Beginning in the 80’s, the HIV/AIDS epidemic swept rapidly through the US and Massachusetts. In 1999, Norfolk County in Massachusetts finally hit an infection rate plateau, and it has been slowly declining ever since. The AIDS rates for the towns of Norfolk County are currently all below the national average (339), with a mean rate of 107.5 per 100,000 AIDS cases. However, the number of people living with AIDS is still significant, and treatment is an important issue.

EARLY ART: Benefits and Costs

Because there is no vaccine as of now, drugs to keep HIV under control are used in treatments. Early initiation of antiretroviral therapy prevents opportunistic infections and increases CD4 cell counts, overall extending a patient’s life span. Unfortunately these drugs come at an extremely expensive price. Financing for AIDS retroviral therapy is a large issue for many of the at-risk groups. Governmental and outside funds may be more generously given if cost efficiency was ensured. A study performed[1] revealed that the incremental cost-effectiveness ratio of quality adjusted life years (QALY) was almost twice as high ($20,00 per QALY) for the deferred vs. early therapy than for the early vs. deferred therapy ($10,800 per QALY). Thus, early initiation of antiretroviral drugs is both economical and medically favorable. With no Medicare waiver, the average cost for the first 5 years of early initiated ART impacts the state budget at about $22,100 per patient. With a Medicare waiver, the average cost for the first 5 years of early initiated HAART moves up to $24,700 per patient. With the Medicare waiver, however, the average cost for the first five years of early initiated HAART only costs about $19,800. Undergoing early retroviral therapy with a Medicare waiver is medically and fiscally beneficial, and thus should be instituted.

Since this therapy is so expensive, many may not have the means to pay for it themselves. To receive government assistance for drugs, one must meet many economic, health, and insurance eligibility categories. This may be difficult for many HIV-positive people (i.e. homeless, unemployed, minors, non-citizens, etc). However, programs such as The Comprehensive Health Insurance Initiative (CHII) help Massachusetts’s residents meet the state’s HIV Drug Assistance Program (HDAP) eligibility to receive health insurance for full prescription drug coverage.[2] Also, private organizations could, and do, offer financial assistance through their own funding.

ADHERENCE

Even for the “lucky” patients who receive antiretroviral therapy drugs, adherence is difficult. “The number of pills per day, frequency of dosing, and food restrictions have been associated with poor adherence to treatment.”[3] Also, some side-effects of these drugs include diarrhea, rash, dizziness, abnormal dreams, sleeping disorders, mood disorders, and memory problems. Especially for HIV positive patients, who may not physically feel the full effects of the virus, the annoyances of their drug regimen may not seem worth it. It is, however, crucial that strict adherence to ART is observed or the drugs will fail. Realizing the problems this could cause, the Beth Israel hospital in Boston has developed an HIV treatment adherence program.[4] Programs such as this one, which provide education and support services for HIV treatment patients in Norfolk County would be greatly beneficial. Also, development of drugs with fewer and gentler side effects are being developed³, and should be made available to replace the old drugs, if possible.

Antiretroviral therapy is typically recognized as the most valuable method of HIV and AIDS treatment. However, studies have shown that psychological therapy may be important to a patient’s health-related quality of life (HRQOL) as well.[5] A lack of social support, for example, is separately linked to both a physiological and psychological poor QOL. An HIV-positive patient’s physical well-being is negatively affected by mental and emotional stresses; Hence, ART should not the sole treatment offered to patients. Referrals for psychological services and social support could be offered by HIV treatment hospitals and clinics, to ensure mental well-being (and in turn physical well-being).

ACCESSIBILITY

Most of Massachusetts AIDS treatment and care centers are located in Boston. While the city does border a few Norfolk County towns, transportation may be an issue for some HIV/AIDS patients residing in the county. The not-for-profit AIDS action committee (AAC) of Massachusetts provides many services including transportation to and from appointments.[6] Mobile clinics may also prove useful for those communities with a more concentrated population of HIV/AIDS patients, such as Brookline (273.2 cumulative AIDS cases per 100,000 people) and Quincy (267.0 cumulative AIDS cases per 100,000). Aside from offering transportation to hospitals and clinics in Boston, the incidence of AIDS and HIV is significant enough for Norfolk County to have its own clinic.

Whatever progress has been made in the treatment effort, marginalized groups still tend to be left out. With effective HIV treatments now available, earlier initiation of treatment has become an important issue. Younger people in Massachusetts are a disproportionately large group of AIDS/HIV patients. Due to a prevalence of risk factors, (including sexual abuse, prostitution, inadequate health education, drug and alcohol abuse, etc,) homeless youth are largely at risk of HIV/AIDS. Ironically, these risk behaviors are the same behaviors that increase survival rates on the street.[7] One program, called Boston HAPPENS (HIV Adolescent Provider and Peer Education Network for Services), targets at-risk homeless12 to 24 year olds.[8] Efforts to seek out potential HIV infected youths have proven successful in this program. It was shown that outreach efforts are much more favored than hospitals or health clinics. More such programs could increase the number of young AIDS patients being treated. In Norfolk County, as opposed to the inner city of Boston, there may not be as many homeless youth. However, from this model one learns that locating certain hard to reach at-risk people is a large part of the treatment effort is used to locate and refer AIDS/HI+V positive patients for treatment. If it is known where specific at-risk patients are in Norfolk County, they can be found, tested, and immediately referred for treatment.

SPECIALIZED EFFORTS

Not only are the marginalized groups hard to reach, but also sometimes efforts to reach the larger demographics of HIV/AIDS patients fall short of effective. Although the white population still makes up the majority of people living with AIDS (PLWA) in the county, (about 65.6%), they constitute about 90.5% of the population. Minorities disproportionately comprise 34.6% of all PLWA. A Black community making up 23.9% of all PLWA in Norfolk County with a rate of 248.2 per 100,000 cases, while only making up 2.87% of the total population signifies an important demographic for treatment targeting. Because of the status and previous treatment of minorities in the US, there may be hesitation on the part of the Black community to listen to the white, established scientists and politicians. In Mattapan, a section of Boston, an integration of faith and health care has been successful in reaching African American citizens. The Health Care Revival (HCR) is a fair that occurs annually in Mattapan to address health issues, including HIV/AIDS treatment and prevention, in a trusted faith-based context. The effectiveness of the HCR was evaluated: “First, by monitoring MCHC use, we found that after each HCR meeting there was an increase in use of services at MCHC [Mattapan Community Health Center]. Second, we asked participants to evaluate the effectiveness of the meeting. Almost all participants (95%) reported that after the HCR meeting they felt they were better informed about health issues in the Mattapan community and about MCHC services.”[9] The HCR, while enormously successful, only occurs once a year. A more consistent outreach effort, such as church-affiliated HIV/AIDS support and information groups that meet regularly, may improve the numbers of patients being treated.

Like African-Americans, gay HIV-positive patients have also been discriminated against. An interview with 18 men who are HIV-positive or have AIDS revealed a “lag time” between diagnosis and treatment, generally from six months to one year. Some reasons given for this delay included “mistrust of the medical establishment, fear of loss of home, family, or jobs” and, “trouble finding a doctor who wanted to provide medical care.”[10] This is a crucial time for treatment initiation; thus, a safe environment must be created for all people to feel comfortable in. Sensitivity training could be effective in establishing a welcoming atmosphere. Also, some of these men in the study claimed that a “team” effort from health workers was beneficial because of the numerous supportive paths available (as opposed to only one potentially narrowly specialized doctor).

Immigration brings people into the US from environments where HIV may be endemic. Massachusetts, especially the Greater Boston area, is home to numerous immigrants and refugees. Many immigrants are coming to America to discover their HIV-positive status for the first time.[12] These new immigrants rarely posses health insurance and are typically unaware of the treatment options available to them in the US. First, there must be an effort to inform the new immigrants of their possibilities, including treatment referrals. Second, health insurance or some other means of paying for treatment must be established. Groups such as the Boston Center for Refugee Health (BCRH) aid in refugee/immigrant health education, as well as advocating for health rights. An effort to advertise groups such as these must be put forth in order for immigrants to realize their options. Also, testing at immigration centers would be helpful in limiting spread and quickly initiated treatment. More efficient treatment may involve heightened awareness of specific countries that emigrate more HIV positive patients to the US, and making an effort to reach those people for testing/treatment. Some of these immigrants and refugees especially, emigrate from countries where they may have been tortured, sexually abused, and psychologically damaged. As stated above, social-psychological factors can have a significant effect on a patient’s health, and should have specialized services provided for them.

"INTEGRATION"

Only second to MSM transmission, injection drug use (IDU) accounts for a large portion of the HIV/AIDS cases in Norfolk County. For the year of 2005, 76 IDU related living AIDS cases, or 20.6% of all PLWA, was reported in Norfolk County. Continued injected drug use in these cases could spread HIV, hinder treatment, or introduce another illness into the already weakened patient’s immune system. For these reasons, substance abuse treatment has been integrated with HIV/AIDS treatment in the state of Massachusetts. This allows for more efficient funding, as well as a more comprehensive understanding of data, as it is shared across the HIV/AIDS Bureau, the Bureau of Substance Abuse Services, and the Bureau of Communicable Disease Control. Collaboration among these three agencies has enabled improved treatment for HIV/AIDS patients with substance abuse related needs.[11] This is a great success for the state, and proves the need for integration of more agencies. A beneficial combination could involve the Massachusetts HIV, Hepatitis, Addiction Services Integration (HHASI) integrating with non-governmental programs, such as the popular Massachusetts AAC. This could offer the widest scope on the AIDS situation.

Because Norfolk County has a dwindling number of new HIV infections, effort must now be put towards treatment. Government compliance with AIDS agencies concerning funding and organization/integration of programs is vital to the treatment effort. Non-governmental agencies are an equally important contributor, as they can provide financial assistance through fund raising, psychological support, and transportation services. Specialized efforts must be tailored towards treating specific demographics, such as homeless youths, immigrants, and social and racial minority communities. There is no “cure” for HIV as of now, yet some governmental and social efforts could significantly improve many lives in Norfolk County, Massachusetts.