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EDITORIAL: Penalizing Success: Is Comprehensive HIV Care Sustainable?
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EDITORIAL
Kenneth H. Mayer and Sreekanth Chaguturu
Infectious Disease Division, Miriam Hospital, Providence, Rhode Island
Clinical Infectious Diseases Feb EPub 2006;42:000
At the outset of the AIDS epidemic in the early 1980s, the initial contact of many patients with the health care system was their hospitalization for life-threatening opportunistic infections. Death rates were unacceptably high, but so were the inordinate expenses for costly and recurrent inpatient stays, the need for frequently invasive diagnostic procedures, and polypharmacy with expensive antimicrobial agents [1]. The advent of HAART led to marked reductions in morbidity, mortality, and inpatient hospitalizations for people living with HIV infection, but as people have lived longer, new costs for optimal care have emerged [2, 3]. HIV care has increasingly become subspecialized, necessitating a cadre of well-trained providers who understand the optimal combinations of the >20 antiretrovirals now available for treatment, their side effects, and the complex interactions with the many other medications patients with HIV infection receive, ranging from cholesterol-lowering medications to antidepressants. HIV care providers also need to be specialists in strategies to optimize medication adherence and deal with common concomitant issues like substance abuse, and they need to be trained in techniques to decrease sexual risk taking [4].
The study by Chen et al. [5] of costs at the University of Alabama HIV clinic (published in this issue of Clinical Infectious Diseases) demonstrates some good news and some worrisome findings about the current state of HIV clinical care one-quarter of a century after the initial recognition of the epidemic. Chen and colleagues were able to clearly show that expert clinical management leading to improvements in patients' CD4+ cell counts is cost effective, with the annual costs of care for patients with CD4+ cell counts <200 cells/mL being $36,533 per patient and the annual costs of care for patients with CD4+ cell counts >350 cells/mL being only $13,885 per patient. Both of these figures are remarkable, compared with the "bad old days," when annualized costs of HIV care routinely exceeded $100,000 per patient [1]. For the sicker patients, inpatient hospitalization costs were the major source of expenses, whereas the average annual cost of HAART (about $10,500) for patients with higher CD4+ cell counts made up the bulk of their annual health care expenses. Because patents will expire for several antiretroviral drugs in the next few years (starting with zidovudine in the next year), the costs of many first-line regimens might be expected to decrease in the coming years, further accentuating the revolution in clinical care and attendant costs associated with HAART. On the other hand, as HIV-infected people live longer, some will need expensive new agents that target new steps in the viral life cycle, such as entry and integration, and common comorbid conditions may become clinically manifest (e.g., chronic liver disease and dyslipidemias with attendant atherogenic complications), each new issue necessitating increased costs to optimize patient quality of life and survival. So, the good news is that patient outcomes have improved along with a decrease in many patient care costs, but the future of continued success is not clear, given new expenses associated with optimizing the management of HIV infection as a complex, chronic disease.
Another concern raised by Chen et al. [5] was the inadequate support for the clinical care of HIV-infected patients, with only $359 per year going to physician costs (about 2% of the aggregate expenses for providing care to the 635 patients they followed up in 2000-2001). Over the past 2 decades, the paradigms for the ideal manner in which HIV care should be provided have been in flux, with some at the outset of the epidemic suggesting that all primary care medical providers should be able to manage HIV-infected patients, to decrease the stigma that has haunted the infection since its initial description in men who had sex with men and injection drug users. The cadre of the first front-line HIV care providers included generalists whose practices involved large numbers of men who had sex with men, physicians involved with addiction medicine, and academic infectious disease specialists, hematologists/oncologists, and immunologists. However, with the advent of HAART (entailing the need to know how to combine >20 antiretroviral drugs) and the emergent complications of long-term infection, partial immunosuppression, and long-term medication exposure, evidence suggests that patient outcomes are best if care is provided by physicians who are highly experienced in HIV care and/or have additional training beyond a grounding in primary care.
The increased specialization of HIV care has led to the creation several national and international organizations of HIV-focused health care providers. In recognition of the fact that there may be many paths to becoming an HIV specialist, the HIV Medicine Association (which operates under the aegis of the Infectious Disease Society of America) includes members with a diverse array of training experiences, including pediatricians, obstetricians/gynecologists, and family medicine providers, as well as infectious disease and other specialists [6]. The American Academy of HIV Medicine also serves a broad array of HIV care providers and offers a credentialing examination developed by leaders in the organization, enabling physicians and other health care providers to demonstrate their competence in HIV care [7]. The HIV Medicine Association has felt that approaching credentialing through the more established route (i.e., having the American Board of Medical Specialties approve the process for the development of an approved certification in HIV medicine by developing an examination overseen by an independent body) made the most sense.
Internationally, organizations like the International AIDS Society have helped to support the creation of national professional organizations of HIV specialists that are grappling with similar issues regarding training and credentialing [8]. Although the goal of the ambitious "3 by 5" initiative of the Joint United Nations Program on AIDS-to administer antiretroviral therapy to 3,000,000 people in the developing world by the end of 2005-was not met, there are now >1,000,000 people in low- and moderate-income countries being treated with HAART [9]. The prospects for further scaling up access to antiretroviral therapy and monitoring during the next few years are great, given the commitments of international donors through the Global Fund, as well as national initiatives, like the US government's Presidential Emergency Program for AIDS Relief. The increased availability of new resources for AIDS care creates an urgent necessity for enhancing professional training opportunities across the globe. There is also a pressing need to develop tools for the ongoing assessment of workforce capability and quality-of-care that address the challenges created by the diagnosis and management of increasing numbers of people living with a complex, chronic infectious disease that requires a panoply of antiretroviral and other medications.
The development of HIV/AIDS care as a medical subspecialty has many ramifications, including the need to support the training and career development of professionals who make a commitment to this vital clinical domain. Ironically, in the current era, the urgent need to support HIV care in the United States is in conflict with the tendency towards fiscal austerity in the health care sector, as one way to address a spiraling federal budget in the wake of the "war on terrorism" and natural disasters. There is a paradox developing that is well-illustrated by the interesting findings of the study by Chen et al. [5], that HIV-infected patients in the United States are faring better in the current care model then they fared earlier in this epidemic, and their health care is costing less and less. However, the actual amount of money being paid to their specialized HIV care providers is very small and is not commensurate with the increasing needs for specialized training. Moreover, because of the increasing US federal debt burden, the US Congress and the Bush administration are trying to squeeze vital programs, such at the Ryan-White Act and the Medicaid program, which are the main sources of funding for the complex, multidisciplinary care that HIV-infected patients need. Cutting physician reimbursement seems like an easy target [10].
It is important for the readership of Clinical Infectious Diseases to be as informed as possible about the latest political developments that could have an impact on HIV care. The reimbursement situation in many other industrialized nations is similar to that in the United States, in that governmental programs are increasingly scrutinizing budgets and attempting to hold down costs, with the possibility of compromising quality by not supporting the work force. This conundrum may become worse in resource-constrained environments, where the costs of generic antiretroviral medications and the necessary clinical monitoring will exceed the average annual per capita expenditures on health care. This may make policy makers think that one area in which they can control costs will be to limit training, provider reimbursement, and ongoing quality-of-care surveillance. This would be penny-wise and pound-foolish. So much has been accomplished in the past quarter of a century that guarantees opportunities for a fine life for HIV-infected people. It would be a shame to have the boulder roll back down the hill in a Sisyphean manner because of the lack of resolve by governmental authorities and international aid agencies to adequately support the increasingly sophisticated health care needs of a highly vulnerable patient population.
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