HIV-related medical service use by rural/urban residents: a multistate perspective.

Objective: Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites.

Methods: Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000).

Contemporary costs of HIV healthcare in the HAART era.

Background: The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.

Associations between outpatient and inpatient service use among persons with HIV infection: a positive or negative relationship?

Objective: To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions.

Data Sources: Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States.

Study Design: This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001.

Catalyzing system changes to make HIV care more accessible.

Although a comprehensive evaluation of the Care System Assessment Project is still several years off, the project quickly catalyzed changes in each of the communities in which it was piloted. All the sites found the system assessment model useful in identifying gaps in services. The project also clarified ways to engage underserved minorities in both care and planning for HIV care, and it helped to create community consensus in shaping initiatives to bring these populations into care.

Adapting RARE to assess barriers to service receipt among people out of care.

This paper describes the components of Rapid Assessment, Response and Evaluation (RARE), developed for HIV prevention planning; the adaptation of its methods to services planning; the venues in which the use of RARE was recommended for the present Care System Assessment Demonstration Project; constraints on what projects using RARE and the system assessment model may expect to accomplish; the focus of RARE questions for the project, concerning the characteristics of PLWH not in regular primary care, the care system as PLWH not in care perceive and experience it, and characteristics of the physical and social environments in which they live; how information from RARE can contribute to the enhancement of care systems; and the types of questions that sites could ask to gather RARE information for services planning.

The care system assessment model and its operationalization.

The care system assessment model is intended to help community planning bodies for HIV services conduct systematic evaluations of existing care systems, with an eye toward changing them to make services more accessible to people living with HIV (PLWH) from underserved minority communities. The model has four structural and three cultural/behavioral dimensions. The structural dimensions are system comprehensiveness, capacity, integration, and accessibility; the cultural/behavioral dimensions are service acceptability, technical competencies (of both providers and potential system users), and client health-seeking behaviors.

Background--the origins of the care system assessment demonstration project.

The Care System Assessment Demonstration Project was designed to assist community planning bodies in determining barriers to care for people living with HIV (PLWH) in selected underserved minority populations and generating recommendations for care system enhancement that would lower those barriers. This paper describes the selection of three sites to participate in the project and sketches the two primary tools used in implementing the project: Rapid Assessment, Response and Evaluation (RARE) techniques initially developed to assess community HIV prevention needs, and a system assessment model created to help communities conduct systematic evaluations of their HIV care systems. The paper also provides an overview of the remaining chapters of the supplement, detailing how the project was implemented at the national level and the three participating sites and evaluating both the project's process and its local impact.

CARE Act planning for unmet need.

The Ryan White CARE Act, a safety net program first enacted in 1990, provides health and support services to people living with HIV (PLWH) in the U.S. through several Titles.

Trends and responsiveness in national resource allocation for needed HIV services: a five year (1996-2000) analysis.

A recent study conducted by the Institute of Medicine concluded that there are approximately 1,200 to 1,400 avoidable deaths per year in the U.S. among people living with HIV (PLWH) who do not have health insurance (Institute of Medicine, 2002).

Using data to make decisions: planning HIV/AIDS care under the Ryan White CARE Act.

This article describes the challenges of using data to plan and fund HIV/AIDS care services for underserved populations under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. It also outlines methods that have been developed by the Health Resources and Services Administration of the U.S.

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

Background: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization.

Objective: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV.

Design: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002.

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001.

Background: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization.

Methods: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN).

Comorbidity-based payment methodology for Medicaid enrollees with HIV/AIDS.

Managed care organizations (MCOs) may be incurring financial losses from persons with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) (PWHA). This study developed a statistical model to examine which specific comorbidities are important contributors to the variations in health care costs of PWHA. Individuals were classified into cost groups to simulate biased selection in MCOs.

Ryan White CARE Act service use by Asian/Pacific Islanders and other clients in three California metropolitan areas (1997-1998).

The HIV epidemic disproportionately affects historically underserved members of racial/ethnic minorities. This paper compares HIV service use patterns for 653 Asians and Pacific Islanders (APIs) with those of other racial and ethnic minority clients (N = 28,201) at three selected Ryan White Comprehensive AIDS Resource Emergency (CARE) Act grantee sites in California. Study results show a relatively high proportion of APIs with advanced HIV disease.

The role of ancillary services in client-centred systems of care.

The studies in this issue reflect the operation of the Ryan White CARE Act's holistic model of health and support services for people living with HIV in the USA. Ancillary services available through the CARE Act are responsive to predisposing factors, enabling factors, and system characteristics that pose barriers to clients' receipt of primary medical care. That nearly all of the studies use cross-sectional rather than longitudinal data makes it difficult to draw causal inferences.

Associations between HIV-positive individuals' receipt of ancillary services and medical care receipt and retention.

This study examines associations between HIV-positive individuals' receipt of ancillary services and their receipt of and retention in primary medical care. Ancillary care services examined include case management, mental health and substance abuse treatment/counseling, advocacy, respite and buddy/companion services, as well as food, housing, emergency financial assistance, and transportation. The selection criterion used was the receipt of care from January-June 1997 at selected facilities receiving funding under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, a federally funded safety net programme in the USA.

Background for the studies on ancillary services and primary care use.

Timely and optimal HIV primary care is a key tenet of the Ryan White CARE Act, a safety net programme for vulnerable and marginalized people living with HIV in the USA. Health services researchers, local providers and policy makers suspect that ancillary services are necessary to improve entry into and retention in HIV primary care for vulnerable populations experiencing barriers to HIV services, including access to antiretroviral therapies. This paper provides background to the eight studies featured in this special supplement to AIDS Care.

Association of medical insurance and other factors with receipt of antiretroviral therapy.

Objectives: This study was designed to assess sociodemographic and medical insurer factors associated with receipt of highly active antiretroviral therapy (HAART).

Methods: Patients included (n = 959) were enrolled in the Johns Hopkins HIV Clinic after April 1, 1996, received > or = 90 days of care, and had a CD4 count > or = 500 cells/mm3 or HIV-1 RNA > 20 000 copies/mL. We assessed the associations of sociodemographic factors and medical insurance with receipt of HAART, stratified by 2 time periods (April 1996 through March 1997 versus April 1997 through March 1999).

Factors associated with delays in accessing HIV primary care in rural Arkansas.

While debate continues at what stage of human immunodeficiency virus (HIV) disease to begin combination antiretroviral therapy, a number of clinical and public health benefits are linked to early entry into primary care soon after first testing HIV positive. However, HIV-infected patients continue to test late and delay entry into care. We used routinely collected demographic and clinical information to examine which factors are associated with delays in seeking care in a predominantly rural, economically poor area of Arkansas.

Medicaid managed care reimbursement for HIV and its implications for access to care.

The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997.

Developing a managed care delivery system for people with HIV/AIDS.

Capitated managed care is now a significant part of the healthcare landscape in the United States. Consequently, states across the country are looking to it as a means of lowering their costs for Medicaid recipients. Implementing Medicaid managed care plans, however, requires considerable planning and research to ensure that providers are fairly reimbursed and that patients continue to receive quality care.

Health-based payment for HIV/AIDS in Medicaid managed care programs.

In recent years, State Medicaid programs have begun adopting health-based payment systems to help ensure quality care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and to ensure equity for the managed care organizations (MCOs) in which these people are enrolled. In this article, the authors discuss reasons why such payment systems are needed and describe AIDS-specific capitation rates that have been adopted in several State Medicaid waiver programs. The authors also examine comprehensive risk-adjustment systems both within Medicaid and outside the program.

Health-Based Payment for HIV/AIDS in Medicaid Managed Care Programs.

In recent years, State Medicaid programs have begun adopting health-based payment systems to help ensure quality care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and to ensure equity for the managed care organizations (MCOs) in which these people are enrolled. In this article, the authors discuss reasons why such payment systems are needed and describe AIDS-specific capitation rates that have been adopted in several State Medicaid waiver programs. The authors also examine comprehensive risk-adjustment systems both within Medicaid and outside the program.