by Bob Roehr
Public policy has not kept pace with the revolution in treating HIV, and experts in the field are saying that has to change. "We know what should be done; it takes structural change in how things are paid for," said Michael Saag, MD, who heads up the HIV clinic at the University of Alabama at Birmingham.
Those changes were laid out in a joint paper from the American College of Physicians and the HIV Medicine Association of the Infectious Disease Society of America. It was released in a telephone news conference on April 17 and published online in Clinical Infectious Diseases.
Saag said voluntary counseling and testing, plus treatment for those who require it, has all but eliminated mother-to-child transmission of HIV in this country. "That same concept needs to be applied to the entire population," he urged, because late initiation of therapy often results in poorer response to it, and untreated persons are more likely to transmit the virus to others.
Even though the Centers for Disease Control and Prevention recommended universal opt out testing and counseling for HIV in September 2006, "reimbursement for the screening lags far behind," said Jeffrey P. Harris, MD, president of ACP.
Furthermore, the Centers for Medicare and Medicaid Services are considering reimbursing only for screening high-risk patients, without defining that category.
"We recommend expanding this to cover all beneficiaries," contradicted Harris.
Saag added that doctors are not likely to recommend or perform a test if they are not going to be paid for it. "The policy was stated very clearly two years ago by the CDC; the challenge now is how to implement it," he said.
Recent trials have shown that circumcision can protect against infection from HIV, herpes and human papillomavirus, but that information did not make it into the report recommendations because of timing. "The magnitude of the effect and the consistency between the three studies," said Saag, "makes it a very, very powerful data set that screams to us that circumcision should be a part of policy."
Another concern is the need to train more specialists in HIV care as the number of people living with the disease continues to grow. Many of the AIDS doctors are baby boomers who will retire and who entered the specialty "when it was a cause. But for younger people to come into this field, the (sense of a) cause really isn't there any more," he said.
"What is there is the debt of medical school and very poor possibilities of making any type of reasonable living doing HIV care" because CMS does not adequately reimburse for services.
The problem mirrors that seen in all general medical care. In recent years, just 2 percent of physicians graduating from medical school choose to go into primary care. The vast majority chose more lucrative medical specialties, said Harris. There is a projected shortfall of 40-45,000 primary care physicians by 2025.
"This transcends HIV practice," Saag said. "It is an issue that is an emerging crisis in our health care discussion regarding health care reform about access to primary care and how are we going to pay for it."
The full policy statement was published in the May 15 edition of Clinical Infectious Diseases http://www.journals.uchicago.edu/doi/pdf/10.1086/598169.
