HD17 - Development of Comprehensive HIV/AIDS Plan Pursuant to HJR 436
Executive Summary: BACKGROUND Ten years into the epidemic, acquired immunodeficiency syndrome (AIDS) continues to be devastating. Few other diseases result in as much physical, psychological and social deterioration. AIDS, caused by the human immunodeficiency virus (HIV), often strikes people in the prime of their lives. The human and economic costs to society are overwhelming. Although the disease was initially concentrated in men who have sex with men and injecting drug users, HIV has begun to affect others. While Virginia's efforts in responding to the HIV epidemic have been commendable, the epidemic is changing and continually presenting new challenges. Activities and programs have been initiated by the public and private sectors in response to the epidemic, without the benefit of a comprehensive long-range plan. The Joint Subcommittee Studying Human Immunodeficiency Viruses recommended that a comprehensive plan for AIDS be developed to cope with the epidemic. This comprehensive plan for HIV/AIDS is critical in providing guidance for future policy directions and resource allocations. HIV is transmitted by sexual contact; by blood injection (most often through needle sharing behavior during drug use); and from an infected woman to her fetus or infant. HIV affects the immune system, which is essential for fighting disease, leaving the individual susceptible to a host of opportunistic and other diseases. Typically, individuals are symptom-free for years before they become ill. There is a gradual increase in symptoms over a varying period of time. Approximately one-half of infected individuals will be diagnosed with AIDS within ten years after infection. The terminology "persons with HIV disease" is used in this document to depict individuals at any stage of this disease continuum from asymptomatic infection to illness. CHANGING TRENDS • As of August 5, 1991, 2504 cases of AIDS were reported in Virginia since reporting of AIDS began in 1982. • Between July 1, 1989 and August 5, 1991, there were 2255 HIV infections reported. • While 91% of AIDS cases in Virginia have occurred among men, the percentage among women has steadily increased over the last several years. • Although people of color comprise 23% of Virginia's population, they represent 41% of the AIDS cases. • The average age of reported AIDS cases is between 30 to 39 years. • Pediatric cases of AIDS represent 2% of the total cases reported, but the number is increasing. • Most AIDS cases report a transmission mode of men having sex with men (MSM). However, the percentage reporting MSM transmission has decreased from 71.0% in 1987 to 61.% in the first seven months of 1991, and the percentage reporting the transmission mode of injecting drug use has increased from 7.4% to 13.8% in the same time interval. • Although urban areas report the highest number of AIDS cases, the rural areas of the state are seeing an increasing number of cases. • Based on past trends, it' is projected that by the year 2000, as many as 120,000 Virginians may have HIV infection, with over 14,000 having AIDS. Further information concerning the current distribution and projected future number of cases of AIDS and HIV infection appears in Section II on page 11. PREVENTION SERVICES Extensive HIV-related knowledge, attitudes, and behavior surveys have been conducted in Virginia on a variety of populations. These surveys show that while most people are aware of how HIV is transmitted, many still have misconceptions about casual contact, and are not significantly reducing behaviors which place them at risk. While many educational programs have been effective, messages are often vague and individuals do not perceive that they are at risk. Additional outreach efforts are needed to reach these individuals to decrease future human and economic costs related to HIV. (See Section III on page 22). HEALTH CARE PROVIDERS Surveys of health care providers in Virginia conducted in 1988 and 1990 identified deficits in knowledge of HIV transmission and treatment as well as willingness to care for persons with HIV disease. Various programs targeted at recruitment, education, and attitudinal change have resulted in a decreased reluctance to treat HIV positive persons. Nonetheless, in 1990, 20% of physicians and nurses and 33% of dentists were still reluctant to treat HIV positive persons. (See Section IV on page 41). COUNSELING AND TESTING SERVICES Early knowledge of one's HIV status provides a critical opportunity to extend life through medical intervention. Through pre- and post-test counseling, an individual should be given sufficient information regarding the meaning of both positive and negative test results. While both confidential and anonymous testing are currently available in Virginia, surveys indicate that adequate pre- and post-test counseling is lacking in the private sector. (See Section V on page 53). PRIMARY CARE SERVICES The ability to access medical care at all stages of HIV disease is essential to prolong and enhance the quality of life. Resources for primary care for persons with HIV disease vary in each region, and are concentrated in more populated areas. Factors such as income, insurance coverage, and lack of transportation limit accessibility of services. Care for indigent, uninsured or underinsured persons is managed primarily by public health departments, hospitals, and volunteer agencies; in some geographic areas, this care is not available. HIV surveillance data indicate ongoing increases in morbidity, which may overwhelm publicly-funded health care systems. (See Section VI on page 58). INPATIENT SERVICES Virtually all persons with AIDS will experience episodic hospital care during the end stage of their illness. There is no current or projected future shortage of hospital beds for AIDS patients; however, access is dependent upon payment source and/or location of the facility. Demands for inpatient care will be greatest for Virginia's teaching hospitals and those with a high indigent caseload. (See Section VII on page 64). LONG-TERM CARE SERVICES Persons with HIV disease will usually require long-term supportive care both in the outpatient and inpatient setting. Situations occur in which an AIDS patient must be placed in a long-term care facility. There is a reluctance in Virginia and nationwide on the part of long-term care facilities to accept individuals with HIV disease. As of November 1991, only three long-term care facilities in Virginia are known to have admitted persons with HIV disease. (See Section VIII on page 68). MENTAL HEALTH SERVICES Many individuals with HIV disease experience at least some difficulty with psychological or neuropsychiatric conditions. Because mental health services may be needed at any point in the illness, an array of programs is necessary to assist all people affected by HIV disease. Mental health services exist throughout Virginia, but not in adequate amounts to meet the needs of all clients. In addition, staff often lack training in the mental health needs of people with HIV disease. (See Section IX on page 71). SUBSTANCE ABUSE SERVICES Injecting drug abusers (IDUs) constitute the second largest transmission category for HIV disease. Innovative approaches to education as well as adequate treatment programs are essential. Access to treatment for IDUs is inadequate. Other substance abusers are also at risk for transmission because they may engage in high-risk behaviors when under the influence of chemicals. (See Section X on page 74). CASE MANAGEMENT/SUPPORT SERVICES Case management provides the person with HIV disease with a link to services. Most case management services are being provided through hospitals, AIDS Service Organizations and community-based organizations. There is a significant shortage of case managers to serve the needs of individuals with HIV disease. Many specialized services are needed to reach underserved populations. (See Section XI on page 77). HOUSING The housing needs of an individual with HIV disease can be complex and may include hospice care, transitional housing care and in extreme cases, shelter care. Approximately six percent of the homeless are infected with HIV disease. A significant number of persons with HIV disease are at risk of becoming homeless due to the financial demands of HIV disease management. There are limited housing resources available to these individuals. Current local and state regulations make it very difficult for community-based organizations to open and operate transitional houses or hospices. (See Section XII on page 81). FINANCING Based on projections derived from national cost of care data, the economic impact of HIV/AIDS in Virginia for direct patient care alone during the period 1991 - 2000 is projected to exceed five billion dollars. Indirect costs including lost earnings, decreased productivity and increased psychological burdens are incalculable. The annual per patient cost for direct medical care in 1991 is estimated to be $5,614 for persons with HIV and $34,880 for persons with AIDS; these costs are expected to double by the year 2000. The extent of current and expected funding for patient care will not meet projected needs. Often, persons with HIV and AIDS are denied or lack access to adequate third party coverage or become uninsured during the course of illness; some of these persons have no access to medical care. Medicaid and Medicare fail to provide coverage of all persons lacking benefits. (See Section XIII on page 84). RECOMMENDATIONS The Task Force has developed recommendations aimed at preventing HIV infection and improving the provision of services for persons with HIV disease. A summary of priority recommendations follows. A complete listing of all recommendations appears in each of the sections previously referenced. PREVENTION SERVICES 1. Improve education/information campaigns by using television, radio and print media. 2. Target prevention messages and outreach efforts to specific populations (e.g., general public, men who have sex with men, injecting drug users, people of color, adolescents, women, and inmates) and involve affected populations in the development of activities. 3. Include sexuality, substance abuse, and self-esteem issues as core components of comprehensive school health instruction. 4. Develop and strengthen organizations responding to HIV issues in communities of color. 5. Train, reward, and support HIV prevention education workers more effectively. 6. Consistent with the recommendations of the National Commission on AIDS, consider any approach that can be shown to be effective in slowing transmission of HIV among IDUs. 7. Expand funding for the AIDS Services and Education Grants Program established by the 1989 General Assembly through House Bill 1974. HEALTH CARE PROVIDERS 1. Continue and expand Regional AIDS Resource and Consultation Center (RARCC) programs, including counseling and testing training courses, which are offered in conjunction with the Department of Health. 2. Incorporate HIV/AIDS education into professional continuing educational programs and professional health care schools. 3. Elicit professional society support for increased Willingness of health care providers to care for those with HIV disease and their families. 4. Increase access to clinical components of training for health care providers regarding management of HIV infection through the RARCCs and health care professional schools. 5. Endorse recent CDC "Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures". Emphasize the necessity for all health care providers to utilize universal precautions with all patients and adopt adequate infection control policies in the work setting. COUNSELING AND TESTING SERVICES 1. Assess and change anonymous test site (ATS) locations where appropriate to improve geographic accessibility. A greater effort must be made to target voluntary testing campaigns toward people of color. 2. Provide CD4 cell count testing in each ATS and public clinic where screening is taking place at the time of post-test counseling. 3. Increase Division of Consolidated Laboratory Services staff to decrease the current 2-3 week wait for positive test results. 4. Expand the staff of the HIV antibody testing and counseling program in drug treatment centers throughout the state. PRIMARY CARE SERVICES 1. Provide access to laboratory tests needed in the evaluation of HIV/AIDS and its complications and establish a central purchasing system (through the provision of funds or pharmacy services) for medications needed by indigent patients. 2. Develop an outreach health care model for providing primary care services to HIV/AIDS patients. INPATIENT SERVICES 1. Enhance outpatient services to decrease the need for hospitalization. 2. Increase State and Local Hospitalization (SLH) funds to the necessary funding level to cover the number of indigent HIV/AIDS patients being treated. LONG-TERM CARE SERVICES 1. Provide respite care programs designed for AIDS patients in addition to traditional hospice care. 2. Ensure access to nursing home beds for persons with HIV disease. Nursing homes must be in compliance with existing civil rights laws and aware of the consequences of violating these laws. MENTAL HEALTH SERVICES 1. Expand public mental health services to alleviate lengthy waiting periods for clients with HIV disease and to address their numerous psychosocial and neuropsychiatric problems. 2. Incorporate HIV education and information into mental health inpatient and outpatient treatment. SUBSTANCE ABUSE SERVICES 1. Ensure that substance abuse treatment is available on demand. 2. Ensure that every client in a substance abuse treatment program receives HIV risk assessment, appropriate education, and counseling. 3. In collaboration with other human resource agencies, develop additional community-based treatment programs. Specifically designed for women, adolescents, IOUs, and inmates which address substance abuse and HIV issues. 4. Promote the identification of IOUs with HIV disease and ensure access to primary care services through improved linkages between primary care and substance abuse treatment. CASE MANAGEMENT/SUPPORT SERVICES 1. Expand comprehensive, effective case management and support services for persons with HIV disease. Services should be specialized to meet the diverse needs of specific populations. 2. Regional Care Consortia should assume a leadership role in coordinating case management among agencies in their regions. Data collection and analysis should be conducted in an effort to establish a statewide data base. 3. Expand the recruitment and training of volunteers. HOUSING 1. Increase the number of housing units available to the disabled through the offices of the Virginia Housing and Development Authority and the U. S. Department of Housing and Urban Development. 2. Increase options such as transitional housing for the homeless with HIV disease by utilizing the expertise of existing groups providing health care for the homeless, along with the Virginia Housing and Development Authority. 3 . Require non-discriminatory access to transitional housing, hospices, and emergency shelters for individuals, including those with HIV disease. FINANCING 1. It is important to place the problem of health care financing for HIV/AIDS into a larger context. Universal health care coverage should be provided for all persons living in the U. S. to assure access to quality health care services. 2. Until universal health coverage is provided, pursue interim options including establishment of a premium buy-in program and risk pools. 3. The U. S. Congress should fund the Ryan White Care Act at its fully authorized level. 4. Increase direct state appropriations necessary to implement the recommendations contained within this plan. At a minimum, state allocations should increase proportional to the change in the number of reported cases of HIV/AIDS. EVALUATION/MONITORING 1. The Department of Health should present annually to the Joint Subcommittee Studying Human Immunodeficiency Viruses, a brief status report on the implementation of the recommendations contained within this plan. Due to the dynamic nature of the HIV epidemic, this report should also provide any significant new information on HIV/AIDS and any new recommendations which might derive from this information. 2. There should be an increased awareness of and focus on the evaluation of HIV/AIDS prevention, services, and treatment. |
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