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The Department of Health and Human Services (HHS) announced on April 14 that it would provide $520 million in 1998 grants to states for HIV/AIDS care under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.
The increased funding comes as data show that despite a decline in the number of new AIDS cases, new HIV infections are continuing to spread essentially unabated.
About a week after the HHS announcement of the Ryan White funding, the Clinton Administration announced there would be no federal funding for needle exchange, despite acknowledging that scientific consensus supports the efficacy of needle exchange in reducing HIV transmission.
The state grants are provided under Title II of the Ryan White CARE Act, which funds HIV/AIDS care for low-income, uninsured, and underinsured people. More than $285 million is earmarked for state AIDS Drug Assistance Programs (ADAP), an increase of more than $118 million over Fiscal 1997 program funding, according to HHS. The grant money is expected to pay for costly AIDS medication and other treatment for an estimated 108,000 low-income HIV/AIDS patients.
For psychiatric clinicians, the increased funding is welcome but hardly a guarantee that more money will be funneled specifically to psychiatric care, observed Karl Goodkin, M.D., and J. Stephen McDaniel, M.D., both of whom are members of the APA Commission on AIDS. The formula grants support more than 25 types of medical and psychosocial services for low-income people with HIV/AIDS, according to HHS. There is, however, no specific language directing funding to psychiatric services.
Unless psychiatrists or other mental health care providers apply for Ryan White grants in their geographic regions, the funding does not go to mental health services, said McDaniel. This is particularly so now, as the majority of funding is used for increasingly expensive antiviral drug therapies, he added.
"As psychiatrists, we should be as energetic around this funding opportunity today as we were 10 years ago," said McDaniel. "Even though news headlines have alluded to decreasing AIDS-related deaths, primarily as a result of new antiviral therapies," this means that there are now more people with HIV than in the past, thus increasing the need for mental health and substance abuse services.
Psychiatric care is important not only in treating primary psychiatric conditions, but also for its indirect impact on survival in HIV-infected patients, said McDaniel. Recent studies have shown that depression and stress are associated with increased HIV-related mortality.
Further, people with untreated psychiatric disorders are less likely to adhere to the complex and costly antiviral treatment regimens and are more likely to engage in high-risk behavior, McDaniel added.
Psychiatrists, particularly those skilled in community mental health, "have an excellent opportunity to reach HIV-affected communities through the collaborative networks in [Ryan White] funding," said McDaniel. This takes on added importance given that HIV infection rates continue to impact disproportionately more socially marginalized and disenfranchised people, including the severely mentally ill receiving care in the public sector. He urged interested psychiatrists to contact the federal Health Resources and Services Administration (HRSA), which administers the CARE Act for HHS, or state AIDS program directors to learn how they might shape use of the money.
In the past, the portion of Ryan White money spent on neuropsychiatric services "has been well below that which would be expected as part of the total burden of AIDS care," observed Goodkin. Given this history, it is crucial that academic and community psychiatrists in their specific eligible metropolitan areas actively provide information about their services to the local consortium of AIDS care providers who administer the Ryan White grants.
Much of this effort must be considered educational, in that administrators must be taught about the significant role that psychiatrists can play in many aspects of AIDS care. Mental health care providers should not assume that funds will go to psychosocial services for AIDS patients, Goodkin cautioned.
"This is a very dangerous period, indeed," said Goodkin. "A major concern is the media coverage given to the impact of highly active antiretroviral therapies (HAART)." Although these therapies can reduce viral load to undetectable levels for years in some people and hence prolong life, this does not mean that the war on AIDS is over, he cautioned.
An "undetectable" viral load is not the same as no viral load, so there is great potential for long-term emergence of drug-resistant strains of HIV. This risk is heightened by the need for strict adherence to HAART regimens. "As little as several days of nonadherence may end in resistance a month or two later," he noted. Further, specific tissues may contain a higher HIV concentration than blood plasma, serving as reservoirs for the development of drug-resistant HIV.
The optimism over the new antiretroviral therapies has led to public complacency over HIV/AIDS prevention, said Goodkin. "This attitude has extended to high-risk populations and already has resulted in relapse of high-risk behaviors in populations" that had earlier reduced such behaviors, he added. The combination of resurgent high-risk behaviors and the need for strict adherence to the new drug therapies heightens the potential for a "second wave" of disease that parallels the development of drug-resistant strains of HIV.
"Such a development could have ominous implications, especially as the currently FDA-approved protease inhibitors are cross-resistant with one another, as are the non-nucleoside reverse transcriptase inhibitors with each other."
The Ryan White formula grants are based on the estimated number of people with HIV/AIDS in each state or territory. Although separate funds are earmarked for state ADAP's to buy medicine for low-income people with HIV/AIDS, the states may designate part of their formula grants to ADAP support. Approximately 55,000 HIV infected people rely on ADAP to receive critical medication, according to HHS. The CARE Act, first funded in Fiscal 1991, has provided more than $1.7 billion in Title II grants to states.