An estimated 25% of the over 1 million Americans living with HIV/AIDS are undiagnosed and unaware of their HIV infection.[1] Diagnosis occurs late in the course of HIV infection for many, with upwards of 50% of newly diagnosed patients presenting with advanced AIDS.[2–5] Individuals diagnosed late in the course of HIV infection have significantly higher mortality and generate 2.5 times more cost of care than those diagnosed early.[6–9]
In response to these problems the Centers for Disease Control and Prevention updated their guidelines for HIV testing late in 2006, now recommending routine, opt-out HIV testing for all patients in all healthcare settings.[10] As a result of this new policy, an estimated 25% to 50% increase in new patients is predicted for outpatient HIV clinics.[11] This leads to the critical question: “Where will the capacity come from to care for these new patients?”
The Ryan White CARE Act was enacted in 1990 to “provide for the development, organization, and operation of more effective and cost efficient systems for delivery of essential services to individuals and families with HIV disease” (Public Law 101–381). Title III of the CARE Act provides funding directly to clinics and other entities that provide comprehensive HIV primary care. With shifts in the epidemiology of HIV in the United States over the past 25 years, Title III HIV clinics operating in smaller communities have become increasingly stressed.[6,9] Despite growth in patient volume of 50% to 100%, most of these clinics have been “flat-funded” since the reauthorization of the CARE Act in 1998. Currently, many Title III clinics are operating at or above capacity. After lengthy debate on Capitol Hill, the Ryan White CARE Act was reauthorized in December 2006 (Public Law 109–415). Part of the debate focused on the provision of increased funding for Title III clinics. The final version provides a modest 3.7% annual increase in Title III funding. While the reauthorization now stipulates that 75% of Ryan White funding be spent on Medical Services, it remains to be seen whether the small amount of increased funding will be adequate to accommodate the growing needs for HIV care provision.
We are at a critical juncture regarding the future care of HIV-infected persons in the US. With the anticipated influx of newly diagnosed HIV-infected persons and clinics already operating at or above capacity, it is imperative that increased funding for Title III clinics be made available to preserve the availability of comprehensive, quality care for all persons with HIV infection in the US.
That is the opinion of my coauthor Dr. Michael Saag and me. I'm Michael Mugavero, Assistant Professor of Medicine at the University of Alabama at Birmingham, and care provider at the UAB 1917 HIV/AIDS clinic.
Footnotes
Readers are encouraged to respond to the authors at mmugavero@uab.edu and msaag@uab.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu
Contributor Information
Michael J. Mugavero, University of Alabama at Birmingham; Author's Email: mmugavero@uab.edu.
Michael S. Saag, UAB Center for AIDS Research, University of Alabama at Birmingham; Author's Email: msaag@uab.edu.
References
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