HIV Care System Is Getting Swamped

The U.S. HIV care system is being swamped by a rising tide of new patients, an Institute of Medicine (IOM) report warns.

As HIV treatment continues to improve, people with HIV are living much longer. Meanwhile, the CDC’s universal HIV screening program is bearing fruit, identifying more people who are infected with the AIDS virus.

The result is a widening gap between the number of Americans with HIV and the resources available to treat them.

“Our system is getting stretched,” IOM panel chair Paul D. Cleary, PhD, dean of the Yale School of Public Health, tells WebMD. “There is going to be a dramatic change in the number of people with HIV detected and cared for. When we start treating this many more people … we find there are barriers to getting them into available treatment facilities.”

Over 20% of the 1.1 million Americans with HIV don’t know they are infected. Learning they have HIV is good for the individual, as earlier treatment means better health. It’s also good for society, as people who know they carry HIV are less likely to infect others — and treatment actually makes a person less infectious.

“There is a moral imperative that if we do testing, we have to get people who test positive into care,” Michael Saag, MD, tells WebMD.

But there’s a raft of problems with actually providing this care, notes Saag, director of AIDS research at the University of Alabama, Birmingham and immediate past president of the HIV Medicine Association.

Saag’s state-of-the-art AIDS clinic is a prime example. In 2000, the clinic was caring for 750 patients. Now the same clinic, with pretty much the same funding and same staff level, is caring for 1,800 patients.

“We are at capacity now,” Saag says.

But more patients soon will be knocking at the door. Saag points to a graph in the IOM report showing that while U.S. funding for HIV care under the Ryan White Act has remained stable at about $200 million per year, the number of patients who qualify for benefits has increased from about 150,000 to 250,000.

That difference reflects the U.S. HIV treatment gap.

“We call it the triangle of misery,” Saag says. “But in this day and age of budget crisis in every state across the country, asking Congress for more money is not going to cut it.”

The IOM notes that states are slashing, not increasing, their HIV/AIDS programs. In 2009, states cut $170 million from these programs:

-22 states cut HIV care and treatment programs
-17 states cut their contributions to AIDS Drug Assistance Programs
-25 states cut HIV prevention programs
The cuts mean more red tape and more waiting lists for people who need HIV care. It sometimes means that people must interrupt their HIV treatment — an extremely dangerous situation, as such interruptions mean an increase in drug-resistant HIV.

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Moreover, the old generation of health-care professionals caring for people with HIV is, well, getting older. And there’s only a trickle of young doctors in the pipeline.

One solution is “task shifting” — allowing trained nurse practitioners, physician assistants, psychologists, dentists, and others to perform tasks previously relegated only to doctors. Saag says this strategy has worked at his clinic, allowing it to double the number of patients treated.

But stretching current resources can only go so far. “It is worrisome. That is why the IOM report is so timely,” Saag says.

But Cleary says he and the other experts on the IOM committee are optimistic. He points to the National HIV/AIDS strategy as an important road map. And he says the committee was relieved at the passage of the Affordable Care Act, as an estimated 529,000 Americans with HIV are uninsured or underinsured.

A big step forward, Cleary says, would be coordination of state regulations to give health care providers flexibility in treating people with HIV. Also important is to find incentives for young doctors to choose primary care as a profession.

“We are a clever and caring nation. The amount of caring and concern on everyone’s part is just amazing,” he says. “HIV care providers aren’t in this for the money. But we should make it less of a burden on the providers and on the system to do this kind of work.”

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