As access to health care expands under the National HIV/AIDS Strategy (NHAS) and the Patient Protection and Affordable Care Act (ACA), a.k.a. health care reform, it is critical that the effective components of HIV management already in place be recognized and continued as health care delivery systems evolve and expand in coming years. To ensure that all people living with HIV benefit, write members of the HIV Medicine Association (HIVMA) and the Ryan White Medical Providers Coalition (RWMPC) in a new policy paper published by Clinical Infectious Diseases, innovative payment mechanisms and continued public health funding to support and expand specialized care will be necessary.

The threat to HIV-related health care is twofold, the authors suggest. A main goal of NHAS is to test more people for HIV, find those unaware of their status and get them into care. However, with ACA, it is unclear what will happen to earmarked funding for HIV services, such as the Ryan White program, which funds HIV care, treatment and support, for uninsured and under-insured people living with HIV in the U.S.

The Ryan White CARE Act is up for renewal in 2013, around the same time the full ACA regulations are scheduled to go into affect.

One particular concern raised is that the Ryan White program will be overhauled and that people living with HIV will be shifted out of, or steered away from, Ryan White-funded HIV clinics and into private medical practices or Medicaid-based community health centers lacking in HIV-specific expertise and services. In other words, while ACA hopes to provide health insurance for those who currently go without, which includes tens of thousands of people living with HIV, the quality of HIV care may suffer as a result.

“HIV medicine is an incredible success story, and people with the virus are now living long, full lives thanks to improved therapy and comprehensive care,” said Joel Gallant, MD, of Johns Hopkins University School of Medicine and lead author of the policy paper in an accompanying statement. “But it’s imperative that people learn their HIV status and get effective treatment. We have good strategies to achieve this, but it requires an integrated team approach, expertise, and a commitment to investing resources upfront that will reduce health care costs over the long-term.”

The president’s NHAS and the ACA are providing an unprecedented opportunity to expand access to health care shown to improve patients’ health and prevent new infections, the statement says. “But to turn this opportunity into reality, and to sustain the great gains made against this disease, it is critical that the essential components of HIV care be incorporated as health care reform is implemented. The U.S. government-funded Ryan White program has been critical to supporting the HIV care model, but as demand for care grows, innovative payment mechanisms for the Medicaid program, which covers 47 percent of people with HIV in care, are urgently needed. As health coverage is expanded, patients’ lives and our nation’s public health will be at risk if we do not build on the HIV care model and continue successful programs like Ryan White.”

The policy paper underscores that people living with HIV can have a nearly normal lifespan if they are diagnosed and receive effective treatment and care from an experienced HIV medical provider working with a team of other providers who can deliver the range of support services that most patients need.

As the NHAS and the ACA begin taking shape, various aspects of HIV care must be continued and expanded, including:

  • Routine HIV testing, particularly in underserved communities, so people with HIV can be diagnosed earlier and linked to integrated systems of care before irreversible harm is done to their immune systems.
  • A care team led by an HIV expert that includes a care coordinator and access to a range of specialists with HIV experience to treat serious co-occurring conditions, including heart disease, hepatitis, cancer, mental illness and substance abuse.
  • Access to HIV medications according to the federal treatment guidelines.
  • Counseling to support adherence to treatment and care.
  • Linkage to social services that address the daily living and psychosocial needs of patients.
  • Regular monitoring of patient outcomes through HIV quality measures and electronic health record systems.
  • Innovative payment mechanisms that recognize the total costs of providing effective HIV care, taking disease severity, nonclinical costs and other factors into account.
  • Continued public health funding through the Ryan White program to support lifesaving and disease-preventing care to the most vulnerable populations.

“The HIV provider is the quarterback, but care is effective only when there is full cooperation and coordination among the entire team, from diagnosis to treatment to supportive services,” said Mari Kitahata, MD, MPH, of the University of Washington at Seattle, in the accompanying statement. “When care isn’t integrated, people often drop out. More than a third of patients who learn they have HIV are not linked to care within three months of being diagnosed. That’s got to change, and we can change it if this model is followed.”