general this community care is seen as the preferred option with adequate backup support from acute services. More than anything, there is a recognition that the service must be responsive to local needs. Because patterns of HIV infection and prevalence of AIDS are so variable there is no substitute for the systematic development of timely local knowledge as the basis of local planning.     

The role of traditional healers in community-based HIV care in rural Lesotho

Traditional healers provide a substantial proportion of health care in resource-poor settings, including countries with high burdens of HIV in sub-Saharan Africa. Traditional healers have played many roles in HIV care, but some biomedical providers view them as obstacles in providing HIV treatment. This is a qualitative study exploring the roles played by traditional healers in a community-based program rolling out antiretroviral therapy (ART) in two rural communities in Lesotho. Seventeen traditional healers took part in interviews focus groups, and participant observation sessions over a 2 years period. Data showed they provided a wide range of HIV services prior to the ART rollout. Baseline knowledge regarding HIV was high, but healers reported mixed emotions about the planned ART rollout. Joint meetings were held between biomedical providers and traditional healers, and a collaborative model of care resulted. Traditional healers took on a variety of roles in the ART rollout, including HIV prevention activities, HIV testing, monitoring patients, and participating in joint learning sessions. All of the traditional healers underwent HIV testing and 7/17 (41.2%) tested positive for the disease, of whom four were eligible for and enrolled in ART. Healers expressed an appreciation for the collaboration with biomedical providers and being paid for their referrals. However, some expressed concern about the biomedical providers’ lack of understanding of HIV in the local context. This research shows that traditional healers can provide a variety of community-based HIV services and are not obstacles for advancing care in the communities they serve.     

Older people and AIDS: quantitative evidence of the impact in Thailand

Discussions of the AIDS epidemic rarely consider the impact on older people except as infected persons. Virtually no systematic quantitative assessments exist of the involvement of parents or other older generation relatives in the living and caretaking arrangements of persons with AIDS in either the West or the developing world. We assess the extent of such types of involvement in Thailand, a country where substantial proportions of elderly parents depend on adult children for support and where co-residence with an adult child is common. Interviews with local key informants in the public health system in rural and urban communities provided quantitative information on a total of 963 adult cases who either had died of AIDS or were currently symptomatic. The results indicate that a substantial proportion of persons with AIDS move back to their communities of origin at some stage of the illness. Two-thirds of the adults who died of an AIDS-related disease either lived with or adjacent to a parent by the terminal stage of illness and a parent, usually the mother, acted as a main caregiver for about half. For 70%, either a parent or other older generation relative provided at least some care. The vast majority of the parents were aged 50 or more and many were aged 60 or older. This extent of older generation involvement appears to be far greater than in Western countries such as the US. We interpret the difference as reflecting the contrasting epidemiological and socio-cultural situations in Thailand and the West. The fact that older people in Thailand, and probably many other developing countries, are extensively impacted by the AIDS epidemic through their involvement with their infected adult children has important implications for public health programs that address caretaker education and social and economic support.     

The infrastructure of religious communities: a neglected resource for care of people with AIDS.

The AIDS Interfaith Council of Houston, sponsored by the Foundation for Interfaith Research and Ministry, recruits, trains, and coordinates volunteers for home-based care for adults and children with AIDS (acquired immunodeficiency syndrome). The program provides compassionate, non-judgmental care for the sick and respite support for the primary care provider. Care is provided by highly motivated, trained volunteers. The respite care team model also represents a support system to complement medical management and other health care services for people with AIDS. With the expanding number of cases and the growing preference for clients to remain at home, such a model will become increasingly important as people continue to live longer with AIDS.     

Women's work: volunteer AIDS care giving in northern Thailand

Because persons with AIDS in Thailand usually are cared for by their families, and because government AIDS policy relies upon this assistance for the care of the country's sick, the research reported here addressed the questions: Who are the home and community care givers for PWA? What kind of care do they give? And, What is the impact of care giving on the care giver(s)? Informants were drawn in 1998-99 from a long-term birth cohort study of a non-clinical urban population in the country's province of highest AIDS mortality, ChiangMai. The study was part of a larger, exploratory ethnographic study of the interplay among health, reproduction and development among persons born in 1964 and their mothers that I began in 1973. Findings include that among care-givers, parents, overwhelmingly mothers, and wives considered it their place, duty and moral benefit to care for adult children or husbands sick with AIDS.     

The private demand for an AIDS vaccine in Thailand

A contingent valuation survey of Thai adults revealed that private demand for a hypothetical AIDS vaccine that is safe, has no side effects, and lasts 10 years, rises with income, the lifetime risk of HIV infection and vaccine efficacy, and declines with vaccine price and respondent's age. Demand for both high (95%) and low (50%) efficacy AIDS vaccines is substantial. Nearly 80% of adults would agree to be vaccinated with a free vaccine. Government will have an important role to ensure that those at highest risk of HIV infection with low incomes have access to the vaccine and to reinforce other safe preventive behavior to prevent reductions in condom use.     

The implementation of community-based crisis services for people with acute psychiatric illness

This article describes three recently established community-based crisis services for people with acute psychiatric illness. Data were obtained from local information systems developed in the early phase of service operation. Patterns of service were found to vary among the teams in terms of the frequency of contact with the client, the period of contact with the client and the overall numbers of contacts. Such diversification of services reflects, at least in part, the differences in the service networks within which the new services were Such diversification of services is inevitable and creative, and the evaluation of these services must consider not only the short-term impact of crisis services, but also the impact of the network of care services on longer term outcomes for the client.