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Multiple diagnoses and the circumstances
in which many people with HIV/AIDS live make a comprehensive
approach to the epidemic the only real response. HIV/AIDS
service providers combine several strategies to address
these issues. This approach offers a model to the health
care system at large for reaching the tens of millions
of people in the United States with inadequate access to
health care. It also takes “chance” out of
the health care equation for hundreds of thousands of people
living with HIV/AIDS.
Special Forces
In a display of flexibility that
is often rare in the tradition-laden medical field, CARE
Act-funded primary care providers have changed their approach
to health care over the past 10 years. Consequently, many
of their clients are living into middle and old age.
At
the University of Kansas School of Medicine/Wichita Medical
Practice Association HIV program, 32 percent of clients
are 45 years of age or older (and 6 clients are over 64).
At the Detroit Medical Center, the proportion of clients
over 45 years old is 44 percent.
“I’m warning many of my patients that a heart
attack caused by smoking or poor diet is going to kill
them long before AIDS does,” says Dr. Lawrence Crane,
medical director of the Center’s HIV clinic.
CARE Act-funded providers have
positioned themselves to address issues commonly associated
with aging, as well as side effects and health problems
associated with HAART and comorbidities often seen in HIV-positive
patients. For example, many providers are
addressing hepatitis C, the incidence of which is estimated
to range from 15 to 30 percent among all people living
with HIV/AIDS in the United States, and up to 90 percent
among patients who contracted HIV through injection drug
use.41,42,43 Providers
are treating mental illness. They provide access to gynecological
care and to specialty care for diseases like cancer and
diabetes. This comprehensive approach reflects that, unlike
10 years ago, HIV almost never exists in isolation and
for those in whom HAART is successful, HIV is, for now,
a chronic disease. (See A Guide to Primary Care for
People with HIV/AIDS, 2004 edition, at hab.hrsa.gov/tools/primarycareguide.)
Search and Rescue
The circumstances in which most CARE
Act clients live are hard to fathom for insured, middle-class
Americans, but a visit to a CARE Act-funded site provides
a temporary, if distant, window into their lives. These clients
are not people who were abruptly thrown off track by HIV and
who, once on HAART, get back on the road to the middle-class
American dream. They are largely individuals who never lived
near good schools or in safe neighborhoods, who have never
had any health care, who never had good prospects of breaking
free from the poverty and deprivation into which they were
born.
In some clinics, over 90 percent
of clients live at or below the poverty line, and less
than 10 percent have private health insurance. For these
people, support services aren’t
optional. They are essential.
Ella Tardy, the director of
special projects at the Southeast Mississippi Rural Health
Initiative, Inc. in Hattiesburg, Mississippi, explains
below
We have many patients
who can’t afford their own transportation
and have difficulty finding friends or relatives
whose schedules are flexible enough to drive them
to clinic appointments. Our shuttle exists for
these patients.
We help many women with
newborns. Once, in the heat of the summer, we used
donations to buy a small window unit air conditioner.
We have also linked mothers to car seats—and
made sure they enrolled in WIC.
We provide Ensure when
patients have wasting syndrome. Sometimes, Ensure
is all people have to eat, so we link them to food
banks and food stamps.
We don’t do this
often—perhaps once a year—but sometimes
we pay a utility bill—which is the difference
between keeping the power on or having the water
shut off.
We can provide babysitting
so a mother can come to her clinic appointment,
and we do a lot of linking to other services. We
have secured donations to provide school supplies
and uniforms. Last fall, we got a huge shipment
of clothing, T-shirts, toys, and shoes from New
York. It was all donated. We worked through the
weekend to get it sorted and distributed to patients. |
The impact of services like these
can be reflected in rising CD4+ T cell counts and falling
viral loads, in increased quality of life, and decreased dependency.
Ultimately, they keep people in care and out of emergency
rooms and help reduce the disproportionate burden of AIDS
born by the poor, racial and ethnic minorities, and the uninsured.
New Recruits
CARE Act grantees have united with
organizations throughout their communities to build a
larger, more comprehensive, and more united force for
addressing HIV/AIDS. By enlarging the tent and enrolling
other health care and support services agencies into the
fight against AIDS, HRSA and CARE Act-funded providers
have improved access to care and functioning for the underserved.
For example, many CARE Act-funded
providers help enroll eligible clients in Medicaid, the largest
single payer for HIV/AIDS services in the country. CARE Act-funded
providers also have built referral relationships with specialists
who help provide treatment to HIV-positive patients coinfected
with hepatitis C. They also build linkages with local providers
like churches and community-based organizations that help
clients meet needs for food, clothing, and housing. Together,
they help create a more seamless continuum of services.
The Best and the Brightest
The CARE Act ensures
that access to services is not determined by income level
or insurance status. Through a bold, multi-faceted technical
assistance strategy, initiated by the HRSA HIV/AIDS Bureau,
Division of Training and Technical Assistance, care and services
providers are given access to the training and capacity-building
assistance they need to address HIV/AIDS in their communities.
Services offered through this strategy increase early access
to HIV counseling and testing, care, and treatment for various
populations, thereby reducing health disparities among underserved
people living with HIV/AIDS. The AIDS Education and Training
Centers (AETC) provide clinical care updates for seasoned
HIV clinicians, ensuring that CARE Act clients have access
to the most skilled HIV/AIDS specialists in the country. The
Centers also provide first-time training to clinicians all
over the country, teaching clinicians in even the most rural
areas how to screen for HIV and provide HIV counseling, testing,
and treatment. While many of these clinicians will never become
specialists, they are a vital link in reaching people unaware
of their serostatus—and in reducing health disparities
among the underinsured and underserved.
Technical assistance
offered through HRSA’s HIV/AIDS Bureau helps organizations
expand their capacity to reach and serve poor racial
and ethnic minorities living with HIV/AIDS. During 2006,
a new technical center will be launched to expand access
to technical assistance for CARE Act-funded grantees
and providers. Called TARGET—Technical
Assistance Resources, Guidance, Education and Training—this
initiative will offer an enriched technical assistance Web
page, a help desk for grantees, and will point users in
the right direction in their pursuit of information, resources,
and topical experts.
The Special Projects
of National Significance (SPNS) program implements demonstration
projects to identify more efficient and productive models
for delivery of HIV/AIDS services. For example, a recent
Adherence Initiative has brought a new body of advanced
knowledge to providers who are helping clients find ways
to adhere to treatment regimens. These efforts increase
the capacity of providers to build the comprehensive continuum
of services on which many people living with HIV/AIDS
depend.
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