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Using the Clinical Setting
Pages 50-67

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From page 50...
... In this chapter, the Committee describes how existing clinical settings might better integrate HIV prevention activities into their care activities. We also discuss several programmatic and funding changes that may be required to better integrate HIV prevention activities in the clinical care setting.
From page 51...
... The Committee believes that, in all clinical care settings serving HIVinfected persons and those at high risk of infection, the standard of care should include the taking of sexual and drug-using histories to help determine each patient's risk and the appropriate level of HIV prevention intervention. If an HIV-infected individual is found to have another STD, this in itself should trigger the delivery of some type of HIV prevention counseling, as STD infection is a marker for risky sexual behavior.
From page 52...
... Although prevention case management techniques have not been fully evaluated for efficacy and more research is clearly needed, limited results show that these techniques hold promise. For example, the Centers of Disease Control and Prevention and the Health Resources Services Administration sponsored a study of community health centers providing HIV prevention and early intervention services within primary care Recent studies have found that some new cases of HIV infection in untreated patients in which the HIV strain that was transmitted was already resistant to protease inhibitors (Hecht et al., 1998; Dietrich et al., 1999)
From page 53...
... are conducting pilot research for an intervention targeted to clinicians and their HIV-infected clients. The intervention is based on the assumption that many clinicians who provide HIV care are not sufficiently skilled to provide HIV prevention services to their clients.
From page 54...
... Perhaps the most significant barrier for providers is the lack of comfort or perceived skill in discussing sensitive issues such as substance abuse, sexual behavior, or psychological well-being with patients. To facilitate the integration of HIV prevention in the care setting, several tools and guides for conducting HIV risk assessments and encouraging safe behaviors have been developed for use by clinical care providers (e.g., Hearst, 1994; American Medical Association, 1996~.
From page 55...
... If one of the objectives of testing is to identify individuals with HIV and get them into appropriate care (both clinical care and prevention services) , the integration of HIV testing services into existing clinical care settings would accomplish several important goals, including assuring that those identified as HIV-infected would have immediate access to clinical care, destigmatizing HIV testing and making it a routine part of care, and promoting the linkage of clinical care and prevention services.
From page 56...
... Many people who are HIV-infected but do not know their status seek care from a wide variety of health care settings. For example, young people typically utilize community health centers, drop-in centers, emergency and ambulatory care departments, family planning clinics, and doctors' offices (Steiner and Gest, 1996; Ryan et al., 1996; Hedberg et al., 1996~.
From page 57...
... Many uninsured or underinsured individuals living with HIV also obtain services through the Ryan White CARE Act and Community and Migrant Health Center (CHC) programs, which are administered by HRSA.
From page 58...
... CHANGES NEEDED TO ENCOURAGE HIV PREVENTION: MEDICAID AND RYAN WHITE CARE ACT PROGRAMS If HIV prevention is to be more fully integrated into publicly supported clinical care settings, financing changes are needed to ensure that preventive services are a covered benefit and that these services are adequately reimbursed (Guglielmo, 1999; Makadon and Silin, 1995~. This section outlines possible changes to the Medicaid and CARE Act programs that could facilitate the integration of prevention in the clinical care setting.
From page 59...
... In order for prevention case management services to be a meaningful service option, HCFA and the CDC need to consider taking a number of steps. HCFA must make clear to state Medicaid agencies that it encourages them to embrace prevention services as part of an HIV-related continuum of care, and that community-based prevention case management, supported through a targeted case management benefit, is one vehicle for achieving this continuum of care.
From page 60...
... A state has some flexibility in affecting the delivery of Medicaid covered prevention services through its contract with a managed care organization. The contracting process can be used to integrate covered preventive services into clinical care delivery and require the provision of these services to uninfected individuals at increased HIV risk.
From page 61...
... Yet, HIV-infected persons also need prevention services that can help them avoid transmitting the virus to others, as well as prevent their own exposure to opportunistic infections. Such prevention-related services may include HIV prevention interventions and the critically important component of mental health and substance abuse services for those who need them.
From page 62...
... · HRSA can encourage all clinical care providers supported by the CARE Act to make HIV risk assessment a standard part of their clinical care encounters in order to judge whether HIV-infected clients are in need of referral to more intensive prevention services. · As part of the services provided by case managers, HRSA can permit referrals to prevention case management services funded by the CDC (or other agencies)
From page 63...
... Therefore, the Committee recommends that: Prevention services for HIV-infected persons should be a standard of care in all clinical settings (e.g., primary care settings, sexually transmitted disease clinics, drug treatment facilities, and mental health centers)
From page 64...
... 1992. Does human T-cell lymphotropic virus type I and human immunodeficiency virus type 1 coinfection accelerate acquired immunodeficiency syndrome?
From page 65...
... 2000. Medicaid and Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection [Web Page]
From page 66...
... 1992. Acquired immune deficiency syndrome occurring within 5 years of infection with human immunodeficiency virus type-l: The Multicenter AIDS Cohort Study.
From page 67...
... Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 17~1~:42-45. Richardson JL, Stoyanoff SR, Bolan R


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