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In the mid-1990s, the University of Vermont, for example, developed a model of care for serving the State’s dispersed rural population by decentralizing care from a single large site and opening three additional small clinics in small regional hospitals that were initially funded by a Special Projects of National Significance (SPNS) grant. Each of the clinics is staffed by a part-time, HIV-trained nurse practitioner and a part-time social worker; a physician travels to each of the clinics once-a-month and is in contact with them weekly. After the initial grant ended, the program began receiving funds from Title II (Part B) and Title III (Part C). “Without those funding streams these clinics wouldn’t exist. I don’t know what those people would be doing or what their level of care would be,” said Dr. Christopher Grace, who created and leads the initiative.16

In 2006, the Wyoming Rural AIDS Prevention Project piloted a peer-led, Internet-based intervention for rural gay men in which two gay men (one HIV positive and one HIV negative) discuss HIV prevention strategies in online communities. The project’s results demonstrated an increase in knowledge, safer sex practices, and self-efficacy among respondents.17 Support for rural providers was augmented further through a provision in the 2000 reauthorization of the Ryan White HIV/AIDS Program legislation that gave preference to providers in rural and underserved areas for Title III funding.

The HAART of the Matter

In June 1995, the FDA approved an open label study of saquinavir, a protease inhibitor. The drug—targeting a cell’s protein needed by HIV to replicate itself—marked so substantial a breakthrough in HIV treatment that just six months later the drug was approved by the FDA.

HHS along with HRSA worked to quickly disseminate saquinavir over the course of the following year. Their efforts resulted in an almost immediate drop in AIDS morbidity and mortality in the U.S. To increase access to this miracle drug, which created the first “combination therapy” known as HAART, HRSA used ADAP and its funding mechanism through State health departments. In 1996, ADAP was funded at $52 million, and by 1997 had increased to $167 million, marking a significant influx of new resources HRSA made available with which to treat people living with HIV/AIDS.

These efforts had an enormous impact on the gay community who were suffering significantly disproportionate rates of HIV/AIDS. HAART meant patients could suppress HIV replication and restore and maintain their immune function. It provided a kind of renewed dedication to the cause and created a sense of hope throughout the gay community. It meant that HIV/AIDS was no longer a death sentence, and it marked another significant milestone in the fight for HIV not only in resources but in improved care, more effective treatment, and in 1998, it also meant a guide.

Guidelines on HIV treatment had been released in association with widespread adoption of HAART and in April 1998, the U.S. Public Health Service issued more comprehensive, evidence-based HIV treatment guidelines (PDF – 767 KB) Exit Disclaimer to address crucial questions, such as when to start HIV treatment, which agents to start with, which to avoid, and what shortcomings exist for antiretroviral therapy. HRSA worked diligently with local providers to get this information into their hands and coordinate associated trainings, many of them through AETCs.

These guidelines are regularly updated as our understanding of HIV and its treatment expands. As providers and researchers became more familiar with HAART, emphasis also turned to medication adherence and side effects.

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