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S U P P L E M E N T A R T I C L E
Ensuring Access to Treatment for HIV Infection
Laura W. Cheever,1Christine Lubinski,2Michael Horberg,3and Judith L. Steinberg4
1HIV/AIDS Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland;
Association, Alexandria, Virginia;
4Neponset Health Center, Dorchester, Massachusetts
3HIV/AIDS Policy, Quality Improvement, Research, Kaiser Permanente Federation, Oakland, California; and
The recent recommendations of the Centers for DiseaseControlandPreventionforopt-outtestingareintended
to address the evolving human immunodeficiency virus (HIV) epidemic in the United States by bringing more
HIV-infected individuals into medical care. This is an important step to better control the epidemic but brings
with it the challenges of adequately caring for more individuals infected with HIV and of funding medications
and medical care for these additional patients. With more patients being offered HIV testing, there will be a
surge in the need for testing and counseling services, which must keep pace with patient demand. This article
describes the current status of HIV screening and care from 4 perspectives:theRyanWhiteProgram(previously
known as the Ryan White Comprehensive AIDS Resources Emergency Act), Medicaid and Medicare reim-
bursement for HIV screening, a managed care organization, and community health centers. The mandate for
if routine HIV screening is to become a reality.
Health policy experts, medical providers (i.e., health
care professionals, health care institutions, and third-
party payers), government officials, and community
members recognize the importance of integrating pro-
grams to prevent HIV infection into the clinical care
setting and of identifying opportunities to reach per-
sons at risk for or living with HIV infection when and
where they interact with the health caredeliverysystem.
However, programs to prevent HIVinfection,including
risk assessment and prevention education and coun-
seling, are not a routine part of clinical care in the
United States. Researchers have increasingly examined
some of the barriers to implementing such programs.
These barriers include the many legal, financial, and
organizational factors that guide or inhibit policy and
clinical decision making. Attention to these factorsmay
Presented in part: Opportunities for Improving HIV Diagnosis, Prevention &
Access to Care in the U.S., Washington, D.C., 29–30 November 2006.
Reprints or correspondence: Dr. Laura Cheever, HIV/AIDS Bureau, Health
Resources and Services Administration, Ste. 7-05, 5600 Fishers Ln., Rockville, MD
Clinical Infectious Diseases2007;45:S266–74
? 2007 by the Infectious Diseases Society of America. All rights reserved.
provide additional opportunities for enhancing activi-
ties to prevent HIV infection.
We describe prevention strategies from the following
variety of health care–associated perspectives: the Ryan
White Program (RWP), previously known as the Ryan
White Comprehensive AIDS Resources EmergencyAct;
Medicare and Medicaid reimbursement of HIV screen-
ing; the managed care program of Kaiser Permanente
(KP); and community health centers (CHCs). Each of
us represents one of these perspectives, and we suggest
processes that could increase and improve opportu-
nities for integration of HIV prevention and medical
care, including development and dissemination of in-
tegration models, review of financing and coveragepol-
icies by federal agencies, development of federal guid-
ance on integration, and investigation of possible
support services that could facilitate integration.
INCREASED HIV TESTING:
CHALLENGES TO RWP RESOURCES
The RWP was enacted on 18 August 1990 as a federal
program designed to improve the quality and avail-
ability of medical care for persons with HIV/AIDS who
are uninsured or underinsured . The RWP was
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Ensuring Access to HIV Care • CID 2007:45 (Suppl 4) • S267
Table 1. Ryan White Programappropriationsforfiscalyear2006.
Program Appropriation, US$
State base award
AIDS Drug Assistance Program
AIDS Education Training Centers
White Programwas previously knownastheRyanWhiteComprehensiveAIDS
Resources Emergency Act.
Descriptions of each program are specified in the text. The Ryan
amended and reauthorized in 1996, 2000, and December 2006
(HIV/AIDS Bureau, informational e-mail). Funding levels are
determined annually by the federal budget.
The RWP is administered by the Health Resources and Ser-
vices Administration (HRSA), which is within the Department
of Health and Human Services. It provides federal funding to
support medical care and essential support services to persons
living with HIV infection who do not have themeanstoacquire
these services on their own. The intent was to offer a safety
net for medically underserved populations, and indeed it has
been an important resource for persons who have no insurance
and/or a low income.
The RWP is a discretionary program rather than an entitle-
ment; that is, the annual funding is based on the will of Con-
gress. In contrast, Medicaid is an entitlement,andfundingfrom
this program is guaranteed to be at a certain level. The RWP
is the only domestic, disease-specific discretionary grant pro-
gram that provides funding for medical care for people with
The RWP builds on the resources provided by Medicaid and
fills gaps in terms of eligibility and services. In stateswithmore-
generous Medicaid programs, RWP dollars go much further to
fill unmet needs and can supplement Medicaid in a much more
complete way. As state Medicaid programs shrink or change,
funding from the RWP should shift to fill critical gaps. Ad-
ditionally, a central tenet of the RWP is that decisions about
how to allocate funding are made at the state and local level.
Most funding to cities and states is distributed by formulas
based on the prevalence of HIV/AIDS in their population.
The RWP provides comprehensive primary care, support
services, and medications. The statute funds a broad range of
services because of the recognition that to ensure access to and
retention in care for truly disenfranchised individuals, it is es-
sential to provide services, such as case management, trans-
portation, and other support services, that help link these in-
dividuals to care.
The RWP as amended is a complex piece of
legislation that consists of several Parts. These include Parts A–
D and Part F.
In fiscal year 2006, RWP appropriations were distributed as
shown in table 1. In 2006, most of the funding was distributed
through formulas based on the prevalence of AIDS; in 2007,
the formulas used data on the prevalence of HIV infection
without AIDS and the prevalence of HIV infection with AIDS.
Part A funds are directed toward cities heavilyaffectedbyAIDS.
Funding priorities and allocation decisions traditionally have
been made by local planning councils. Part B grants are des-
ignated for states and territories and fund health care and sup-
port services for persons with HIV/AIDS. These grants include
the AIDS Drug Assistance Program (ADAP), a program that
provides medications to persons with HIV/AIDS . Part C
funding supports community-based programs, including local
health departments, programs for homeless persons, CHCsand
migrant health centers, and hemophilia centers, that provide
primary HIV care and support services. Part D provides fund-
ing for health care and support services for children, adoles-
cents, women, and families via comprehensive, community-
based care systems or networks of care. Part F provides
competitively awarded grants for Special Projects of National
Significance, which support the development of innovative
models of HIV/AIDS care, particularly for hard-to-reach pop-
ulations. Past initiatives have focused on examining outreach
programs, increasing health care capacity along the border be-
tween the United States and Mexico, improving treatment ad-
herence, and using technology to improve medical care. Part
F also includes a small dental program and the AIDS Education
and Training Centers program.
Funding has changed with the advances in HIV treatment
and changes in the epidemic since 1991 (figure 1). Since the
advent of HAART in 1996, Congress has allocated increasing
amounts of money to ADAP, with almost 40% of RWP funding
directed to ADAP in 2006. Funding for Part A, which is al-
located to cities, also increased through the 1990s. In the past
few years, most of the RWP programs have received small cuts
as mandated by across-the-board Congressional rescissions.
RWP spending has been heavily weighted towardmedication
and medical care. In 2005, forty percent of RWP spending was
allocated to ADAP, 3% to other medication programs, 25% to
medical care, 7% to case management, and 10% to support
More than half a million people are
served by the RWP annually, including HIV-negative children
born to HIV-positive women. The RWP provides lifesaving
medications to almost 150,000 persons. The RWP has reached
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by program, during fiscal years 1991–2006. Because of Congressionally mandated rescissions on the budget for the last several years, appropriations
for all programs except the AIDS Drug Assistance Program (ADAP) are decreasing. Data are from . AETCs, AIDS Education and Training Centers.
Appropriations history of the Ryan White Program (previously known as the Ryan White Comprehensive AIDS Resources Emergency Act),
the targeted populations: 72% of its clients areracialminorities,
33% are women, and 79% are uninsured, underinsured, or
receiving other public health benefits.
Demand for RWP services is increasing with-
out significant increases in new resources, and medical care
costs continue to rise. As more HIV-positive persons are iden-
tified, the burden on the RWP will become greater. The RWP
has continued to prioritize primary care services for these per-
sons. HRSA has worked closely with ADAPs to ensure that
medications are purchased at the lowest possible cost, as de-
termined by the Section 340B Drug Discount Program ,
which limits the cost of covered outpatient drugs to certain
federal grantees, federally qualified CHC look-alikes, and qual-
ified disproportionate share hospitals, and to improve ADAPs’
efficiency. For example, state ADAPs have achieved consider-
able cost savings by working more closely with Medicaid to
ensure that all qualified patients are funded through Medicaid.
It is important thatsupportservicesforHIV-infectedpersons
continue to be funded as the health care environment places
greater emphasis on medications and medical services within
the RWP. Multiple studies have demonstrated the strong re-
lationship between support services and retention of patients
in medical care. For example, Sherer et al.  conducted a
retrospective analysis of clinical data sets on 2647 patients at
the Cook County HIV Primary Care Center in Chicago during
1997–1998 to investigate the relationship between access toand
retention in HIV primary care and the following 4 support
services: case management, transportation, mental health, and
chemical dependency. They reported that patientswhoreceived
support services were significantly more likely to receive any
care or regular care and had more clinic visits than patients
who received none of the services. In addition, retention in
medical care increased by15%–18% after1yearamongpatients
who received support services (figure 2). Thus, the increasing
pressure on the RWP to fund services for more people may
mean that fewer support services are provided and that a
smaller proportion of patients are retained in care.
ROUTINE HIV TESTING IN HEALTH CARE
SETTINGS: MEDICARE AND MEDICAID
recently Congress moved to increase the number of preventive
services available to Medicarebeneficiaries.Currently,Medicare
covers screening procedures for cardiovascular disease, breast
cancer, colorectal and prostate cancers, diabetes, glaucoma, ab-
normal cervical and vaginal conditions, and bone density but
not for HIV infection. Recent Medicare Part D legislationman-
dated that Medicare include coverage for a preventive physical
examination . Although this mandate affords some oppor-
tunity to discuss HIV risk reduction and testing, Medicaredoes
not reimburse for HIV screening. Many of the screening tests
in Medicare as well as Medicaid are linked torecommendations
from the US Preventive Services Task Force (PSTF), which has
not yet recommended population-based screening for HIV in-
fection . The lack of a recommendation by the PSTF could
pose a barrier for some payers.
Medicare covers few preventive services, although
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Ensuring Access to HIV Care • CID 2007:45 (Suppl 4) • S269
after 1 year, by support service received or not received. Adapted with
permission from the following article published by Taylor & Francis Ltd.:
Sherer R, Stieglitz K, Narra J, et al. HIV multidisciplinary teams work:
support services improve access to and retention in HIV primary care.
AIDS Care 2002;14(Suppl 1):S31–44.
Percentage of HIV-infected patients retained in medical care
ical care, by program, during fiscal year 2005. Data are from [7, 8].
Federal spending in billions of US dollars on HIV/AIDS med-
The current recommendations for HIV screening from the
CDC, discussed extensively elsewhere in this issue, focus on
testing for individuals aged 13–64 years. The overwhelming
majority of Medicare beneficiaries are 165 years old, but there
are 6.8 million current Medicare beneficiaries who are disabled
and !65 years old, including ∼100,000 people living with HIV/
Medicaid is far more relevant in the discussion
of HIV screening. It is the major health care program for 55
million low-income Americans. It does not cover all low-in-
come people, and it does not provide coverage to most single
adults, including all men who have sex with men and women
by AIDS or some other condition. Thus, Medicaid does not
cover medical care for many persons who would likely benefit
from HIV screening. It is, however, thelargestpayerformedical
care received by persons with AIDS (figure 3) [7, 8]. Kates 
noted that ∼20% of persons in whom HIV infection is diag-
nosed are eligible for Medicaid at the time of diagnosis, sothere
is an opportunity to identify many low-income persons with
HIV infection who are already Medicaid beneficiaries but are
unaware of their positive HIV serostatus.Federallawdoesallow
HIV screening to be covered, either in a fee-for-service or a
managed care context, by Medicaid; however, it is an optional
service, as is prescription drug coverage. Routine HIV testing
has not been widely adopted by state Medicaid programs; one
exception is New Jersey, where the percentage of persons re-
ceiving Medicaid through managed care plans is high. New
Jersey also provides increased capitation for AIDS care, so as
not to createadisincentivetoidentifyHIV-infectedpeople.
In the absence of risk-adjusted capitation for HIV care, man-
aged care plans have little incentive to identify persons infected
with HIV; these plans are structured in the hope that HIV-
infected people are identified at another time, when fundsfrom
an alternative plan are available.
Currently, Medicaid programs in 32 states cover HIV testing
and counseling in some fashion; 19 cover prenatalandperinatal
HIV counseling and testing . However, routine testing is
not covered at a broad range of sites: only 3 states reimburse
anonymous or confidential testing sites for HIV tests .
CHCs are going to be very important targets for imple-
menting the CDC’s HIV testing recommendations. All states
must provide federally qualified health center (FQHC) services
in their Medicaid programs. These FQHCs are required to
screen for communicable diseases; however, HRSA has not yet
included HIV screening as part of this requirement.There-
fore, a major challenge is to encourage states and communities
to implement HIV screening and fill in the gaps in federal
policy. California uses a family planning waiver to reimburse
for HIV testing and counseling for persons with incomes up
to 200% of the federal poverty level and for women of child-
bearing age, but this was a very special waiver and is probably
not a model that can be adopted elsewhere.
States may also offer a Medicaid-financed diagnostic,screen-
ing, preventive, and rehabilitative option. This broadens the
definition of “medical necessity” to allow coverage for preven-
tive services, such as HIV screening. For example, in Massa-
chusetts, a service is considered to be medically necessary if it
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S270 • CID 2007:45 (Suppl 4) • Cheever et al.
health maintenance organizations, 2006.
Demographic characteristics of HIV-infected members of the Kaiser Permanente–Group Health Cooperative
Region or program
members, no. (%)
were female, %
were black, %
were Latino, %
covered, total no.
Group Health Cooperative
cases are still gay white men, the numbers of HIV-infected black and Latino persons are increasing. The percentage of HIV-infected women has
remained steady. NA, not available.
Some data are estimates. Data are from an unpublished internal communication from Kaiser Permanente. Although the majority of
ening of, alleviate, correct, or cure conditions in the member
that endanger life [or] cause suffering or pain” .
The New Jersey Medicaid Managed Care Contract contains
strong language stipulating that contractors are required to
cover HIV screening and care. Contractors must provide pre-
vention services for all enrollees and must address the special
needs of HIV-infected enrollees. The contractor’s plan must
establish methods of promotingHIVpreventiontoallenrollees,
methods for accommodating self-referral and early treatment,
a process to facilitate access to specialists and/or include HIV/
AIDS specialists as primary care physicians, methods for ed-
ucation about HIV/AIDS riskreduction,andaprocessbywhich
HIV/AIDS testing and counseling can be accessed . Man-
aged care organizations are required to offer counseling and
testing and are required to report on how many people they
counseled and tested.
The Florida Medicaid Program contains provisionsrequiring
that pregnant women be offered counseling and testing at the
initial prenatal care visit and again 28–32 weeks later. This has
been broadened to require the provider service network to
target all women of childbearing age—not just those who are
pregnant—for HIV counseling and testing .
Financing for implementation of HIV guidelines.
CDC regulations for HIV testing are to be implemented,federal
financing is essential for both testing and medical care. The
relatively modest amount of discretionary funding through
CDC, RWP, and state and local health departments will not be
adequate to implement population-based HIV screening.Med-
icaid, with its significant reach into low-income populations,
especially the women, adolescents, and ethnic and racial mi-
norities in these populations, must be part of the financing
mix, and federal leadership could and should facilitatecoverage
of routine screening by state Medicaid programs.
However, there are significant challenges to Medicaid fi-
nancing of routine HIV testing. The Center for Medicare and
Medicaid Services and the current presidential administration
have little commitment to expanding the Medicaid program,
particularly the federal contribution. Furthermore, state bud-
may limit allocations for HIV screening, particularly in states
where the prevalence of HIV infection is low. Finally, many
community AIDS advocates who work at the state level do not
support the new CDC guidelines. They may discourage the
adoption of routine HIV testing and raise barriers to reallo-
cating funds for routine testing by states.
It is hoped that the new recommendationsof
the CDC that call for routine HIV screening of all adults and
adolescents in US health settings [14, 15] will lead to stronger
recommendations from the US Preventive Services Task Force
, which limits its current recommendation to persons at
“increased risk” for HIV infection. A recent analysis  sug-
gests that, from both the clinical and economic perspectives,
the benefits of routine HIV testing in all adults in the United
States outweigh the likely harms. If the CDC recommendations
are to be implemented, however, Medicaid will take on a large
proportion of the added costs. Federal leadership is essential
care under Medicaid and through FQHCs, which are not cur-
rently required to provide HIV counseling and testing to in-
dividuals who present for medical care and services.
DELIVERING ON THE PROMISE:
THE MANAGED CARE VIEW
KP is the largest staff-model health maintenance organization
(HMO) in the country. It has 19 million members and cares
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for ∼3% of the US population. This managed care organization
offers a wide variety of care plans, although most members are
enrolled in a more traditional integrated HMO care plan. Most
members receive their KP insurance coverage through their
employer or through another family member’s employment
or Medi-Cal HMO plans; some members receive KP care
through individual or small-group HMO plans.
KP is the second largest integrated care provider for HIV
care in the country, after the Veterans Administration system.
There are 116,000 members presently under care who are in-
fected with HIV, ranging from 180 HIV-infected patients in
Ohio to nearly 5500 HIV-infected patients in northern Cali-
fornia. The members include individuals enrolled in Group
Health Cooperative (GHC), KP’s “sister” organization head-
quartered in Seattle.
KP has adopted a specialty model of HIV care, with 1100
health care professionals caring for all of the HIV-infected pa-
tients. Only ∼200 HIV-infected patients are aged ?19 years.
KP has 1100,000 total patient-years of experience with HIV
infection; the mortality rate among HIV-infected KP member
is !2%, compared with a national average of 3.4% (KP, internal
The demographic characteristics of the KP HIV-infected
population are shown in table 2 and vary greatly from region
to region. Although 33 states have reported statistics on HIV
infection to the CDC for at least 4 years, KP mainly serves
states not part of this reporting structure. Therefore, the de-
mographic characteristics of the KP patient pool are different
from the national data reported by the CDC. At KP, HIV in-
fection remains largely a disease of men who have sex with
men, and a majority of HIV-infected members are white.How-
ever, the number of black HIV-infected members is increasing.
Likewise, the number of HIV-infected Latino members is in-
creasing, particularly in California. The percentage of HIV-
infected women has remained steady at 16%.
Specialty model of HIV medical care.
multidisciplinary care model that affords more-organized and
more-comprehensive care, and many of the hidden costs of
treating HIV infection are subsumed within the overall cost of
providing care. Although there may be variation between spe-
cific KP and GHC medical centers, the multidisciplinary HIV
treatment team usually includes an HIV specialist (usually an
infectious diseases specialist or internal medicine or family
medicine specialist with experience in treating HIV disease;
many of these professionals have HIV Medicine Association or
American Academy of HIV Medicine certification),acaseman-
ager (a professional with an RN, PharmD, or MA degree),
clinical pharmacy support, a social worker with or without a
benefits coordinator, mental health support, a health educator,
and, for larger coverage regions, a regional coordinator. If in-
The KP HMO is a
creased HIV testing is to take place, as recommended by the
CDC, health educators and care coordinators will become in-
creasingly important in alleviating the burden of pretest and
posttest counseling on busy primary care facilities.
Clinical findings of the specialty model of HIV care.
At the time of diagnosis, many patients meet the diagnostic
criteria for AIDS, suggesting that case finding needs improve-
ment. However, once HIV infection is diagnosed, 190% of
infected individuals receive medical care within 120 days, and
most receive care within 30 days. Among patients receiving
HAART, 180% have viral loads belowthelimitofquantification
(defined as !75 HIV RNA copies/mL). More than 74% of HIV-
infected patients have a history of HAART use, and 170% have
received HAART in the past year. More than 60% of patients
presently have a CD4 cell count of 1350 cells/mL. Most im-
portant, once patients receive access to care, no significant dif-
ferences in the quality of care or clinical outcome are apparent
by sex, race, or ethnicity.
HIV antibody testing.
Most states in which KP provides
services still require that the patient provide informed consent
before undergoing HIV testing. For all diseases, KP differen-
tiates screening from testing. Screening is defined as testing
without counseling, which, for example, might involve sending
out a massive mailing with a form that patients taketoascreen-
ing center, where their cholesterol and blood sugar levels are
measured. This is not an appropriate method by which to de-
termine whether HIV is present in an individual. Testing for
HIV includes pretest and posttest counseling and patient ed-
ucation. Testing as defined here is the desired norm for KP and
KP’s policy is that HIV antibody testing is a process; it does
not consist simply of the test itself. Testing should be part of
routine primary care, but it has to be done within the context
of a discussion of risk behavior, sexuality, harm reduction, and
testing for other sexually transmitted diseases. The appropriate
frequency of testing and counseling may be determined on an
individual basis, but testing only once in a patient’s life is
probably not sufficient, because risk behaviors and sexual ex-
pression change over the course of adulthood and require that
a patient be reevaluated over time.
Rapid HIV testing is currently being used mainly during
labor and delivery and after episodes of occupational exposure.
However, as rapid testing becomes more accepted, its use by
KP will likely increase accordingly.
KP performs 1340,000 antibody tests annually. In KP’s pre-
natal care program, 190% of women are tested. However, KP
treats nearly 9 million patients, and 16 million members fit the
CDC testing recommendations. Therefore, only ∼15% of the
targeted KP members have been tested in the last 5 years,
assuming each patient was tested only once; a KP biostatician
suggested that ∼8% of the KP pool has ever been tested (KP,
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S272 • CID 2007:45 (Suppl 4) • Cheever et al.
million uninsured patients in 2004. EDs, emergency departments; OPDs,
outpatient departments. Data are from .
Sites of ambulatory care, by percentage of all visits, for 70
unpublished data). Thus, to adhere with the new CDC guide-
lines, KP would have to perform 15 million additional tests,
which will have a dramatic effect on the cost of care. With the
prevalence of HIV infection in the KP population at ∼0.3%,
routine HIV testing would identify nearly 1773 new cases. This
would likely cost an additional $26,599,450 per year for care,
assuming all patients with newly diagnosed HIV infection re-
ceived antiretroviral drugs at a cost $15,000 per patient per
Policies of other managed care organizations.
to KP, most other managed care organizations follow PSTF
recommendations , which propose screening for HIV in all
adolescents and adults at increased risk for HIV infection and
in pregnant women but do not comment on routine screening
for HIV in adolescents and adults who are not at increased risk
for HIV infection. These recommendations must be reconciled
with the CDC recommendations . Most managed care or-
ganizations support targeted testing. Thus far, most managed
care organizations have not revised their policies to accordwith
the new CDC recommendations, and new PSTF recommen-
dations do not include universal testing.
KP plans to implement more-comprehensive testing but is
examining the implications. Antiviral medication is now the
largest line item in the pharmacy budget in the larger KP
regions, where it surpasses the cost of statins and antihyper-
tensive agents. Very few generic drugs are approved in the
United States, and most probably would not meet the current
paradigm of care. Although KP is confident that it can accom-
modate all of the patients with newly identified HIV infection,
HIV testing without counseling is inconsistent with the pre-
ventive health management philosophy at KP.
ENSURING ACCESS TO CARE:
THE CHC PERSPECTIVE
CHCs are a major component of the safety net for our nation’s
health care system. CHCs are located in high-need areas, and
their mission is to provide comprehensive health and related
services to all residents in their community, regardless of the
residents’ ability to pay. CHCs are governed by community
boards to ensure that the community has control over the
direction and vision of the services provided. CHCs have been
successful in reducing health disparities, with few or no dis-
parities existing among CHC users. They are also effective in
treating patients with chronic diseases. CHCs meet or exceed
nationally accepted practice standards for the delivery of
chronic disease care. CHCs are located in all 50 states and
territories. They provide one fourth of all ambulatory care for
uninsured patients (figure 4) . This is crucial, considering
that infection in 250,000–300,000 HIV-infected persons has yet
to be diagnosed. Most of these patients with undiagnosed HIV
infection will likely be uninsured and disenfranchised and will
seek out CHCs to undergo HIV testing and receive medical
HIV testing andmedicalcare.
ulation. The seropositivity rate at CHCs is 2.4%, compared
with 1.2% at all other CDC-funded sites (table 3) (CDC, un-
published data). Even for clients at high risk for HIV infection
(i.e., injection drug users and men who have sex with men),
the seropositivity rates at CHCs are higher than those for all
other CDC-funded sites. Fortunately, 95% of all patientsreturn
to CHCs for their test results. This is the highest return rate
of all CDC-funded HIV testing sites.
Approximately 75,000 HIV-infected patients receive their
medical care at CHCs. More than 400,000 users of CHCs have
received an HIV test, and nearly 700 pregnant HIV-positive
women have received their care at CHCs (Uniform Data Sys-
tem, unpublished data).
Many CHCs receive funds from Part C of the RWP; one-
third of Part C grantees are CHCs. Paradoxically, only 10% of
CHCs receive RWP Part C funding, yet HIV services are avail-
able at CHCs that do and those that do not receive RWP
Table 4 lists findings from a survey of HIV testing practices
at CHCs. These findings underscore the impact of funding on
the ability of CHCs to deliver services. Ninety-six percent of
Part C–funded sites provide HIV testing, whereas 63% of non–
Part C funded sites provide testing. Similarly, at CDC-funded
sites, 71% provide outreach or off-site HIV testing, compared
with 40% of sites not funded by the CDC .
Service provision also depends on the locale. Eighty-twoper-
cent of urban CHCs provide HIV testing, compared with 64%
of rural CHCs. This disparity must be addressed, considering
that the evolving geography of the HIV epidemic in the United
States is shifting toward the southern and southeastern parts
of the country, which are more rural than other regions.
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Ensuring Access to HIV Care • CID 2007:45 (Suppl 4) • S273
(CHCs) and all other sites funded by the Centers for Disease
Control and Prevention (CDC) during 2004, by population.
Rate of HIV seropositivity at community health centers
% of patients
Injection drug users
Men who have sex with men
test results, which is the highest rate among all CDC testing sites.
A total of 95% of patients who were tested at CHCs received their
community health centers (CHCs).
Findings of a 2003 survey of HIV testing practices at
Receipt of RWP Part C funding
Provision of outreach or off-site HIV testing
Sites funded by the CDC
Sites not funded by the CDC
a response rate of ∼70%. Data were collected through the combined efforts
of the National Association of Community Health Centers, CentersforDisease
Control and Prevention (CDC), Health Resources and Services Administration,
and AIDS Policy Research Center at the University of California,SanFrancisco.
RWP , Ryan White Program, previously known as the Ryan White Compre-
hensive AIDS Resources Emergency Act.
The survey was submitted to a random sample of 402 CHCs, with
Models of HIV care at CHCs are dependent in large part on
the richness of funding. More-robust programs have multidis-
ciplinary teams and dedicated HIV specialists, defined as phy-
sicians who have expertise in caring for HIV-infected patients,
primary care physicians who have experience treating persons
who are infected with HIV. Other programs provide primary
care and support services but either refer patients to HIV spe-
cialists or have HIV specialists on site at regular intervals. Pro-
grams with less HIV funding may refer patients to HIV spe-
cialists, usually at sites funded by the RWP, and may offereither
on-site or off-site HIV testing along with primary care.
Challenges to accessing HIV care.
at CHCs are access to primary care professionals, HIV spe-
cialists, HIV medications, and funding.
Access to primary care professionals is a major challenge not
just for CHCs but also for the primary care delivery system.
The number of US medical schoolgraduatesmatchinginfamily
medicine and internal medicine (i.e., primary care) decreased
by 51.6% and 56.7%, respectively, during 1997–2005 . This
is likely a direct result of the prioritization of funding in our
health care delivery system, which favors specialty care and
high-risk procedures over primary care and disease prevention.
Because of low reimbursement rates, primarycareprofessionals
are expected to see an increased number of patients and have
less time to spend with each patient. Their quality of life has
diminished and their salaries are lower, compared with their
colleagues in specialty care. It is no wonder, then, that young
physicians choose specialty care over primary care. A 2004
survey of all CHCs in the 50 states showed that, in an average
CHC, 13% of its family physician full-time employee positions
are unfilled.One-thirdof CHCshadbeenrecruitingforafamily
physician for 17 months .
Access to HIV specialists is a particular problem for sites not
The primary challenges
funded by the RWP, particularly rural CHCs. One rural CHC
that is not funded by the RWP has been participating in a pilot
program to implement routine HIV testing. The center must
provide transportation for patients with newly diagnosed HIV
infection to the nearest RWP site 30 miles away. In addition,
there is a limited supply of nurses, case managers, and nutri-
tionists with experience treating HIV-infected patients.
An informal survey of CHC directors revealed that they view
the limitation of ADAP funding as another major challenge.
An estimated $300 million is needed just to catch up with the
current case load, according to some ADAP experts. Many
states have ADAP wait lists; restrictions in formularies and
income eligibility have been implemented as ways to cut the
budget. Walensky et al.  concluded that state variability in
funding of ADAPs results in geographic differences in disease
CHCs with RWP and CDC funding can better provide in-
creased and enhanced HIV treatment services. Part C of the
RWP has been flat funded for 6 years; the fiscal year 2006
funding was $193.6 million. For fiscal year 2007, the National
Association of Community Health Centers recommended an
increase of $150 million in Part C funding over that received
during the previous fiscal year. However, Part C did not receive
a significant increase in fiscal year 2007.
CHCs are an important component of our
health care system. They excel in managing chronic diseases
and in reducing disparities in health care, they are important
providers of HIV testing and medical care, and they serve a
high-risk population. RWP Part C funding is a key source of
support for HIV programs at CHCs. However, only 10% of
CHCs receive this funding, and Part C has been flat funded.
by guest on January 13, 2016
S274 • CID 2007:45 (Suppl 4) • Cheever et al.
Routine testing will further stress a system that is already chal-
lenged in terms of access to health care professionals, funding,
If the CDC’s recent recommendations for opt-out testing for
HIV infection are to be widely implemented, providers (i.e.,
health care professionals, third-party payers, and health care
institutions) will confront major challenges in reaching mar-
ginalized populations, funding testing, providing counseling
and follow-up, and providing medications. At the same time,
the opportunity to identify more HIV-infected individuals and
bring them into the health care system will likely be an im-
portant step in further stemming the tide of the epidemic. It
is essential that these health care providers have strategies as
well as the means to keep pace with the increased need for
services. All parts of the health care systems, including publicly
funded programs and commercial insurers, will need to over-
come the obstacles of routine HIV screening if this strategy is
to be effectively implemented in the United States.
We thank Margaret Inman for her assistance in preparing this manu-
script. J.L.S. thanks everyone who helped in the preparation of her pre-
sentation, particularly Kathy McNamara and Lisa Cox at the National
Association of Community Health Centers.
The “Opportunities for Improving HIV Diagnosis, Prevention & Access
to Care in the U.S.” conference was sponsored by the American Academy
of HIV Medicine, amfAR, the Centers for Disease Control and Prevention,
the Forum for Collaborative HIV Research, the HIV Medicine Association
of the Infectious Diseases Society of America, and the National Institute
of Allergy and Infectious Diseases. Funding for the conference wassupplied
through an unrestricted educational grant from Gilead Sciences, amfAR,
GlaxoSmithKline, Pfizer, Abbott Virology, OraSure Technologies, Roche
Diagnostics, and Trinity Biotech.
This article was published as part of a sup-
of, and Access to Treatment for HIV Infection in the United States,” spon-
sored by the American Academy of HIV Medicine, amfAR, the Centers
for Disease Control and Prevention, the Forum for Collaborative HIV
Research, the HIV Medicine Association of the Infectious Diseases Society
of America, and the National Institute of Allergy and Infectious Diseases.
Potential conflicts of interest.
All authors: no conflicts.
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