Association of race, substance abuse, and health insurance coverage with use of highly active antiretroviral therapy among HIV-infected women, 2005.

OBJECTIVES: We examined racial/ethnic disparities in highly active antiretroviral therapy (HAART) use and whether differences are moderated by substance use or insurance status, using data from the Women's Interagency HIV Study (WIHS). METHODS: Logistic regression examined HAART use in a longitudinal cohort of women for whom HAART was clinically indicated in 2005 (N = 1354). RESULTS: Approximately 3 of every 10 eligible women reported not taking HAART. African American and Hispanic women were less likely than were White women to use HAART. After we adjusted for potential confounders, the higher likelihood of not using HAART persisted for African American but not for Hispanic women. Uninsured and privately insured women, regardless of race/ethnicity, were less likely than were Medicaid enrollees to use HAART. Although alcohol use was related to HAART nonuse, illicit drug use was not. CONCLUSIONS: These findings suggest that expanding and improving insurance coverage should increase access to antiretroviral therapy across racial/ethnic groups, but it is not likely to eliminate the disparity in use of HAART between African American and White women with HIV/AIDS.

Financing public health: diminished funding for core needs and state-by-state variation in support.

This article documents the instability and variation in public financing of public health functions at the federal and state levels. Trust for America's Health has charted federal funding for the Centers of Disease Control and Prevention, which in turn provides a major portion of financing for state and local public health departments, and has compiled information about state-generated revenue commitments to public health activities nationwide. The federal-level analysis shows that funding has been marked by diminished support for "core" public health functions. The state-level analysis shows tremendous variation in use of state revenues to support public health functions. The combination of these factors results in very different public health capacities across the country, potentially leaving some states more vulnerable, while simultaneously posing a general threat to the nation since public health problems do not honor state borders. On the basis of this analysis, the authors suggest changes in the financing arrangements for public health, designed to assure a more stable funding stream for core public health functions and a more consistent approach to financing public health activities across the country.

Insurance coverage and access to HIV testing and treatment: considerations for individuals at risk for infection and for those with undiagnosed infection.

The Centers for Disease Control and Prevention estimates that of the approximately 1.2 million people with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome in the United States, approximately 500,000 are not receiving care for their disease, including approximately 250,000 who do not know they are HIV positive. Although little is known about these 2 subgroups of HIV-infected people, they are likely to be reflective of the larger population of people with HIV infection; that is, they are predominantly racial minorities, more likely to be unemployed and/or poor, and much more likely to be uninsured or dependent on public insurance programs such as Medicaid, compared with the US population overall. In addition, many persons receive a diagnosis of HIV infection late during the course of the disease, and those who are difficult to reach are less likely to receive standard-of-care antiretroviral therapy. New testing initiatives attempting to diagnose infection in persons who do not know their HIV infection status have raised important questions about the funding and program capacity of the current system to handle new patients. Given these challenges and questions, measuring the success of new testing initiatives will be critical but difficult.

Overcoming policy and financing barriers to integrated buprenorphine and HIV primary care.

Treatment for substance abuse and human immunodeficiency virus (HIV) infection historically have come from different providers, often in separate locations, and have been reimbursed through separate funding streams. We describe policy and financing challenges faced by health care providers seeking to integrate buprenorphine, a new treatment for opioid dependence, into HIV primary care. Regulatory challenges include licensing and training restrictions imposed by the Drug Addiction Treatment Act of 2000 and confidentiality regulations for alcohol and drug treatment records. Potential responses include the development of local training programs and electronic medical records. Addressing the complexity of funding sources for integrated care will require administrative support, up-front investments, and federal and state leadership. A policy and financing research agenda should address evidence gaps in the rationales for regulatory restrictions and should include cost-effectiveness studies that quantify the "value for money" of investments in integrated care to improve health outcomes for HIV-infected patients with opioid dependence.