Access to healthcare for HIV disease remains an important issue both domestically and internationally.

In the United States, the average annual cost of care for an HIV-infected individual is between $10,000 and $15,000 annually. For those in the "advanced stages" of AIDS, the average annual cost of care is $34,000. In delving further into access to healthcare in the United States, it is necessary to discuss two areas: private coverage of HIV infection and coverage of HIV infection by public programs.

HIV-infected individuals may face several difficulties with private healthcare insurance. Most individuals in the United States with healthcare coverage receive it through their employers. Employers and insurers may seek to control the soaring cost of health insurance by limiting coverage for HIV infection. A 1990 federal appeals court case affirmed employers' "freedom to amend or eliminate employee benefits" in health insurance and allowed self-insured employers to reduce or eliminate benefits for any particular illness, even if all other medical conditions are covered (McGann v. H & H Music Company, 1991). A 2000 federal appeals court decision concluded that such limits do not violate the Americans with Disabilities Act (Doe v. Mutual of Omaha Insurance Co., 2000). Those who do not receive healthcare coverage through their employers may find it impossible to obtain private coverage for their HIV infection because, if coverage for individual applicants with HIV infection is available at all, it is very expensive or provides limited coverage.

As their disease progresses, previously employed persons cease working and lose their employment-based health insurance. About half of HIV-infected adults and 90 percent of HIV-infected children receiving medical care are covered through publicly funded sources. There are several ways to receive such coverage. First, patients may be insured through Medicaid. To be eligible for Medicaid, patients must either have AIDS or HIV-related disability and meet (low) income eligibility requirements. Second, state AIDS drug assistance programs (ADAP), which are funded through the federal Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990, make HIV medications available to low-income and uninsured persons. Because each state receives different funding and determines eligibility and benefits packages, Medicaid coverage and access to medications vary widely from state to state. In addition, because, unlike Medicaid, the drug assistance programs are not entitlement programs (i.e., programs in which all those who meet the eligibility criteria are entitled to receive the benefits), they are funded through annual appropriations, which may vary year to year. Finally, the CARE Act provides funding for HIV/AIDS services that are not covered by Medicaid or state or local government funds. Although the majority of the CARE Act funds are used for medical care (including the ADAP programs), they also provide funding for HIV/AIDS-related support services. These services include counseling, emergency housing assistance, training for clinicians who treat HIV-infected patients, and developing programs to improve treatment. States and other local governments receive CARE Act funds based, in part, on the prevalence of HIV/AIDS in their populations. Because of shifts in the epidemic and the effectiveness of antiretroviral therapies in delaying progression to AIDS, using AIDS cases to allocate funds may not accurately reflect the burden of HIV disease in the population. Reporting of HIV infection can provide essential information to ensure that funds are appropriately distributed to meet the needs of HIV-infected patients.

The shift to Medicaid and other public funding causes several problems. Because of low reimbursement levels, many physicians do not accept Medicaid patients. Thus, patients who lose private insurance may also lose access to care. As a result, emergency departments and public hospitals bear a greater burden of care. In addition, because of large budget deficits, many states and counties are finding it increasingly difficult to pay for such care.

Specific funding that provides for HIV care, but not for other fatal illnesses whose treatments are expensive, such as cancer, raises issues about equitable allocation of resources. AIDS activists exerted considerable political pressure to obtain this funding and to continue the programs supported by it. There are public policy reasons for providing special funding for HIV care. First, HIV is an infectious disease. Providing care and access to antiretroviral medications slows the progress of disease, which may decrease transmissibility and, therefore, help control the spread of the epidemic. In addition, because AIDS patients are categorically eligible for Medicaid and the overall cost of antiretroviral therapy is less than caring for a patient with AIDS, it may be more cost effective for the government to provide antiretroviral therapy to delay progression to AIDS.

There have been many efforts to make HIV medications more available to the developing world by pressuring pharmaceutical manufacturers to reduce prices, permitting production of generic versions of effective therapies, and providing funds for drug purchases. Even though the annual cost of antiretroviral therapy has been reduced to between $500 and $1,350 for the developing world, this cost is beyond the means of many developing nations. In 2001 the United Nations secretary general, Kofi Annan, proposed a $7 billion to $10 billion fund to combat AIDS globally, although, as of 2003, funding has fallen well short of this goal. The obligation of developed nations to address the AIDS epidemic in the developing world can be justified on several grounds. First, compassion may motivate developed nations to help alleviate the suffering caused by the AIDS epidemic. Second, to the extent that good health and healthcare are basic human rights, nations who are able are obligated to contribute resources to guarantee these rights. Third, because the wealth (and health) disparities between the developed and developing world are largely a legacy of colonialism, the developed nations have an obligation to address those problems to which they contributed. Finally, it is in the self-interest of developed nations to assist the developing world. If the AIDS epidemic is not controlled in the developing world, the resulting economic and political instability will threaten the security of all nations.

Even if antiretroviral therapy can be made affordable, there are challenges in providing treatment in developing countries that have little healthcare infrastructure. Because failure to adhere to the treatment regimen may lead to drug resistance, it is important to develop treatment protocols that can be implemented effectively using existing infrastructure. Once-a-day regimens are being developed that could facilitate implementation of antiretroviral treatments in the developing world. Also being studied are programs for providing care when intensive laboratory monitoring is not available. To successfully maintain HIV treatment programs in the developing world, host-country personnel must be trained to provide and monitor the treatments.

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