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Laura W. Cheever, Christine Lubinski, Michael Horberg, Judith L. Steinberg, Ensuring Access to Treatment for HIV Infection, Clinical Infectious Diseases, Volume 45, Issue Supplement_4, December 2007, Pages S266–S274, https://doi.org/10.1086/522549
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Abstract
The recent recommendations of the Centers for Disease Control and Prevention for opt-out testing are intended to address the evolving human immunodeficiency virus (HIV) epidemic in the United States by bringing more HIV-infected individuals into medical care. This is an important step to better control the epidemic but brings with it the challenges of adequately caring for more individuals infected with HIV and of funding medications and medical care for these additional patients. With more patients being offered HIV testing, there will be a surge in the need for testing and counseling services, which must keep pace with patient demand. This article describes the current status of HIV screening and care from 4 perspectives: the Ryan White Program (previously known as the Ryan White Comprehensive AIDS Resources Emergency Act), Medicaid and Medicare reimbursement for HIV screening, a managed care organization, and community health centers. The mandate for routine HIV screening challenges each of these health care entities, but all will need to overcome these challenges if routine HIV screening is to become a reality.
Health policy experts, medical providers (i.e., health care professionals, health care institutions, and third-party payers), government officials, and community members recognize the importance of integrating programs to prevent HIV infection into the clinical care setting and of identifying opportunities to reach persons at risk for or living with HIV infection when and where they interact with the health care delivery system. However, programs to prevent HIV infection, including risk assessment and prevention education and counseling, are not a routine part of clinical care in the United States. Researchers have increasingly examined some of the barriers to implementing such programs. These barriers include the many legal, financial, and organizational factors that guide or inhibit policy and clinical decision making. Attention to these factors may provide additional opportunities for enhancing activities to prevent HIV infection.
We describe prevention strategies from the following variety of health care–associated perspectives: the Ryan White Program (RWP), previously known as the Ryan White Comprehensive AIDS Resources Emergency Act; Medicare and Medicaid reimbursement of HIV screening; the managed care program of Kaiser Permanente (KP); and community health centers (CHCs). Each of us represents one of these perspectives, and we suggest processes that could increase and improve opportunities for integration of HIV prevention and medical care, including development and dissemination of integration models, review of financing and coverage policies by federal agencies, development of federal guidance on integration, and investigation of possible support services that could facilitate integration.
Increased HIV Testing: Challenges to RWP Resources
The RWP was enacted on 18 August 1990 as a federal program designed to improve the quality and availability of medical care for persons with HIV/AIDS who are uninsured or underinsured [1]. The RWP was amended and reauthorized in 1996, 2000, and December 2006 (HIV/AIDS Bureau, informational e-mail). Funding levels are determined annually by the federal budget.
The RWP is administered by the Health Resources and Services Administration (HRSA), which is within the Department of Health and Human Services. It provides federal funding to support medical care and essential support services to persons living with HIV infection who do not have the means to acquire these services on their own. The intent was to offer a safety net for medically underserved populations, and indeed it has been an important resource for persons who have no insurance and/or a low income.
The RWP is a discretionary program rather than an entitlement; that is, the annual funding is based on the will of Congress. In contrast, Medicaid is an entitlement, and funding from this program is guaranteed to be at a certain level. The RWP is the only domestic, disease-specific discretionary grant program that provides funding for medical care for people with HIV/AIDS.
The RWP builds on the resources provided by Medicaid and fills gaps in terms of eligibility and services. In states with more-generous Medicaid programs, RWP dollars go much further to fill unmet needs and can supplement Medicaid in a much more complete way. As state Medicaid programs shrink or change, funding from the RWP should shift to fill critical gaps. Additionally, a central tenet of the RWP is that decisions about how to allocate funding are made at the state and local level. Most funding to cities and states is distributed by formulas based on the prevalence of HIV/AIDS in their population.
The RWP provides comprehensive primary care, support services, and medications. The statute funds a broad range of services because of the recognition that to ensure access to and retention in care for truly disenfranchised individuals, it is essential to provide services, such as case management, transportation, and other support services, that help link these individuals to care.
Programs. The RWP as amended is a complex piece of legislation that consists of several Parts. These include Parts A–D and Part F.
In fiscal year 2006, RWP appropriations were distributed as shown in table 1. In 2006, most of the funding was distributed through formulas based on the prevalence of AIDS; in 2007, the formulas used data on the prevalence of HIV infection without AIDS and the prevalence of HIV infection with AIDS. Part A funds are directed toward cities heavily affected by AIDS. Funding priorities and allocation decisions traditionally have been made by local planning councils. Part B grants are designated for states and territories and fund health care and support services for persons with HIV/AIDS. These grants include the AIDS Drug Assistance Program (ADAP), a program that provides medications to persons with HIV/AIDS [2]. Part C funding supports community-based programs, including local health departments, programs for homeless persons, CHCs and migrant health centers, and hemophilia centers, that provide primary HIV care and support services. Part D provides funding for health care and support services for children, adolescents, women, and families via comprehensive, community-based care systems or networks of care. Part F provides competitively awarded grants for Special Projects of National Significance, which support the development of innovative models of HIV/AIDS care, particularly for hard-to-reach populations. Past initiatives have focused on examining outreach programs, increasing health care capacity along the border between the United States and Mexico, improving treatment adherence, and using technology to improve medical care. Part F also includes a small dental program and the AIDS Education and Training Centers program.
Funding has changed with the advances in HIV treatment and changes in the epidemic since 1991 (figure 1). Since the advent of HAART in 1996, Congress has allocated increasing amounts of money to ADAP, with almost 40% of RWP funding directed to ADAP in 2006. Funding for Part A, which is allocated to cities, also increased through the 1990s. In the past few years, most of the RWP programs have received small cuts as mandated by across-the-board Congressional rescissions.
RWP spending has been heavily weighted toward medication and medical care. In 2005, forty percent of RWP spending was allocated to ADAP, 3% to other medication programs, 25% to medical care, 7% to case management, and 10% to support services.
Accomplishments. More than half a million people are served by the RWP annually, including HIV-negative children born to HIV-positive women. The RWP provides lifesaving medications to almost 150,000 persons. The RWP has reached the targeted populations: 72% of its clients are racial minorities, 33% are women, and 79% are uninsured, underinsured, or receiving other public health benefits.
Challenges. Demand for RWP services is increasing without significant increases in new resources, and medical care costs continue to rise. As more HIV-positive persons are identified, the burden on the RWP will become greater. The RWP has continued to prioritize primary care services for these persons. HRSA has worked closely with ADAPs to ensure that medications are purchased at the lowest possible cost, as determined by the Section 340B Drug Discount Program [3], which limits the cost of covered outpatient drugs to certain federal grantees, federally qualified CHC look-alikes, and qualified disproportionate share hospitals, and to improve ADAPs' efficiency. For example, state ADAPs have achieved considerable cost savings by working more closely with Medicaid to ensure that all qualified patients are funded through Medicaid.
It is important that support services for HIV-infected persons continue to be funded as the health care environment places greater emphasis on medications and medical services within the RWP. Multiple studies have demonstrated the strong relationship between support services and retention of patients in medical care. For example, Sherer et al. [4] conducted a retrospective analysis of clinical data sets on 2647 patients at the Cook County HIV Primary Care Center in Chicago during 1997–1998 to investigate the relationship between access to and retention in HIV primary care and the following 4 support services: case management, transportation, mental health, and chemical dependency. They reported that patients who received support services were significantly more likely to receive any care or regular care and had more clinic visits than patients who received none of the services. In addition, retention in medical care increased by 15%–18% after 1 year among patients who received support services (figure 2). Thus, the increasing pressure on the RWP to fund services for more people may mean that fewer support services are provided and that a smaller proportion of patients are retained in care.
Routine HIV Testing in Health Care Settings: Medicare and Medicaid Reimbursement
Medicare. Medicare covers few preventive services, although recently Congress moved to increase the number of preventive services available to Medicare beneficiaries. Currently, Medicare covers screening procedures for cardiovascular disease, breast cancer, colorectal and prostate cancers, diabetes, glaucoma, abnormal cervical and vaginal conditions, and bone density but not for HIV infection. Recent Medicare Part D legislation mandated that Medicare include coverage for a preventive physical examination [5]. Although this mandate affords some opportunity to discuss HIV risk reduction and testing, Medicare does not reimburse for HIV screening. Many of the screening tests in Medicare as well as Medicaid are linked to recommendations from the US Preventive Services Task Force (PSTF), which has not yet recommended population-based screening for HIV infection [6]. The lack of a recommendation by the PSTF could pose a barrier for some payers.
The current recommendations for HIV screening from the CDC, discussed extensively elsewhere in this issue, focus on testing for individuals aged 13–64 years. The overwhelming majority of Medicare beneficiaries are >65 years old, but there are 6.8 million current Medicare beneficiaries who are disabled and <65 years old, including ∼100,000 people living with HIV/AIDS.
Medicaid. Medicaid is far more relevant in the discussion of HIV screening. It is the major health care program for 55 million low-income Americans. It does not cover all low-income people, and it does not provide coverage to most single adults, including all men who have sex with men and women without dependent children, unless they are completely disabled by AIDS or some other condition. Thus, Medicaid does not cover medical care for many persons who would likely benefit from HIV screening. It is, however, the largest payer for medical care received by persons with AIDS (figure 3) [7, 8]. Kates [9] noted that ∼20% of persons in whom HIV infection is diagnosed are eligible for Medicaid at the time of diagnosis, so there is an opportunity to identify many low-income persons with HIV infection who are already Medicaid beneficiaries but are unaware of their positive HIV serostatus. Federal law does allow HIV screening to be covered, either in a fee-for-service or a managed care context, by Medicaid; however, it is an optional service, as is prescription drug coverage. Routine HIV testing has not been widely adopted by state Medicaid programs; one exception is New Jersey, where the percentage of persons receiving Medicaid through managed care plans is high. New Jersey also provides increased capitation for AIDS care, so as not to create a disincentive to identify HIV-infected people [10]. In the absence of risk-adjusted capitation for HIV care, managed care plans have little incentive to identify persons infected with HIV; these plans are structured in the hope that HIV-infected people are identified at another time, when funds from an alternative plan are available.
Currently, Medicaid programs in 32 states cover HIV testing and counseling in some fashion; 19 cover prenatal and perinatal HIV counseling and testing [11]. However, routine testing is not covered at a broad range of sites: only 3 states reimburse anonymous or confidential testing sites for HIV tests [11].
CHCs are going to be very important targets for implementing the CDC's HIV testing recommendations. All states must provide federally qualified health center (FQHC) services in their Medicaid programs. These FQHCs are required to screen for communicable diseases; however, HRSA has not yet included HIV screening as part of this requirement [11]. Therefore, a major challenge is to encourage states and communities to implement HIV screening and fill in the gaps in federal policy. California uses a family planning waiver to reimburse for HIV testing and counseling for persons with incomes up to 200% of the federal poverty level and for women of childbearing age, but this was a very special waiver and is probably not a model that can be adopted elsewhere.
States may also offer a Medicaid-financed diagnostic, screening, preventive, and rehabilitative option. This broadens the definition of “medical necessity” to allow coverage for preventive services, such as HIV screening. For example, in Massachusetts, a service is considered to be medically necessary if it is “reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life [or] cause suffering or pain” [12].
The New Jersey Medicaid Managed Care Contract contains strong language stipulating that contractors are required to cover HIV screening and care. Contractors must provide prevention services for all enrollees and must address the special needs of HIV-infected enrollees. The contractor's plan must establish methods of promoting HIV prevention to all enrollees, methods for accommodating self-referral and early treatment, a process to facilitate access to specialists and/or include HIV/AIDS specialists as primary care physicians, methods for education about HIV/AIDS risk reduction, and a process by which HIV/AIDS testing and counseling can be accessed [10]. Managed care organizations are required to offer counseling and testing and are required to report on how many people they counseled and tested.
The Florida Medicaid Program contains provisions requiring that pregnant women be offered counseling and testing at the initial prenatal care visit and again 28–32 weeks later. This has been broadened to require the provider service network to target all women of childbearing age—not just those who are pregnant—for HIV counseling and testing [13].
Financing for implementation of HIV guidelines. If the CDC regulations for HIV testing are to be implemented, federal financing is essential for both testing and medical care. The relatively modest amount of discretionary funding through CDC, RWP, and state and local health departments will not be adequate to implement population-based HIV screening. Medicaid, with its significant reach into low-income populations, especially the women, adolescents, and ethnic and racial minorities in these populations, must be part of the financing mix, and federal leadership could and should facilitate coverage of routine screening by state Medicaid programs.
However, there are significant challenges to Medicaid financing of routine HIV testing. The Center for Medicare and Medicaid Services and the current presidential administration have little commitment to expanding the Medicaid program, particularly the federal contribution. Furthermore, state budgetary constraints and competing priorities for Medicaid dollars may limit allocations for HIV screening, particularly in states where the prevalence of HIV infection is low. Finally, many community AIDS advocates who work at the state level do not support the new CDC guidelines. They may discourage the adoption of routine HIV testing and raise barriers to reallocating funds for routine testing by states.
Conclusions. It is hoped that the new recommendations of the CDC that call for routine HIV screening of all adults and adolescents in US health settings [14, 15] will lead to stronger recommendations from the US Preventive Services Task Force [6], which limits its current recommendation to persons at “increased risk” for HIV infection. A recent analysis [16] suggests that, from both the clinical and economic perspectives, the benefits of routine HIV testing in all adults in the United States outweigh the likely harms. If the CDC recommendations are to be implemented, however, Medicaid will take on a large proportion of the added costs. Federal leadership is essential to encourage additional financing of HIV screening and medical care under Medicaid and through FQHCs, which are not currently required to provide HIV counseling and testing to individuals who present for medical care and services.
Delivering on the Promise: the Managed Care View
KP is the largest staff-model health maintenance organization (HMO) in the country. It has >9 million members and cares for ∼3% of the US population. This managed care organization offers a wide variety of care plans, although most members are enrolled in a more traditional integrated HMO care plan. Most members receive their KP insurance coverage through their employer or through another family member's employment plan. Some members are covered through Medicare HMO plans or Medi-Cal HMO plans; some members receive KP care through individual or small-group HMO plans.
KP is the second largest integrated care provider for HIV care in the country, after the Veterans Administration system. There are >16,000 members presently under care who are infected with HIV, ranging from 180 HIV-infected patients in Ohio to nearly 5500 HIV-infected patients in northern California. The members include individuals enrolled in Group Health Cooperative (GHC), KP's “sister” organization headquartered in Seattle.
KP has adopted a specialty model of HIV care, with >100 health care professionals caring for all of the HIV-infected patients. Only ∼200 HIV-infected patients are aged ⩽19 years. KP has >100,000 total patient-years of experience with HIV infection; the mortality rate among HIV-infected KP member is <2%, compared with a national average of 3.4% (KP, internal communication).
The demographic characteristics of the KP HIV-infected population are shown in table 2 and vary greatly from region to region. Although 33 states have reported statistics on HIV infection to the CDC for at least 4 years, KP mainly serves states not part of this reporting structure. Therefore, the demographic characteristics of the KP patient pool are different from the national data reported by the CDC. At KP, HIV infection remains largely a disease of men who have sex with men, and a majority of HIV-infected members are white. However, the number of black HIV-infected members is increasing. Likewise, the number of HIV-infected Latino members is increasing, particularly in California. The percentage of HIV-infected women has remained steady at 16%.
Specialty model of HIV medical care. The KP HMO is a multidisciplinary care model that affords more-organized and more-comprehensive care, and many of the hidden costs of treating HIV infection are subsumed within the overall cost of providing care. Although there may be variation between specific KP and GHC medical centers, the multidisciplinary HIV treatment team usually includes an HIV specialist (usually an infectious diseases specialist or internal medicine or family medicine specialist with experience in treating HIV disease; many of these professionals have HIV Medicine Association or American Academy of HIV Medicine certification), a case manager (a professional with an RN, PharmD, or MA degree), clinical pharmacy support, a social worker with or without a benefits coordinator, mental health support, a health educator, and, for larger coverage regions, a regional coordinator. If increased HIV testing is to take place, as recommended by the CDC, health educators and care coordinators will become increasingly important in alleviating the burden of pretest and posttest counseling on busy primary care facilities.
Clinical findings of the specialty model of HIV care. At the time of diagnosis, many patients meet the diagnostic criteria for AIDS, suggesting that case finding needs improvement. However, once HIV infection is diagnosed, >90% of infected individuals receive medical care within 120 days, and most receive care within 30 days. Among patients receiving HAART, >80% have viral loads below the limit of quantification (defined as <75 HIV RNA copies/mL). More than 74% of HIV-infected patients have a history of HAART use, and >70% have received HAART in the past year. More than 60% of patients presently have a CD4 cell count of >350 cells/μL. Most important, once patients receive access to care, no significant differences in the quality of care or clinical outcome are apparent by sex, race, or ethnicity.
HIV antibody testing. Most states in which KP provides services still require that the patient provide informed consent before undergoing HIV testing. For all diseases, KP differentiates screening from testing. Screening is defined as testing without counseling, which, for example, might involve sending out a massive mailing with a form that patients take to a screening center, where their cholesterol and blood sugar levels are measured. This is not an appropriate method by which to determine whether HIV is present in an individual. Testing for HIV includes pretest and posttest counseling and patient education. Testing as defined here is the desired norm for KP and GHC.
KP's policy is that HIV antibody testing is a process; it does not consist simply of the test itself. Testing should be part of routine primary care, but it has to be done within the context of a discussion of risk behavior, sexuality, harm reduction, and testing for other sexually transmitted diseases. The appropriate frequency of testing and counseling may be determined on an individual basis, but testing only once in a patient's life is probably not sufficient, because risk behaviors and sexual expression change over the course of adulthood and require that a patient be reevaluated over time.
Rapid HIV testing is currently being used mainly during labor and delivery and after episodes of occupational exposure. However, as rapid testing becomes more accepted, its use by KP will likely increase accordingly.
KP performs >340,000 antibody tests annually. In KP's prenatal care program, >90% of women are tested. However, KP treats nearly 9 million patients, and >6 million members fit the CDC testing recommendations. Therefore, only ∼15% of the targeted KP members have been tested in the last 5 years, assuming each patient was tested only once; a KP biostatician suggested that ∼8% of the KP pool has ever been tested (KP, unpublished data). Thus, to adhere with the new CDC guidelines, KP would have to perform >5 million additional tests, which will have a dramatic effect on the cost of care. With the prevalence of HIV infection in the KP population at ∼0.3%, routine HIV testing would identify nearly 1773 new cases. This would likely cost an additional $26,599,450 per year for care, assuming all patients with newly diagnosed HIV infection received antiretroviral drugs at a cost $15,000 per patient per year.
Policies of other managed care organizations. In addition to KP, most other managed care organizations follow PSTF recommendations [6], which propose screening for HIV in all adolescents and adults at increased risk for HIV infection and in pregnant women but do not comment on routine screening for HIV in adolescents and adults who are not at increased risk for HIV infection. These recommendations must be reconciled with the CDC recommendations [14]. Most managed care organizations support targeted testing. Thus far, most managed care organizations have not revised their policies to accord with the new CDC recommendations, and new PSTF recommendations do not include universal testing.
KP plans to implement more-comprehensive testing but is examining the implications. Antiviral medication is now the largest line item in the pharmacy budget in the larger KP regions, where it surpasses the cost of statins and antihypertensive agents. Very few generic drugs are approved in the United States, and most probably would not meet the current paradigm of care. Although KP is confident that it can accommodate all of the patients with newly identified HIV infection, HIV testing without counseling is inconsistent with the preventive health management philosophy at KP.
Ensuring Access to Care: the Chc Perspective
CHCs are a major component of the safety net for our nation's health care system. CHCs are located in high-need areas, and their mission is to provide comprehensive health and related services to all residents in their community, regardless of the residents' ability to pay. CHCs are governed by community boards to ensure that the community has control over the direction and vision of the services provided. CHCs have been successful in reducing health disparities, with few or no disparities existing among CHC users. They are also effective in treating patients with chronic diseases. CHCs meet or exceed nationally accepted practice standards for the delivery of chronic disease care. CHCs are located in all 50 states and territories. They provide one fourth of all ambulatory care for uninsured patients (figure 4) [17]. This is crucial, considering that infection in 250,000–300,000 HIV-infected persons has yet to be diagnosed. Most of these patients with undiagnosed HIV infection will likely be uninsured and disenfranchised and will seek out CHCs to undergo HIV testing and receive medical care.
HIV testing and medical care. CHCs serve a high-risk population. The seropositivity rate at CHCs is 2.4%, compared with 1.2% at all other CDC-funded sites (table 3) (CDC, unpublished data). Even for clients at high risk for HIV infection (i.e., injection drug users and men who have sex with men), the seropositivity rates at CHCs are higher than those for all other CDC-funded sites. Fortunately, 95% of all patients return to CHCs for their test results. This is the highest return rate of all CDC-funded HIV testing sites.
Approximately 75,000 HIV-infected patients receive their medical care at CHCs. More than 400,000 users of CHCs have received an HIV test, and nearly 700 pregnant HIV-positive women have received their care at CHCs (Uniform Data System, unpublished data).
Many CHCs receive funds from Part C of the RWP; one-third of Part C grantees are CHCs. Paradoxically, only 10% of CHCs receive RWP Part C funding, yet HIV services are available at CHCs that do and those that do not receive RWP funding.
Table 4 lists findings from a survey of HIV testing practices at CHCs. These findings underscore the impact of funding on the ability of CHCs to deliver services. Ninety-six percent of Part C–funded sites provide HIV testing, whereas 63% of non–Part C funded sites provide testing. Similarly, at CDC-funded sites, 71% provide outreach or off-site HIV testing, compared with 40% of sites not funded by the CDC [18].
Service provision also depends on the locale. Eighty-two percent of urban CHCs provide HIV testing, compared with 64% of rural CHCs. This disparity must be addressed, considering that the evolving geography of the HIV epidemic in the United States is shifting toward the southern and southeastern parts of the country, which are more rural than other regions.
Models of HIV care at CHCs are dependent in large part on the richness of funding. More-robust programs have multidisciplinary teams and dedicated HIV specialists, defined as physicians who have expertise in caring for HIV-infected patients, including infectious diseases specialists and other specialists and primary care physicians who have experience treating persons who are infected with HIV. Other programs provide primary care and support services but either refer patients to HIV specialists or have HIV specialists on site at regular intervals. Programs with less HIV funding may refer patients to HIV specialists, usually at sites funded by the RWP, and may offer either on-site or off-site HIV testing along with primary care.
Challenges to accessing HIV care. The primary challenges at CHCs are access to primary care professionals, HIV specialists, HIV medications, and funding.
Access to primary care professionals is a major challenge not just for CHCs but also for the primary care delivery system. The number of US medical school graduates matching in family medicine and internal medicine (i.e., primary care) decreased by 51.6% and 56.7%, respectively, during 1997–2005 [19]. This is likely a direct result of the prioritization of funding in our health care delivery system, which favors specialty care and high-risk procedures over primary care and disease prevention. Because of low reimbursement rates, primary care professionals are expected to see an increased number of patients and have less time to spend with each patient. Their quality of life has diminished and their salaries are lower, compared with their colleagues in specialty care. It is no wonder, then, that young physicians choose specialty care over primary care. A 2004 survey of all CHCs in the 50 states showed that, in an average CHC, 13% of its family physician full-time employee positions are unfilled. One-third of CHCs had been recruiting for a family physician for >7 months [17].
Access to HIV specialists is a particular problem for sites not funded by the RWP, particularly rural CHCs. One rural CHC that is not funded by the RWP has been participating in a pilot program to implement routine HIV testing. The center must provide transportation for patients with newly diagnosed HIV infection to the nearest RWP site 30 miles away. In addition, there is a limited supply of nurses, case managers, and nutritionists with experience treating HIV-infected patients.
An informal survey of CHC directors revealed that they view the limitation of ADAP funding as another major challenge. An estimated $300 million is needed just to catch up with the current case load, according to some ADAP experts. Many states have ADAP wait lists; restrictions in formularies and income eligibility have been implemented as ways to cut the budget. Walensky et al. [2] concluded that state variability in funding of ADAPs results in geographic differences in disease outcome.
CHCs with RWP and CDC funding can better provide increased and enhanced HIV treatment services. Part C of the RWP has been flat funded for 6 years; the fiscal year 2006 funding was $193.6 million. For fiscal year 2007, the National Association of Community Health Centers recommended an increase of $150 million in Part C funding over that received during the previous fiscal year. However, Part C did not receive a significant increase in fiscal year 2007.
Conclusions. CHCs are an important component of our health care system. They excel in managing chronic diseases and in reducing disparities in health care, they are important providers of HIV testing and medical care, and they serve a high-risk population. RWP Part C funding is a key source of support for HIV programs at CHCs. However, only 10% of CHCs receive this funding, and Part C has been flat funded. Routine testing will further stress a system that is already challenged in terms of access to health care professionals, funding, and medications.
Conclusion
If the CDC's recent recommendations for opt-out testing for HIV infection are to be widely implemented, providers (i.e., health care professionals, third-party payers, and health care institutions) will confront major challenges in reaching marginalized populations, funding testing, providing counseling and follow-up, and providing medications. At the same time, the opportunity to identify more HIV-infected individuals and bring them into the health care system will likely be an important step in further stemming the tide of the epidemic. It is essential that these health care providers have strategies as well as the means to keep pace with the increased need for services. All parts of the health care systems, including publicly funded programs and commercial insurers, will need to overcome the obstacles of routine HIV screening if this strategy is to be effectively implemented in the United States.
Acknowledgments
We thank Margaret Inman for her assistance in preparing this manuscript. J.L.S. thanks everyone who helped in the preparation of her presentation, particularly Kathy McNamara and Lisa Cox at the National Association of Community Health Centers.
The “Opportunities for Improving HIV Diagnosis, Prevention & Access to Care in the U.S.” conference was sponsored by the American Academy of HIV Medicine, amfAR, the Centers for Disease Control and Prevention, the Forum for Collaborative HIV Research, the HIV Medicine Association of the Infectious Diseases Society of America, and the National Institute of Allergy and Infectious Diseases. Funding for the conference was supplied through an unrestricted educational grant from Gilead Sciences, amfAR, GlaxoSmithKline, Pfizer, Abbott Virology, OraSure Technologies, Roche Diagnostics, and Trinity Biotech.
Supplement sponsorship. This article was published as part of a supplement entitled “Opportunities for Improving the Diagnosis of, Prevention of, and Access to Treatment for HIV Infection in the United States,” sponsored by the American Academy of HIV Medicine, amfAR, the Centers for Disease Control and Prevention, the Forum for Collaborative HIV Research, the HIV Medicine Association of the Infectious Diseases Society of America, and the National Institute of Allergy and Infectious Diseases.
Potential conflicts of interest. All authors: no conflicts.
References
Presented in part: Opportunities for Improving HIV Diagnosis, Prevention & Access to Care in the U.S., Washington, D.C., 29–30 November 2006.
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