[1991] Impact of AIDS on American Cities

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[1991] Impact of AIDS on American Cities

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THE IMPACT OF AIDS ON AMERICA'S CITIES

A 26 City Report for The U.S. Conference of Mayors Task Force on AIDS

June 1991


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The United States Conference of Mayors

 

The United States Conference of Mayors is the official nonpartisan organization of cities with populations of 30,000 or more. There are well over 900 such cities in the country today, each represented in the Conference of Mayors by its chief elected official, the Mayor. The U.S. Conference of Mayors is in its second half-century of service to the Mayors and the citizens of America's principal cities. Throughout its history, the Conference of Mayors has taken the lead in calling national attention to the problems and the potential of urban America. Since its founding it has carried the message of cities to every President, every Congress. This is the heritage of the Conference of Mayors. It is the heritage of every mayor who serves today.

 

Robert M. Isaac
President
Mayor of Colorado Springs

 

Art Agnos
Chair, Task Force on AIDS
Mayor of San Francisco

 

  1. Thomas Cochran
    Executive Director

 

The Impact of AIDS on America’s Cities is a publication of The United States Conference of Mayors, with support from the U.S. Department of Health and Human Services under grant #U62/CCU300609-08. Robert M. Isaac, Mayor of Colorado Springs, President; Art Agnos, Mayor of San Francisco, Chair, Task Force on AIDS; J. Thomas Cochran, Executive Director; Richard D. Johnson, Assistant Executive Director; Alan E. Gambrell, Editor. This report was prepared by Alan E. Gambrell, Richard D. Johnson, and Paula M. Jones. Tables and charts were designed and prepared by Jeffrey A. Menzerand Richard D. Johnson. Database design and compilation of data was by William Brian Mays. Layout design by Stuart P. Campbell, Production Editor. Any opinions expressed herein do not necessarily reflect the policies of the U.S. Department of Health and Human Services. The Conference of Mayors was greatly assisted by officials in 26 cities and counties who provided information for this report.

© The United States Conference of Mayors, June, 191


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Preface

Ten years ago this month, the first cases of AIDS were reported among a handful of Gay men in the nation’s largest cities. Since that time, over 110,000 Americans have died of AIDS (as of the month ending April 1991)—more than the total number of American deaths in all military conflicts since World War II combined.


Over one million Americans are now estimated to be infected with the HIV virus. An estimated 165,000 to 215,000 Americans will die of AIDS from 1991 to 1993 alone, according to the Centers for Disease Control.


Over the past decade, waves of fear, discrimination, and misunderstanding have flashed, disappeared and reappeared in the nation’s media headlines. Yet, behind the undulation of press reports, the wave of the epidemic has been constant—and escalating. Despite policy debates over testing issues, admission of foreigners with HIV, and the best methods of preventing the further spread of the HIV virus that causes AIDS, there can be no debate on the impact of AIDS in our cities: this year is worse than last, and next year will be even worse.

 

AIDS Cases: The Numbers Explode

 

The United States Conference of Mayors this past month surveyed 26 of the cities hardest hit by the AIDS crisis to assess—one decade into the epidemic—the status of AIDS in America’s cities and its impact on urban health systems.

 

The magnitude of the AIDS epidemic is made evident when reflecting on landmark events in the AIDS crisis and combining them with the findings of this survey.

 

In 1985, the year Rock Hudson died from AIDS, there were close to 10,000 total cases in the 26 surveyed cities. Our survey found that:

 

  • In Baltimore, there were 116 cases in 1985; by the end of 1990 there were 1,599, nearly 14 times the number.
  • In Tampa, 63 cases had been diagnosed by the end of 1985; by the end of February of this year, 866 had been reported, or 1,274 percent more.

 

Five years ago, in 1986, Surgeon General C. Everett Koop issued his landmark Surgeon General's Report on AIDS.

 

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  • Through 1986, 25,048 cumulative AIDS cases had been reported in the 26 surveyed cities; (this constituted the majority of the over 37,000 in the nation). In 1986 alone, 10,973 cases were reported in the 26 surveyed cities
  • By the end of 1986, there were 59 AIDS cases in Indianapolis. As of March 1991, Indianapolis reports 452 cases, an increase of 666 percent.
  • In Philadelphia, 368 cases had been reported by the close of 1986. That city’s total increased 528 percent to 2,313 by March.

 

Five years from now, in 1996:

 

  • Houston estimates there will be 27,000 cumulative AIDS cases.
  • Boston estimates 3,341 cumulative cases.

 

The nation’s cities have yet to recover from the recession that began soon after the start of the AIDS epidemic. Numerous studies have shown that federal funding for cities throughout the 1980s was reduced by 60 to 70 percent. During the same period, a recent Conference of Mayors study has shown that city budgets have risen by 95 percent in response to increased problems.

 

Throughout the Desert Shield /Desert Storm operation in the Persian Gulf, 378 Americans lost their lives in support of the effort. During that same time, over 10,000 Americans lost their lives to AIDS.

 

If the federal government can spend many billions of dollars to rescue mismanaged and corrupt financial institutions, it certainly can expend just a fraction of that amount on the crisis in American cities. Just as we can find resources to protect our troops abroad, we must find resources to protect and care for our citizens at home.

 

  1. Thomas Cochran

Executive Director

 

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Table of Contents

 

Executive Summary […] 1

Overview of Findings […] 3

Survey Cities Comprise Most of Nation's AIDS Cases […] 9

Paying for AIDS Care: Medicaid, Public Systems Cover Major Share […] 17

HIV Testing and Counseling: More Individuals Seek Results […] 19

Early Intervention: Waiting Lists for Public Services […] 20

Federal AIDS Drug Funds Inadequate […] 22

Service Needs of People With HIV/AIDS […] 24

Preventing the Spread of AIDS: Gaps Identified in Education Efforts […] 26

Strains on Service and Prevention Systems […] 28

The Future […] 29

 

 

 

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Executive Summary

 

During April and May of this year, The U.S. Conference of Mayors (USCM) surveyed 26 major cities—members of the USCM Task Force on AIDS and others with the highest numbers of AIDS cases. The purpose of the survey was to assess, one decade into the epidemic, the status of AIDS in those cities most affected by the disease. Survey results reveal:

 

  • Survey Cities Represent Majority of Nation's AIDS Cases. Over 56 percent of the nation’s AIDS cases are in the 26 survey cities; 51 to 66 percent of the estimated one million Americans infected with HIV are in the survey cities—508,720 to 657,421 persons.
  • Minority Gay/bisexual Men, IV Drug Abusers, Women Increasingly Affected. The impact of AIDS varies significantly from city to city, with specific populations—including minority Gay/bisexual men, IV drug abusers, and women -- experiencing the largest increases in cases over the past three years.
  • Racial/ethnic Groups Increasing Proportion of Cases. Racial and ethnic minorities continue to represent a disproportionate number of cases. From 1987 to 1990, minorities have increased as a percentage of AIDS cases, particularly Blacks. In several cities, projections of persons infected with HIV—future AIDS cases—show a continued increase of minorities, particularly Blacks, as a proportion of total cases.
  • Public Resources Cover Large Portion of Cases. Health insurance coverage estimates indicate a varying percentage of diagnosed persons are covered by Medicaid; estimates of coverage range from 31 to 66 percent of AIDS cases in cities.
  • Waiting Lists for Early Intervention. Early intervention services often are characterized by long waiting lists; persons with HIV seeking access to publicly-funded early treatment systems often must wait several months. Fifty percent of cities report waiting lists for appointments at publicly funded clinics.
  • AIDS Drugs: Federal Funds Insufficient to Meet Local Demand. Local funds are used to provide AIDS drugs in half of surveyed cities. Seventy-six (76) percent indicate that the federal AIDS drug reimbursement program for low income persons will not meet demands this year.
  • Service Needs: Local Conditions Vary. Substance abusers, the uninsured and women were identified as having the greatest service shortages. Outpatient care, substance abuse treatment and housing were the greatest service needs across all groups.
  • Prevention Education: Programs Need Ongoing Support. The most significant gaps in prevention education efforts to date by transmission categories were identified for minority Gay/bi-sexual men, nonminority Gay/bisexual men, and heterosexuals. Among racial/ethnic groups, the greatest gaps were identified for Hispanics and Blacks. For all groups, ongoing education was the greatest need. Youth in risky situations—those on the streets, engaged in illicit drug use and/or sex for money or drugs —were also identified as a group in particular need of re-education. The need for continuing AIDS education to reinforce messages about making changes in sex and needle sharing practices was identified across all population groups.
  • Service Systems Strained. Seventy-five percent of cities stated that service systems were experiencing strains due to the AIDS crisis—most often staffing shortages and staff burnout, and inadequate space and facilities. Prevention education systems, as well, were also facing stress in 64 percent of cities, typically because of staff shortages and burnout.
  • Future: Local Resources Inadequate to Meet Growing Needs. None of the surveyed cities indicated that local funds could meet projected demand for HIV-related prevention education and health services. Often, cities were looking to funding through the Ryan White CARE Act to meet projected demands.

 

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Respondents

26 Survey Cities

 

Anaheim (Orange County)

Atlanta (Fulton County)

Baltimore

Boston

Chicago

Cleveland

Dallas (Dallas County)

Denver

Ft. Lauderdale (Broward County)

Houston

Indianapolis (Marion County)

Jersey City

Kansas City, MO

Los Angeles (Los Angeles County)

Minneapolis (Hennepin County)

New Haven

New Orleans

New York City

Newark

Philadelphia

Phoenix (Maricopa County)

San Diego (San Diego County)

San Francisco

San Juan

Seattle (Seattle/King County)

Tampa (Hillsborough County)

 

Methodology

 

The United States Conference of Mayors surveyed 26 cities during April through May 1991, including members of the U.S. Conference of Mayors Task Force on AIDS as well as others with the highest numbers of AIDS cases. The Task Force is chaired by San Francisco Mayor Art Agnos and was formed in 1983 in order to focus federal attention to the impact of the AIDS epidemic on America’s cities.

 

Data were collected by city and county health departments in the cities surveyed. Epidemiological data provided by respondents are for their local health department jurisdictions (i.e., city or county). In addition to survey information, the Conference of Mayors supplemented data with information collected from city and county applications for federal Title I Ryan White CARE Act supplemental funding. Year one funding (fiscal 1991) of Title I provides direct AIDS care funds to sixteen cities with the highest numbers of AIDS cases. Fourteen of the 16 cities which receive Title I funding are represented in this survey.

 

The denominator for calculating percentages in this report is comprised of only those cities which responded to a particular question. The reader should note that in no case do percentages reported for a survey question include a city which did not respond to that question.

 

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Overview of Findings

 

Ten years ago this month, the first cases of AIDS were reported by the federal Centers for Disease Control (CDC), reporting on five cases among Gay men in Los Angeles. Since that time, over 110,000 Americans have died of AIDS (as of the month ending April 1991). There are 174,893 cases of AIDS in the U.S. as of the month ending April 1991. An estimated 165,000 to 215,000 Americans will die of AIDS during 1991-1993, according to CDC.

 

CDC estimates that there are one million Americans currently infected with the HIV virus. An estimated 40,000 new infections occur each year, according to CDC.

 

The United States Conference of Mayors during April and May surveyed 26 major cities—members of the Conference of Mayors Task Force on AIDS as well as others with the highest numbers of AIDS cases. The purpose of the survey was to assess, one decade into the epidemic, the status of AIDS in America’s cities and its impact on urban health systems (see Methodology, page 2).

 

AIDS Cases in 26 Survey Cities: Today, Five Years From Now

 

  • As of the month ending February, 56.1 percent of the nation’s AIDS cases were in the 26 cities surveyed by the Conference of Mayors (cases reported by survey cities as of 2/28/91). (Sixty-one percent of the nation’s AIDS cases are in the 26 “Metropolitan Statistical Areas” represented by the surveyed cities; MSAs include the central city and immediate surrounding areas.)
  • The population of survey cities represent 16.8 percent of the total U.S. population.
  • Today, there are an estimated 508,720 to 657,421 persons with HIV infection who have yet to develop AIDS in the 26 cities surveyed by the Conference of Mayors. This represents 51 to 66 percent of the estimated one million infected with HIV in the U.S. as estimated by CDC.
    • In New York City, from 125,000 to 235,000 are HIV infected.
    • In Los Angeles, an estimated 41,000 are infected.
    • In San Diego, an estimated 15-20,000 are HIV infected.
    • Lauderdale estimates 21,000 people with HIV.
    • In Baltimore, an estimated 20,000 people are HIV infected.
    • Phoenix estimates nearly 8,000 residents are HIV infected.
    • San Francisco estimates that 28,000 are infected with HIV.
    • Tampa has an estimated 7,400 HIV infected persons.
  • Fifteen cities provided estimates on the number of AIDS cases they project by the end of 1996. By that date, these cities will have experienced a 240 percent increase — from 44,518 to an estimated 151,652 cases.
    • Houston estimates that in five years there will be 27,000 cumulative AIDS cases.
    • Cleveland projects 6,500 cases.
    • Los Angeles estimates 33,000.
    • Boston estimates 3,341 cumulative cases in five years.

 

Populations Disproportionately Affected

 

AIDS cases from 1987-90 among some categories were rising relatively faster. Limited projections of future cases in some cities point to growing proportions of cases among Blacks and women.

 

Across select cities, between years ending 1987 and 1990, AIDS cases increased as follows:

 

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Total U.S. Population

[Pie chart that states: Survey Cities – 16.8%, Remaining U.S. – 83.2%]

 

Total AIDS Cases*

[Pie Chart that states: Survey Cities 56%, Remaining U.S. 44%]

 

*As of 2/28/91

 

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  • Dallas Gay/bisexual cases increased from 864 to 2,262 from 1987 to 1990.
  • In Anaheim, minority Gay/bisexual males increased from 43 to 165 for the years ending 1987-90, an increase of 283 percent.
  • In 1990, 17 percent of Houston's cases were among Blacks. In 1987, 12 percent were reported among Blacks (270 in 1987, up to 876 in 1990).
  • Eighty-five percent of the women with AIDS in Philadelphia are Latina. There were 50 Latina cases in 50 and 150 by 1990 in the city.

 

Health Insurance: AIDS Diagnosed Covered by Medicaid, Other Public Sources

 

Research is still underway to determine the percentage of AIDS care costs that are covered by public and private sources. Various local studies have attempted to determine coverage of AIDS care costs, although comprehensive findings are lacking on AIDS care costs covered by public health insurance or private insurance.

 

In order to estimate the source of payment of AIDS care costs, the Conference of Mayors asked surveyed cities the following question: “What percentage of AIDS diagnosed persons in your jurisdiction do you estimate are” covered by public or private health insurance. According to surveyed cities:

 

  • In eight of 15 cities providing data, Medicaid covers from 31 to 66 percent of AIDS diagnosed persons in those cities.
  • In 10 cities, “Other public health insurance” covers from two (2) percent to 45 percent of AIDS cases (e.g., Newark, 45 percent; Houston, 21 percent; Los Angeles, 16 percent).
  • In 14 cities, private insurance covered from 15 percent to 55 percent of AIDS cases (Cleveland, 55 percent; Indianapolis, 50 percent; Philadelphia, 49 percent).

 

Counseling and Testing: Many Seek Results

 

  • Seventy-six percent of surveyed cities (of 17 responding) report an increase of from one to 500 percent or greater in number of individuals seek HIV counseling and testing. Indianapolis reports that the number seeking testing has stayed the same. Two cities, Minneapolis and Ft. Lauderdale, report a decrease in numbers being tested and counseled.
  • Over the past three years, the rate of AIDS test results reported as positive from HIV counseling and testing sites (for 19 reporting cities) has decreased in 42 percent; stayed the same in 32 percent; and increased in 26 percent.
  • Thirty-two percent of the 26 cities indicated that the majority of those who have utilized HIV counseling and testing services over the past year are primarily “generally at lower risk.”

 

Early Intervention: Waiting Lists Exist for Services

 

Early identification and treatment of HIV has proven effective in prolonging survival of persons with HIV infection. Cities surveyed were asked to indicate if publicly-funded HIV early intervention services existed and if there were waiting lists for services in their locales.

 

Publicly-funded services exist in all surveyed cities, with funding coming from a variety of sources—federal, state, local, and private foundations. In 50 percent (12 of 24 cities) there were waiting lists for initial appointments at publicly funded early intervention clinics. For example:

 

  • Newark has a wait of 3 to5 weeks for HIV immune assessment services funded by Medicaid and city welfare. Black IV drug abusers earning less than $8,500 make up the majority of those waiting for appointments.
  • San Diego hasawaitof4 to 6 weeks for initial HIV immune assessment appointments at public facilities.
  • At the Grady Infectious Disease Clinic in Atlanta, the county hospital-run HIV clinic, there is a three month waiting period for initial HIV immune assessments.

 

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AIDS Drug Treatment Money: Half of Cities Provide Local Funds

 

One half (50 percent) of the 26 cities indicated that local funds are used to provide AIDS drugs to persons not covered by the federal/state AIDS drug reimbursement program. The federal AIDS drug reimbursement program will not meet the demand for AIDS drugs this year, according to 76 percent of the surveyed cities.

 

Gaps in Services: Local Conditions Define Needs

 

The unmet service needs—and the subpopulations experiencing the greatest gaps—vary from city to city, reflecting the different characteristics of persons infected with HIV, and variations in health service delivery systems in communities. Generally, systems are strained and a wide range of populations have unmet needs.

 

  • Substance abusers were identified by 50 percent of respondents as having major service needs. The “uninsured” and women were each identified by 46 percent of respondent cities (11 of 24 providing data) as service need populations. Other populations identified most often by respondent cities as having major service needs included: the homeless (42 percent, 10 of 24 cities), and the incarcerated (21 percent). Others listed included racial/ethnic minorities, mentally ill, minority Gay/bisexual men, and Gay/bisexual adolescents.
  • Services most frequently listed as lacking—across all groups—were outpatient care, substance abuse treatment, and housing, followed by home care and long term care. Other categories listed included: mental health services, social services (including legal services and transportation), and case management.
    • Outpatient Care - Houston estimates that demand for outpatient care for indigents will increase by 48 percent from 1990 to 1991.
    • Substance Abuse Treatment - In Los Angeles, 38 percent of the need for resident detox programs for those with HIV is not met.
    • Housing - San Francisco estimates that, over the next three years, 1,200 new housing units will be needed for people with AIDS.

Preventing Education: Speaking Rises, Gaps Seen

 

Local Prevention Spending Rises, Gaps Seen

 

Local Prevention Spending Rises

 

Eighty percent (20 of 25 cities) use local funds for prevention; 60 percent (12 of 20) have increased their local funds spent on AIDS prevention education. In Kansas City, MO, spending rose 100 percent over last year. In New York City, a50 percent increase occurred. Indianapolis and Baltimore each reported 30 percent increases.

 

Prevention Loses Against Services

 

Decisions about health spending often pit health “service” dollars against “prevention” funds. In such budgetary struggles, prevention often loses: its impact is less immediate and documentable. This scenario holds true for local AIDS spending. Fifty-five percent (10 of 20 responding) indicate that the impact of demand for AIDS services has been to decrease or keep constant local funds spent on AIDS prevention education.

 

Gaps in Education Identified

 

Gaps reported in prevention education efforts include the need for re-education due to relapse into unsafe behaviors; lack of success in developing effective interventions; and obstacles posed by lack of community support for HIV education for specific populations, particularly gay/bisexual minorities and substance abusers.

 

Infrastructure Weakens: System Seeing Strains

 

Service Infrastructures. Seventy-five percent of cities (18 of 24) indicate that service system strains are being realized due to the AIDS crisis. Sixty-three percent (15 of 24 reporting) indicate service system problems with staffing, training and facility/space inadequacies. Thirty-three percent (8 of 24) listed inadequate facilities and space as a major infrastructure problem.

 

Prevention Education Infrastructures. Sixty-four percent of cities responding (16 of 25) reported that infrastructure problems had resulted in a “negative impact on prevention education efforts.” Fifty-two percent listed

staffing as the most common concern (e.g., difficulty in recruiting qualified staff, retention, staff burnout, train-

 

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Survey Cities

AIDS Cases, Percent Living

Cases reported as of February 28, 1991

 

City                              # Reported AIDS Cases                        % Living

Anaheim                      1,445                                                   36.6

Atlanta                        3454                                                    40.0

Baltimore                    1,641                                                   41.0

Boston                         1,546                                                   354

Chicago                       3,552                                                   35.0

Cleveland                    506                                                      59.0

Dallas                          2,769                                                   340

Denver                        1,071                                                   33.9

Fort Lauderdale           2,632                                                   38.0

Houston                      5,151                                                   34.0

Indianapolis                 452                                                      45.0

Jersey City                   1,106                                                   38.0

Kansas City, MO          696                                                      51.0

Los Angeles                 11,534                                                 32.0

Minneapolis                586                                                      37.0

New Haven                  387                                                      32.0

New Orleans               1513                                                    34.0

New York City              31,845                                                 34.0

Newark                        2,151                                                   39.0

Philadelphia                2313                                                    34.0

Phoenix                       972                                                      39.0

San Diego                    2,525                                                   38.1

San Francisco              10,055                                                 30.0

San Juan                      1,732                                                   37.0

Seattle                         1,634                                                   42.0

Tampa                         866                                                      59.0

 

*** Total ***              94,134

 

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ing). Specifically, cities reported difficulty in recruiting qualified staff (i.e., those willing to work on HIV related issues or culturally sensitive staff), staff retention, and burnout.

 

  • Atlanta reported that employees remain in HIV-related positions for an average of 1.5 to 2 years, making it difficult to maintain continuity in programs.
  • Houston cited difficulties in recruiting bilingual/bicultural staff.

 

The Future: Increasing Cases, Lack of Funds

 

All respondents indicated that local resources are inadequate to deal with future AIDS prevention and healthcare needs.

 

Seventy-two percent have no identifiable source of funding for expansions of services and prevention efforts needed in response to growing caseloads.

 

Only 28 percent of survey respondents had identified sources of future funds. Survey respondents often cited federal resources as a source for coping with future caseloads. Baltimore, Boston, Chicago, Dallas, Jersey City, and San Diego specifically refer to Ryan White CARE Act funds as a needed resource.

 

  • Baltimore will look to state and federal medical assistance, research money, and Ryan White CARE Act Title I funds to cover needed expansions.
  • Boston has no identified source of funding future needs but rather states that “only limited federal funds have been identified through the CARE Act. With the potential dismantling of state Medicaid optional services (as proposed in the current state budget), services will be cut, not expanded.”

 

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Surveyed Cities Comprise Majority of Nation’s AIDS Cases

 

As of the month ending February 1991, 56.1 percent of the nation’s AIDS cases were in the 26 cities surveyed by the Conference of Mayors. (When totaling the number of cases in the surveyed cities by the 26 “Metropolitan Statistical Areas” (MSAs) of those cities, which include the surrounding suburban cities/areas, the 26 MSAs account for 61 percent of the nation’s total AIDS cases.)

 

Among the 26 cities surveyed, 94,134 cases were reported through the month ending February 1991 (over 167,803 had been reported in the nation). In 1990 alone, 16,364 cases were reported in these 26 cities.

 

Approximately 34 percent of the cumulative AIDS cases in the 26 cities surveyed are living. Persons living with AIDS require a range of often costly care and services as episodic debilitating opportunistic infections weaken the immune system.

 

Perspective on Epidemic: Five Years Ago, Projections for 1996

 

Five years ago, by the end of 1986, 25,048 AIDS cases had been reported in the 26 surveyed cities.

 

In 1996, five years from now, an estimated 151,652 cumulative AIDS cases will have been reported in only 15 of the surveyed cities providing these data.

 

Below the Tip of the Iceberg: Persons Infected With HIV

 

Today, there are an estimated 508,720 to 657 421 persons with HIV infection in the 26 cities. This represents 51 to 66 percent of the CDC-estimated one million infected with HIV in the U.S.

  • In New York City, from 125,000 to 235,000ar e HIV infected.
  • In Los Angeles, an estimated 41,000 are infected.
  • Lauderdale estimates 6,175 to 30,876 people with HIV.
  • In Baltimore, an estimated 20,000 people are HIV infected.
  • Phoenix estimates 7,651 residents are HIV infected.
  • San Francisco estimates that 28,000 are infected with HIV.
  • Tampa has an estimated 7,350 HIV infected persons.

 

Projections: Significant Increases in AIDS Cases, HIV Infected Persons

 

Fifteen cities provided estimates on the number of AIDS cases they project by the end of 1996. By that date, these cities will have experienced a 240 percent increase—from 44,518 to an estimated 151, 652 cases.

 

  • Houston estimates that in five years there will be 27,000 cumulative cases of AIDS in the city. Houston will have an estimated 44,400 to 68,000 persons with HIV infection.
  • Los Angeles projects 33,000 cumulative AIDS cases by 1996. The city estimates 35,000 HIV infected by 1996.
  • Cleveland estimates 6,500 cumulative cases in 1996. Projections are that the city will have 20,000 HIV infected by 1996.

 

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Survey Cities Estimated Number of HIV Infected as of February 28, 1991

 

City                              Estimated Number, of HIV Infected                Source of Estimate

Anaheim                      14,000                                                             A

Atlanta                        50,000

Baltimore                    20,000                                                             ABCEG

Boston                         11,028                                                             AG

Chicago                       14,000                                                             BG

Cleveland                    15,000                                                             G

Dallas                          5,000-10,000                                                   G

Denver                        10,000                                                             A

Fort Lauderdale           6,175-30,876

Houston                      30,000                                                             A

Indianapolis                 2,200                                                               ABEFG

Jersey City                   16,590

Kansas City, MO          5,000-8,000                                                     G

Los Angeles                 41,000                                                             BDEG

Minneapolis                5,500                                                               BEG

New Haven                  3,096                                                               A

New Orleans               15,130                                                             EFG

New York                     125,000-235,000                                            G

Newark                        23,000-27,000                                                 G

Philadelphia                20,000                                                             A

Phoenix                       7,651                                                               A

San Diego                    15,000-20,000                                                 ABEG

San Francisco              28,000                                                             BDEG

San Juan                      9,000                                                               G

Seattle                         10,000                                                             AG

Tampa                         7,350                                                               AB

 

*** Total ***              508,720 - 657,421

 

HIV Infection Estimates: Report Key

 

A - Extrapolation from national (i.e., CDC) estimates

B - Testing of local STD clinic patients

C - Prison intake screening in your jurisdiction

D - Screening of military recruits in your jurisdiction

E - Testing of IVDUs in your jurisdiction

F - Testing of homeless persons in your jurisdiction

G – Other

 

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AIDS Impact Varies By City, Changing Over Time

 

Background

 

While Gay/bisexual males still comprise the largest number of AIDS cases nationwide, many cities’ AIDS caseloads vary significantly from the national average and are experiencing disproportionate growth in different case categories, such as Gay/bisexual minorities, IV drug users, racial and ethnic minorities, women, pediatrics and hard-to-reach populations, such as the homeless and youth in risky situations.

 

In some cities, the overwhelming number of cases are IV drug use related. In others, Gay/bisexual AIDS cases comprise the majority. In some, women comprise a much greater percentage of city cases than the national average. Proportions of cases among racial/ethnic minorities also vary.

 

As of the year ending 1990, in the various transmission categories, the average of the data collected from the 26 cities surveyed corresponds closely to national data, with Gay/ bisexual transmission higher in the 26 cities.

 

  • Nationally, Gay/bisexual transmission comprises 59 percent of total of adult/adolescent cases as of 1990. The proportion of Gay/bisexual transmission among the 26 cities surveyed is higher, at 64 percent.
  • IVDUs comprise 22 percent of the nation’s adult/ adolescent AIDS cases. In the 26 survey cities, they also comprise 22 percent of cases.
  • Gay/bisexual IV drug abusers are seven percent of surveyed city cases, and seven percent nationally.
  • Racial and ethnic breakdown of AIDS cases nationally through 1990 is as follows: whites (54.8 percent), Blacks (28.2 percent), Hispanics (15.9 percent), Asian/Pacific Islanders (0.6 percent), and Native Americans (0.1 percent). Among the 26 cities surveyed, the racial/ethnic breakdown closely follows the national percentages: whites (54 percent), Blacks (27.3 percent), Hispanics (17.8) (as compared to 15.9 percent of national cases reported as Hispanics), Asian/Pacific Islanders (0.8 percent) and Native Americans (0.1 percent).

 

An Examination of individual cities, however, reveals a greater variation from national averages.

 

Gay/Bisexual Men: Lower Percents, Higher Numbers More Cases Among Minority Gays

 

Gay/bisexual men comprise from 13 percent (Newark) to 85 percent (Anaheim, San Francisco, and Seattle) of total AIDS cases in individual cities surveyed. Nationally, 59 percent of cases are among Gay/bisexual men.

 

From 1987 to 1990, cases attributable to Gay /bisexual transmission decreased from 70.9 percent to 66 percent of total cases in the 22 survey cities reporting for both periods. For the 22 cities with 1987 and 1990 data:

 

  • In 1987, 22,747 cases were reported by surveyed cities providing data. In 1990, 53,529 cases were reported, an increase of 42 percent.
  • In 1990, Minneapolis had the highest percentage of its cases reported among Gay/bisexual men, at 90 percent of total city cases; Newark had the lowest at 13 percent.
  • From 1987-90, Los Angeles’ AIDS cases among Gay/bisexual men remained relatively stable as a percentage of total Los Angeles AIDS cases—85 percent to 84 percent—although actual cases increased from 4,238 to 8,859.
  • Dallas Gay/bisexual cases increased from 75 percent to 83 percent of the city’s cases (864 to 2,262 from 1987-90).
  • The most significant percentage decrease was in Baltimore, where 66 percent of the city’s cases were among Gay/bisexual men in 1987; in1990,46 percent were in this category. This occurred because, although Baltimore's Gay/bisexual AIDS cases tripled over 1987-90, IV drug abuse cases increased dramatically.

 

Gay Minority Cases Up. An increasing number of AIDS cases are occurring among minority Gay/bisexual men in select cities.

 

  • San Francisco reported 518 minority Gay/bisexual cases as of 1987; in 1990, 1,316 were reported, an increase of 154 percent.

[Page 17]

In Seattle, from 1987 to 1990 cases increased from 52 to 147, a 182 percent increase.

 

In New York City, 2,491 cases were reported through 1987 among minority Gays; 5,680 were reported through 1990, cumulative, a 128 percent increase.

 

IV Drug Abusers: Increasing Proportion of Total

 

From 1987 to 1990, IV drug use transmission increased as a percentage of total cases among 22 surveyed cities providing data for both periods—from 15.8 percent in 1987 to 20 percent in 1990.

 

In 1990, 54 percent of the nation’s IV drug abuse AIDS cases were in the 26 survey cities.

 

  • Baltimore, Ft. Lauderdale, Houston, Kansas City, MO, New Orleans, San Diego San Juan, and Tampa all experienced at least a four-fold increase in cases of IVDUs from 1987 to 1990.
  • In 1990, Newark had the highest proportion of cases reported among IV drug abusers, 69 percent of the city’s total cases. Jersey City (65 percent) and New Haven (56 percent) were the next highest.
  • In Houston in 1987, two percent of cases were among IV drug abusers. By the end of 1990, five percent of cases were in this category, an increase of 473 percent (from 45 to 258 cases).
  • Sixty-nine percent of Newark’s cumulative cases in 1990 were IV drug users. (Newark estimates that 50 percent of its approximately 15,0001V drug users are HIV infected.)
  • An estimated 60 percent of New York City IV drug users are infected with HIV.

 

Gay/Bisexual/IV Drug Abuse

 

For the year ending 1987, among 22 surveyed cities providing data, 7.6 percent of cases were reported among Gay/bisexual IV drug abusers. By the end of 1990, this had fallen slightly to seven percent of total cases in surveyed cities. Fifty-four percent of the nation’s Gay/bisexual/IV drug abuse cases were in the survey cities.

 

  • New York City, San Francisco, and Los Angeles reported the largest number of cases among Gay/bisexual IV drug abusers. From 1987 to 1990, Houston's cases among Gay/bisexual IV drug users rose from 203 to 464 cases, This represented no change in the proportion of Houston's AIDS cases (nine percent) but a 129 percent increase in cases.
  • Seattle reports an increase in cases of Gay/bisexual IVDUs from 60 to 148 over 1987 to 1990, a 147 percent increase.

 

AIDS: Increasingly Among Minority Populations

 

A significant and growing proportion of cases are among minorities, particularly Gay/bisexual minority men, substance abusers, and women.

 

  • In 1987, 22 percent of survey city cases (in 20 surveyed cities providing data for both time periods) were among Blacks; in 1990, this had increased to 27.2 percent.
  • In 1987, 15.9 percent of survey city cases were among Hispanics. In 1990, Hispanics comprised 17.8 percent of AIDS cases in surveyed cities.

 

Fifty-three percent of the nation’s cumulative 1990 Black cases were in the survey cities, while 62 percent of the nation’s cumulative 1990 Hispanic cases were in survey cities.

 

Blacks

 

Nationally, Blacks comprise 28 percent of AIDS cases as of December 30, 1990. The percentage of cases reported among Blacks ranged from 2.6 percent in Anaheim to 85 percent in Newark.

 

  • In 1990, 66 percent of New Haven's total cases were among Blacks and 13 percent among Hispanics. In 1987, those percentages were 66 and 15, respectively.
  • In 1990, 17 percent of Houston's total cases were among Blacks; 11 percent were among Hispanics. In 1987, 12 percent were among Blacks and 10 percent among Hispanics.

 

[Page 18]

[Image of a 3-axis graph]

Number of Cumulative Diagnosed AIDS Cases in Survey Cities, by Transmission Category, for Years Ending 1987 and 1990

 

[Page 19]

  • Fifty-five (55) percent of Philadelphia’s cumulative AIDS cases are among Blacks. Three years ago, 51 percent were among Blacks.

 

Future: Estimates on HIV Infection Among Blacks

 

A select number of surveyed cities provided estimates on the racial/ethnic breakdown of their HIV infected populations. In several cities, an increasing proportion of the estimated HIV infected are Black as compared to current AIDS cases.

 

  • In Houston, 17 percent of current cases are among Blacks. An estimated 26 percent of Houston's HIV infected persons are Black, according to local estimates.
  • Eighty-five percent of Newark’s AIDS cases are Black; 95 percent of the HIV infected are estimated to be Black.

 

Hispanics

 

Nationally, Hispanics make up 16 percent of the total AIDS cases.

 

  • In the year ending 1990, the percentage of Hispanics among the total number of surveyed city AIDS cases ranged (from one percent in Baltimore, 98 percent in San Juan, 18.8 percent in Los Angeles and 27 percent in New York.
  • Eighty-five (85) percent of the women in Philadelphia with AIDS are Latina.
  • In Dallas, there were 56 cases among Hispanics in 1987; in 1990, 182 Hispanic cases were reported, a 225% increase.
  • Boston's Hispanic cases increased from 40 to 124 over 1987 to 1990, a 210 percent increase.

 

Future: Estimates on HIV Infection Among Hispanics

 

For estimates provided by cities on racial /ethnic breakdown of HIV infected persons, several cities project a greater proportion of their HIV infected populations will be Hispanic as compared to current city AIDS cases.

 

  • In Anaheim, 12.5 percent of AIDS cases are Hispanic; an estimated 17 percent of the HIV infected in Anaheim are Hispanic.
  • San Francisco reports 8.3 percent of its AIDS cases among Hispanics but estimates that 12 percent of the HIV infected are Hispanic.

 

Asian/Pacific Islanders

 

  • In Seattle, 1.6 percent of the city’s AIDS cases were among Asian/Pacific Islanders in 1990. In San Francisco in 1990, 1.9 percent (188 cases) were among Asian/Pacific Islanders.

 

Native American

 

  • Fifty-two Native American AIDS cases were reported in Houston in 1990.
  • Los Angeles had 16 Native American AIDS cases in 1990.

 

Women: An Increasing Proportion of Cases

 

Nationally, 10.5 percent of AIDS cases are among women.

 

  • Among surveyed cities, Newark has the highest proportion of its cases among women: 32 percent of diagnosed AIDS cases as of the month ending February 1991.
  • New Haven is second among reporting surveyed cities, with 28 percent of its cases among women.
  • Jersey City reports 23.5 percent are female AIDS cases.
  • San Juan is fourth: 21 percent are among women.
  • Baltimore reports that 17.6 percent are among women—the fifth highest among surveyed cities.

 

Future: Estimated Women with HIV Infection

 

Projections for the male/female proportions for estimated HIV infected populations also point to future increased cases of AIDS among women.

 

[Page 20]

[Image of a 3-axis graph]

Number of Cumulative Diagnosed AIDS Cases in Survey Cities, by Race/Ethnicity, for Years Ending 1987 and 1990

 

[Page 21]

  • Houston estimates that 155 percent of the HIV infected in the city are women; only four percent of the city’s cumulative AIDS diagnosed cases are women.
  • Current San Juan cases are 21 percent female. Officials there estimate that 28 percent of the city’s HIV infected are women.

 

Heterosexual

 

Heterosexual AIDS cases are a low but increasing proportion of AIDS cases in surveyed cities. Nationally, five percent of cases are reported as occurring through heterosexual transmission.

 

  • Houston heterosexual cases rose from 23 for the year ending 1987 to 155 by the end of 1990.
  • Tampa reported seven heterosexual cases in 1987; by 1990, that total had risen to 57.
  • In New York City, 1073 cases by 1990 were among heterosexuals.
  • Lauderdale reports 322 cases by 1990.
  • Philadelphia's heterosexual cases rose from six to 67 from 1987 to 1990.

 

Pediatric Cases (0-12 years)

 

In 1987 there were 762 cases of AIDS among children under 12 year sin 22 surveyed cities providing data; for 1987 and 1990. By 1990 there were 1,564 cases, an increase of 105 percent. As HIV increases among women, the number of children born with the disease will also rise.

 

The Face of AIDS in America’s Cities Varies

 

National statistics on AIDS present a composite picture of AIDS cases in the U.S. In individual cities, however, the face of AIDS may vary greatly from national statistics. For example: national figures show that by the month ending February 1990, 59 percent of all AIDS is caused are related to Gay/bisexual transmission, 22 percent through IV drug use. Blacks comprise 28 percent of the total and Hispanics 16 percent. Nationally, 10.5 percent of cases are among women.

 

In cities, for the month ending February 1990:

 

  • In Jersey City, 23 percent of the AIDS cases are among women.
  • Newark estimates that 95 percent of the HIV infected population is Black; currently, 85 percent of the city’s AIDS cases are among Blacks.
  • In Seattle, 85 percent of the AIDS cases are among Gay/ bisexual males. Women account for two percent of cases. Fourteen percent of cases are among minorities.
  • In Dallas, 70 percent of the AIDS cases are among white Gay/ bisexual men; 13 percent are among minority Gay/bisexual men.
  • Denver estimates that 64 percent of the HIV infected population is white; 82 percent of the AIDS cases are among whites. Ninety-eight (98) percent of the AIDS cases in Denver are among men.
  • By the end of 1990, half of New Haven’s AIDS cases were among IV drug abusers.

 

[Page 22]

Paying for AIDS Care: Medicaid, Public Systems Carry Heavy Burden

 

Background

 

In order to estimate the source of payment of AIDS care costs, the Conference of Mayors asked surveyed cities the following question: “What percentage of AIDS diagnosed persons in your jurisdiction do you estimate are” covered by public or private health insurance. According to 15 surveyed cities providing data (out of 26 surveyed cities):

 

  • Medicaid coverage ranged from 31 to 66 percent of AIDS diagnosed persons in those cities (e.g., Houston, 66 percent; Denver, San Diego and Indianapolis, 50 percent each; Cleveland, 40 percent; Chicago, 35 percent).
  • In 10 cities, “Other public health insurance” covers from two (2) percent to 45 percent of AIDS cases (e.g., Newark, 45 percent; Houston, 21 percent; Los Angeles, 16 percent).
  • In 14 cities, private insurance covered from 15 percent to 55 percent of AIDS cases (Cleveland, 55 percent; Indianapolis, 50 percent; Philadelphia, 49 percent; Los Angeles, 37 percent; Jersey City, 20 percent; Newark, 15 percent).

 

Medicaid Pays Disproportionate Share

 

The percent of persons diagnosed with AIDS covered by Medicaid ranges from 31-66 percent in the cities surveyed.

 

  • In Houston, 66 percent of cases are Medicaid covered.
  • Sixty percent of Jersey City’s cases are covered under Medicaid.
  • San Diego reports that 50 percent of cases are Medicaid covered.
  • In Boston and Cleveland, 45 percent and 40 percent, respectively, are covered under Medicaid.
  • Medicaid covers 30 percent of the AIDS care costs in Baltimore; 50 percent of Baltimore's costs are completely uncovered by public or private health insurance (see below, The Uninsured).

 

The Uninsured

 

Persons not insured by public or private health insurance may have their costs covered by self-pay; local funds, particularly to public hospitals to provide for uncompensated care; state funds; or private resources.

 

City estimates on AIDS diagnosed persons not covered by public or private health insurance included:

 

  • Chicago, with 35 percent uninsured;
  • In Baltimore, an estimated 30 percent;
  • Minneapolis, where 29 percent are uninsured;
  • Denver, 25 percent;
  • San Diego, with 20 percent are uninsured;
  • Boston, 15 percent uninsured; and
  • Newark, 13 percent.

 

Local Government Costs

 

Local government payment of AIDS care costs can occur through earmarked local funds for AIDS care, as well as through uncompensated costs made through payments typically to public hospitals and other mechanisms in hospitals such as: cost-cutting measures in other hospital services, cross subsidies from private paying patients, draining of capital funds, and drawing down of hospital reserves.

 

[Page 23]

  • Chicago reports that 35 percent of AIDS cases are uninsured, of which 40 percent are costs paid by local government and 40 percent are uncompensated. In Chicago and Cook County, HIV-related medical expenses are projected to increase by 252 percent between 1989 and 1994. City and county HIV expenditures are estimated to reach $317 million by 1994, of which 45 percent will be nonreimbursable and shifted to local government or absorbed by service providers.
  • In Newark, 13 percent of cases are uninsured, of which 95 percent are covered by local funds. Baltimore reports that 50 percent of AIDS cases are uninsured. Of this, 75 percent is uncompensated and 20 percent is paid for with other, federal research funds. Five percent is covered by private resources.
  • In Minneapolis, 29 percent are not insured, of which 75 percent is uncompensated care and 25 percent paid for with local funds.

 

  • In San Diego, 20 percent are uninsured; 50 percent of these costs are covered by local funds and 30 percent are uncompensated.
  • In Cleveland, five percent of AIDS care costs are uninsured, of which90 percent are uncompensated.
  • In Boston, 15 percent of costs are uninsured, of which 50 percent are uncompensated and 10 percent are city funds. Ten percent of the costs of the medically indigent are covered by the federal government, through HRSA and BHCDA funds. Twenty percent are state funds (i.e., general relief, state).
  • Seattle estimates that seven percent of cases are uninsured, of which 30 percent is uncompensated care.

 

Health Insurance Coverage of Persons Diagnosed with AIDS estimated percentages

 

City                              Covered by or eligible for Medicaid               Covered by other public health insurance     Privately Other* Insured

 

Baltimore                   30.0                                                                10.0                                                                30.0 30.0

Boston                       45.0                                                                10.0                                                                30.0 15.0

Chicago                      35.0                                                                0                                                                      30.0 35.0

Cleveland                   40.0                                                                0                                                                      55.0 5.0

Denver                       50.0                                                                0                                                                      25.0 25.0

Houston                    66.0                                                                21.0                                                                ** **

Indianapolis              50.0                                                                0                                                                      50.0 0

Jersey City                 60.0                                                                20.0                                                                20.0 0

Los Angeles               39.0                                                                16.0                                                                37.0 8.0

Minneapolis***      31.0                                                                0                                                                      26.0 29.0

Newark                      27.0                                                                45.0                                                                15.0 13.0

Philadelphia              39.0                                                                2.0                                                                  49.0 10.0

San Diego                  50.0                                                                10.0                                                                30.0 20.0

San Francisco           48.0                                                                2.0                                                                  45.0 5.0

Seattle                        36.0                                                                8.0                                                                  38.0 18.0

 

*Includes those not insured by private or public insurances (i.e., self pay, other)

**Unknown distribution of 12% among these three categories

***Coverage of 14% of AIDS diagnosed persons is unknown

 

[Page 24]

Testing and Counseling: More Seek Results

 

Background

 

As the efficacy of early intervention services becomes more evident, public education campaigns stressing the importance of HIV testing have been carried out at the local and national level. Survey results show that more people are seeking HIV counseling and testing services.

 

Increased Numbers Vary Widely

  • Of the 17 cities reporting on changes in demand for HIV testing, 82 percent (14 cities) experienced an increase in demand for testing and counseling services, ranging from one percent in San Francisco to 500 percent in San Juan. Indianapolis reported that demand for testing remained constant. Two cities (Ft. Lauderdale and Minneapolis) experienced a decrease in percentages of persons seeking HIV testing and counseling services, 38 percent and 10 percent, respectively.
  • For the nineteen cities reporting on the rate of HIV+ test results over the past three years:
    • 42 percent (eight cities) reported a decrease in the rate of HIV positive results from testing and counseling sites over the past three years. The decrease ranged from one percent in Anaheim to 40 percent in San Juan. Other cities reporting a decrease include: Dallas, Houston, Kansas City, MO, Minneapolis, Philadelphia, and Seattle.
    • in 32 percent of the cities (six respondents), the rate of HIV positive test results remained constant.
    • 26 percent (five cities) reported the ratee of people testing HIV positive has increased. The number of HIV positive test results over the last three years increased by 60 percent in New Orleans; 50 percent in Boston and New Haven; 12 percent in Tampa; and one percent in Baltimore.

 

Testing People at Disproportionate Risk

 

Cities were asked to characterize the majority of persons receiving HIV testing and counseling services over the past year as either at “disproportionate” risk or generally at lower risk. Of the 26 responding, 69 percent reported that individuals at “disproportionate” risk of AIDS comprise the majority tested.

 

For the 32 percent reporting that a majority seeking testing are “generally at lower risk,” cities attributed the failure of greater numbers of people at disproportionate risk to seek counseling and testing services to: fear of confidentiality breaches, lack of protection against discrimination, inability to deal emotionally with HIV positivity, distrust of government bureaucracy, and concerns that universal HIV reporting will be mandated (name reporting).

 

Two cities (Seattle and San Juan) indicating a large increase in those being tested for HIV also reported that the majority of those tested were “generally at lower risk.”

 

[Page 25]

Early Intervention

 

Background

 

Early identification and treatment of HIV has proven effective in prolonging survival of persons with HIV infection. These services are not widely available to the HIV infected population. Services can range from an immune system assessment (e.g., T-cell count, white blood cell counts, platelet counts) to determine at what stage an individual is in the disease spectrum, to treatments including prophylactic drugs, management of opportunistic infections and a range of supportive services (e.g., psychosocial support, assistance in the modification of high risk behaviors, case management).

 

In many cities there is direct referral from testing and counseling sites to early intervention services. Many early intervention programs have been overwhelmed since program operations began and have been forced to establish waiting lists for appointments. Newly established clinics must deal with a backlog of patients and itis difficult to catch up and meet increasing demand, especially if lack of funding permits clinics to be open only on a limited basis (one or two times a week).

 

Waiting Lists Reported

 

Cities surveyed were asked to indicate if waiting lists for early intervention services existed in their locales: 50 percent (12 of 24 cities) reported delays in scheduling appointments:

 

  • In Houston, initial assessments are readily available but the service system is so overwhelmed that no services are offered to asymptomatic individuals.
  • In New York City the wait for an appointment ranges from 2 to 6 weeks.
  • In Anaheim, 300 people are waiting up to two weeks to receive services. Ninety-five percent of the people on the waiting list are medically indigent.
  • The New Haven Health Department provides HIV case management services. To schedule an initial appointment takes six weeks for adults and one month for children.
  • San Diego has a wait of 4 to 6 weeks for initial appointments at publicly funded clinics.
  • Newark has a wait of 3 to 5 weeks for early intervention services (immune system assessment and prophylactic treatment) funded by Medicaid and city welfare. Black IV drug users earning less than $8,500 make up the majority of those waiting for appointments.
  • Indianapolis provides early intervention services with Medicaid funds and at the local county hospital for the indigent. There is a two week wait for services. Low income gay males (50% white, 50% Black) are primarily those waiting for services.
  • In New Orleans, there is a 32 week wait for federally and state funded early intervention services.
  • In Dallas, clients may have to wait one week for services and the waiting list for public services may contain up to 20 people. Among those waiting for appointments there is a disproportionate representation of IV drug users, heterosexuals, Hispanics, Blacks and low to moderate income individuals.
  • At the Grady Infectious Disease Clinic in Atlanta, the county hospital-run HIV clinic, there is a three month waiting period for initial immune system assessments.
  • In San Francisco, the wait for scheduling an initial appointment for early intervention services ranges from two to six weeks. There are 50-100 HIV infected individuals waiting for appointments.

[Page 26]

Future Numbers of HIV Infected Will Overwhelm Systems

 

Projections concerning the number of HIV infected individuals indicate that early intervention services will be in even higher demand. In Philadelphia, for example, with an estimated 24,000 in need of early intervention services, the city estimates that Ryan White CARE Act Title I funding will assure services for only one percent of the asymptomatic HIV infected population.

 

Publicly Funded Early Intervention Services

 

Publicly funded early intervention services exist in all of the cities surveyed.

 

Early intervention services are funded by a variety of source in the 26 cities surveyed including HRSA Demonstration Grants, the State /Federal Drug Reimbursement Program, state funds, local funds (e.g., public hospitals, community health centers), private foundations and through the use of research funds (clinical trials).

 

It is difficult to track the total number of HIV+ individuals receiving early intervention services in cities because individuals may receive care at private, non profit agencies. Those with private insurance will receive services from their own physicians.

 

Examples of the number of HIV+ individuals receiving publicly funded early intervention services include:

 

  • 100 clients in Baltimore partially funded by Medicaid, STD program funds and through research grants.
  • 151 clients in Seattle funded by federal HRSA funds and state funds. Seattle is beginning a promotional campaign to increase public awareness of the availability of the program.
  • 180 clients in Cleveland are partially funded by Medicaid and by public funds at the Free Medical Clinic Early Intervention Program. The number of clients increased by 25 percent over the past year.
  • 500 clients in Dallas are funded by Medicaid and other public funds for the Parkland HIV Outpatient Clinic.
  • 200 clients in Houston receive immune system assessments in three clinics funded by the state and Harris County.
  • 500 clients in San Diego receive services funded by HRSA and state funds.
  • 1000 clients in Anaheim are funded by HRSA demonstration funds and state early intervention funds;
  • 1850 clients in San Juan are funded by HRSA demonstration funds, a grant from the Robert Wood Johnson Foundation and local city funds. The number of clients increased 50% over last year.
  • 400 clients receive publicly funded early intervention services in San Francisco. These services are funded by Medicaid and Medi-Cal (state funds).

[Page 27]

Federal AIDS Drug Funds Inadequate: Half of Cities Cover Drug Costs

 

Background

 

State AIDS drug reimbursement— which pays for AZT (Retrovir) and other pharmaceuticals for low income, non-Medicaid eligible persons with HIV disease—is a federally funded program begun in fiscal year 1987 to provide formula grant funds to the states. The program was initiated by the Congress because of the high annual cost of AZT therapy.

 

States determine their own income eligibility levels, which drugs to cover under their program, and their own method of operation. Beginning in fiscal year 1991, this program was incorporated into Title Il of the Ryan White CARE Act of 1990, making it one of four eligible activities to carry out under this authority. Generally, these programs are operated by the state government, utilizing a variety of mechanisms to provide therapeutics.

 

Although AZT costs have come down since 1987, AZT and other AIDS drug costs continue to be significant. A typical AIDS patient's annual costs for AZT is $2,000-$3,000. (One manufacturer of pentamidine, a preventive therapy for the most common opportunistic AIDS-related illness, pneumocystis carinii pneumonia, has raised the price of the drug by 400 percent according to the state of New York Department of Consumer Affairs.)

 

City Residents on State Drug Programs

 

Because the AIDS drug reimbursement programs are administered by states, many respondent cities were unable to document the number of city residents receiving drugs under their state programs. Only 14 cities could provide data. Twelve stated there were increases in the number of persons covered last year, ranging from five to 100 percent. San Diego and San Juan were the only two cities indicating no increases in the number of persons covered by their state drug reimbursement programs; cases of AIDS increased in both cities, however.

 

City experiences with AIDS drug reimbursement were as follows:

 

  • Seattle experienced a 100 percent increase in the number of city residents covered under the state AZT drug reimbursement program, currently covering 252 persons.
  • In Houston, a 50 percent increase occurred over last year, with the program currently covering 1,231 city residents.
  • In Los Angeles, 1,650 city residents were receiving AZT in the state program.
  • Anaheim increased by 30 percent, to 413 city residents.

 

Other cities experiencing increases included:

 

  • Cleveland (up 25 percent, to 23 persons);
  • Tampa (20 percent increase, to 275 persons);
  • Denver (15 percent over last year, to 424 city residents).
  • In Jersey City, the number of people on the program doubled, from 50 to 100, from September 1989 to September 1990. Costs increased from $66,276.83 (for 357 prescription claims) to $104,626.27 (788 claims).
  • In Newark, the number of people on the program also doubled, 78 to 157, from September 1989 to September 1990. Costs increased from $104,197 (for 485 prescription claims in 88-89) to $181,185 (1,034 claims in 89-90).

 

[Page 28]

Local Funds Used to Pay for AIDS Drugs

 

Fifty (50) percent of respondents (13 of 26) indicate that they utilized local funds to provide drugs to persons with AIDS and HIV infection who were not covered by the federal /state AIDS drug reimbursement program. However, only three (3) could provide data on the cost of these programs; difficulties cited in collecting data included the fact that drug expenses are not broken down by patient diagnosis.

 

In New Haven, drugs are provided as part of medical benefits to city welfare recipients but no breakdown in costs are available for HIV drugs. Newark, under general assistance, pays for AIDS drugs, for which there is no dollar figure.

 

Three (3) cities providing data on the amount of local funds expended, included: Denver ($650,000, an increase of 15 percent over last year); New Orleans (4 percent above last year); and Tampa ($78,000 or 15 percent above last year’s expenditures).

 

Federal Drug Funds Won’t Meet Demand This Year in Most Cities

 

Seventy-six percent (20 of 26) indicated that the federal AIDS drug reimbursement program will not meet the demand for AIDS drugs in their cities this year. Minneapolis reports that “everyone who meets requirements” is in the program. By contrast, other cities report:

 

  • Boston states that the state’s federal AIDS drug reimbursement program “will run out of money in mid-year.”
  • New Haven states that the “program is underfunded and only provides AZT.”
  • San Diego reports that the “projected shortfall is expected to be $150,000” by the end of June.

 

Federal Funds: Ryan White Act Called a “Band-aid, Not a Bailout”

 

In 1990, the Ryan White Comprehensive AIDS Resources Emergency Act (CARE) of 1990 was passed overwhelmingly by the Congress, bringing the federal government's AIDS service dollars under a unified legislative package. Authorized at$275 million in fiscal year 1990, Title I of the Act, which provides funding directly to cities most affected by the AIDS epidemic, received $87.8 million (32 percent of the authorized level). Title II, also receiving $87.8 million of its $275 million authorization, provides funding for AIDS services through the states.

 

One city official referred to the Ryan White CARE Act as “a band-aid, not a bail-out.”

 

In its FY91 supplemental competitive application for funding, Boston’s Ryan White planning council identified $10 in care needs for every dollar received in Title I funds. San Diego’s planning council estimates $6.1 million of unmet needs.

 

Two more cities, Baltimore and Oakland, will become eligible for Title I funding in FY92 and will compete for an as yet unknown amount of funds.

 

[Page 29]

Service Needs of People With AIDS: Local Conditions Define Gaps

 

Background

 

Persons with HIV / AIDS have a range of service needs, depending on the stage and specific manifestation of their HIV illness. Inpatient hospital care comprises only one part of the spectrum of service needs of persons with AIDS and reflects management of the periodic and debilitating opportunistic infections that overtake a person with AIDS.

 

Ongoing service needs, those that help in avoiding hospitalization, include: home care, housing, ongoing outpatient care, case management, mental health, substance abuse treatment, and social services (e.g., food, advocacy).

 

Most Common Gaps

 

Cities were asked to identify specific populations of persons diagnosed with AIDS for whom services are lacking. Cities were also asked to identify which services are most needed, but are currently unavailable. Twenty-four of 25 surveyed cities responded that services were lacking for some population.

 

The unmet service needs—and the subpopulations experiencing the greatest gaps—vary from city to city, reflecting the different characteristics of AIDS caseloads, persons infected and health service delivery systems in communities. Generally, systems are strained, with a wide range of populations with unmet needs and services lacking.

 

For example, in Kansas City, MO, all groups were identified as having service gaps, as determined by the city’s Ryan White Title II planning process. In New Orleans, racial and ethnic minorities in general were identified as populations lacking services. Cleveland identified Hispanic persons with AIDS as a population in need.

 

  • Groups in Greatest Need. Substance abusers were identified by 50 percent of respondents as a service need population. The “uninsured” and women were each identified by 46 percent of respondent cities (11 of 24 providing data) as service need populations. Other populations identified most often by respondent cities as having unmet service needs included: the homeless (42 percent, 10 of 24 cities), and the incarcerated (21 percent). Others listed included racial/ethnic minorities, mentally ill, minority Gay/bisexual men, and Gay/bisexual adolescents.
  • Services Most Lacking. Services most frequently listed as lacking – across all groups – were outpatient care, substance abuse treatment and housing, followed by home care and long term care. Other categories listed included: mental health services, social services (including legal services and transportation), and case management.

 

Populations With Greatest Gaps

 

  • Substance Abusers - Twelve cities list substance abusers as a service population in need. Services identified most frequently as lacking are substance abuse treatment, and housing, followed by home care, case management, outpatient health care, and social services.
    • Houston lists minority IV drug users as a service need population. In describing service needs, Houston explains that the system is overwhelmed in all areas for everyone. However, minority substance abusers (as well as women and the homeless) have an especially hard time accessing care.
    • Newark lists substance abuse treatment, long term care, and mental health services as top needs of substance abusers.
  • Women - Home care, housing, long term care, outpatient care, and mental health were most frequently listed as service needs.
    • According to New Haven, “support for women with HIV who are caregivers is sorely lacking.”
    • In Ft. Lauderdale, these services for women and children are described as “sorely lacking.”

 

[Page 30]

  • Housing for women with HIV, case management, and outpatient health care are the top identified needs in Indianapolis.
  • In Newark, social services, substance abuse treatment, and home care are the top three service needs.

 

In New York City, close to 5,000 women have AIDS; 16-20,000 children will lose their mothers from AIDS by 1993 in the city. Houston reports the city has the highest prevalence of HIV in Texas among women of childbearing age.

 

  • Uninsured - Home care, outpatient care, and housing are most frequently identified as service needs for the uninsured.

 

  • Housing, case management, and outpatient care are top identified needs for the uninsured in Indianapolis.
  • Outpatient care is “seriously lacking” for the uninsured in Ft. Lauderdale.
  • Chicago identifies outpatient care as a top need for the uninsured.

 

  • Homeless - Housing and outpatient care are the top service needs for homeless persons with HIV.
    • Boston lists chief service needs for the homeless with HIV as case management, homecare, housing, mental health, substance abuse treatment, and social services (e.g., food, advocacy, support groups).
    • Outpatient health care and housing are service needs described by New Orleans.
    • In New York City, an estimated six percent of the homeless are HIV infected. In San Francisco, there are 1,000 homeless persons with AIDS.

 

Services Most Often Lacking

 

Services most frequently listed as lacking—across all groups—were outpatient care, substance abuse treatment, and housing, followed by home care and long term care. Other categories listed included: mental health services, social services (including legal services and transportation), and case management.

 

  • Substance Abuse Treatment - In Los Angeles, 38 percent of the need for resident detox programs for those with HIV is not met.
  • Housing - San Francisco estimates that, over the next three years, 1,200 new housing units will be needed for people with AIDS.
  • Home Care - In 1989 in Houston, 78 percent of AIDS patients discharged from the hospital were without any home care service.
  • Outpatient Care - Houston estimates that demand for outpatient care for indigents will increase by 48 percent from 1990 through 1991.
  • Mental Health - In Chicago this year, 87 percent of the 642 persons estimated to seek mental health services will receive none, despite Ryan White CARE Act funds.
  • Case Management - Los Angeles states that only 17 percent of those with HIV needing case management receive it. In Chicago, approximately 2,800 persons with HIV need case management services; over half will not receive them despite Ryan White CARE Act funds.
  • Dental - In Houston, there is a 2-3 month wait for dental services at the only publicly funded clinic serving people with HIV.

 

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Prevention Education: Gaps Seen, Ongoing Education Needed

 

Background

 

It has long been recognized that effective HIV prevention programs must be locally developed and based. With no cure for AIDS foreseen, prevention programs are the only truly effective weapon against the further spread of the disease.

 

In this time of severe fiscal constraints, it has been increasingly difficult for cities to maintain funds for prevention efforts as caseloads and the cost of care and services increase.

 

  • Eighty percent (20 of 25) of cities utilize local funds for prevention activities. Of these cities, twelve (60 percent) had increased their funding of AIDS prevention activities in the past three years. The increase over the past three years ranged from 10 percent in San Diego to 2,000 percent in San Juan.
  • Of the 18 cities providing dollar amounts of funding for AIDS prevention efforts, the amount of local funds spent in the past fiscal year ranged from $10,000 in Cleveland to $3,776,103 in Seattle.

 

Increased Service Needs Rob Prevention Dollars

 

Decisions about health spending often pit health services against prevention, with prevention spending often losing.

 

  • Fifty percent of cities (10 of 20 cities responding) indicated that AIDS services demands have held constant or decreased local funding for AIDS prevention.
  • Thirty percent (six cities) indicated that their prevention spending had increased.
  • Twenty percent (four cities) responded that the demand for services had no impact on funding for services.

 

Factors in addition to service demands in the community can also result in a decrease of funds (not limited to public funds) available for HIV prevention efforts. Seattle, for example reported that decreases in state grant funds in the city coupled with growing demand for services has caused support for prevention efforts to erode.

 

Gaps in Prevention Education

 

Cities were asked to list which population groups in their locality have been identified as having gaps in HIV prevention education. Twenty-five of the 26 survey respondents indicated that gaps existed in their community.

 

Transmission categories

 

  • Minority Gay/bisexual males. Gaps in educating minority Gay/bisexual males were identified by 88 percent (22 of 25) of the cities with education gaps. Of these the most prevalent gaps were noted as “lack of success in identifying effective intervention” (7 cities) and the need for re-education given relapse into unsafe behavior (8 cities). Five cities reported that no programs have specifically targeted this population.
  • Non-minority Gay males. Eighty percent identified gaps in educating non-minority, Gay white males; most commonly, the cities cited a need for re-education, given identified relapse into unsafe behaviors (16 of 20). New York City and Los Angeles reported that programs do exist but that they must be expanded to meet needs within the community. Boston identified segments of the Gay population (Gay youth, bisexual men who do not identify as Gay, and Gay IV drug users) as populations for which successful interventions have not been developed.
  • IV Drug Abusers. Forty percent (8 of 20 cities reporting) identified IV drug abusers as having prevention education gaps. The major gap identified was lack of programs designed to prevent “relapse” into unsafe behaviors. The lack of […]

 

[Page 32]

[…] effective interventions was also cited as a barrier to providing HIV risk reduction information to IV drug users, identified by seven respondents.

  • Sixteen cities (64 percent) reported gaps in prevention education programs for heterosexuals. Twenty-five percent of these cities (4) noted that no programs specifically target this population locally, while a like number reported a lack of success in developing effective interventions and the need for re-education due to relapse.

 

Racial/ethnic minorities

 

  • Seventy-six percent reported gaps in prevention education targeted to African-Americans. Of these, 42 percent (8 cities) noted a need for re-education due to relapse into unsafe behaviors. Six cities (32 percent) reported a lack of success in developing successful interventions to reach Blacks.
  • Eighty percent indicated that gaps existed in HIV prevention education for Hispanics. Of this number, 35 percent (7 cities) noted a need for re-education due to relapse into unsafe behaviors, and 20 percent (4 cities) cited a lack of success in developing effective interventions.

 

Youth, Women

 

  • Seventy-two percent (18 cities) reported gaps in education targeting high-risk youth. Of these, five (28 percent) indicated that no programs have specifically targeted this population, while six (33 percent) reported a need for re-education given relapse into unsafe behaviors. Two cities (11 percent) notes a lack of success in developing successful interventions.
  • Seventy-two percent also reported gaps in education targeting women. Of these, five (28 percent) reported a need for re-education due to relapse into unsafe behaviors, and four (22 percent) reported no programs specifically targeting this population.

Constraints to the Provision of HIV Prevention Education

 

When asked to identify constraints to HIV education efforts, eight cities (32 percent) reported the top constraint as the difficulty in accessing hard-to-reach persons. Six cities (24 percent) identified as a significant restraint denial among high risk populations. Other constraints identified by cities tended to reflect problems that were unique or resulting from local conditions.

 

  • Houston reported the most significant constraint as the geographic dispersity of the community and physical difficulty in accessing target populations.
  • Lack of culturally appropriate staffing was a significant concern of many cities. Houston, Cleveland, Jersey City, New Orleans, Newark and San Francisco reported difficulty in recruiting bilingual/bicultural public health educators.
  • Two cities, Los Angeles and San Diego, identified lack of funding as the greatest constraint to prevention efforts.

 

[Page 33]

Systems Realize Strains

 

Health Service Systems Under Stress

 

In 75 percent of cities responding (18 out of 24 responses), service systems were realizing strains due to the AIDS crisis. Most often cited were staff shortages, training needs, staff burnout, and inadequate space and facilities.

 

Sixty-three percent (15 of 24 cities) listed staff issues (i.e., insufficient staff, staff recruitment, or high turnover) as major problems.

 

  • Cleveland and New Haven, New Orleans, and San Francisco referenced staff burnout.
  • Los Angeles, Minneapolis, New Orleans, Philadelphia, and Tampa mention staff recruitment problems.
  • Kansas City, MO, calls attention to the “limited number of providers who treat HIV / AIDS cases.”
  • In Chicago, chronic staff shortages in the Cook County Hospital are evident. The AIDS unit has only 20 of 30 AIDS dedicated beds filled due to chronic nursing shortages and difficulty in recruiting personnel for the ward.

 

Thirty-three percent (8 of 24) listed inadequate facilities and space as a major infrastructure problem.

 

  • Boston, Houston, New York City, and Philadelphia list inadequate space and facilities.

 

Prevention Systems Also Realize Weaknesses

 

Sixty-four percent of cities (16 of 25 cities) reported that infrastructure problems had resulted in a “negative impact on prevention education efforts.” Fifty-two percent listed staffing as the most common concern (e.g., difficulty in recruiting qualified staff, retention, staff burnout, training). Specifically, cities reported difficulty in recruiting qualified staff (i.e., those willing to work on HIV related issues or culturally sensitive staff), staff retention, and burnout.

 

  • Atlanta reported that employees remain in HIV related positions for an average of 1.5-2 years, making it difficult to maintain continuity in programs.
  • Houston cited difficulties in recruiting bilingual/bicultural staff.
  • New York City states that the city’s fiscal crisis “has led to staff shortages” and that “space shortages] (chronic) undercut training programs.”

 

Other problems mentioned included: lack of stable funding from year to year, interdepartmental competition for funds, and funding restrictions for HIV prevention programs. Chronic facility space shortages were also identified as a problem.

 

[Page 34]

Future: AIDS Care and Prevention Needs

 

Local Resources Inadequate to Meet Growing Need

 

The future impact of the AIDS epidemic on America’s cities is reflected in the increase in projected AIDS cases in surveyed cities. Local resources cannot fill the gap between future caseload estimates and care and prevention needs.

 

None of the cities surveyed indicated that they would be able to meet projected demand for HIV-related prevention and health care services with existing local resources. City comments included:

 

  • Los Angeles: “The local caseload is too large. Los Angeles County is fiscally overburdened in most public service areas and cannot absorb all AIDS related expenses.”
  • New Haven: “Because New Haven is overwhelmed with multiple urgent health and social problems, the volume of demand for services due to our large population of residents with HIV infection and illness is already overstressing systems that were stretched thin before AIDS hit. The majority of people affected are indigent and a significant proportion must also be medically indigent though we do not have available data on this phenomenon at present.”
  • Seattle: “Local resources comprise approximately four (4) percent of the AIDS resources for Seattle- King County. The majority of support is dependent on federal, state and foundation grants. Many of these grants expire within the next 18 months. Local revenues are unlikely to meet these resultant gaps.”
  • Tampa: “The growing numbers of infected individuals will quickly overload the medical care system.”

 

Other city responses:

 

  • Lauderdale: “Local resources do not put a dent in the problem.”
  • Baltimore: “The economy makes any major increase in local budget out of the question” in dealing with projected increased demand for HIV prevention and health services.
  • Houston simply states that “projected numbers exceed local resource capability.”
  • Indianapolis, in explaining the inability to meet projected demand, states that “HIV is not perceived as a threat to the general heterosexual community yet.”
  • In Kansas City, Missouri, “local resources are inadequate.”
  • Minneapolis: “Decreasing dollars in all areas of local programs mean that HIV prevention may not be a priority.”
  • San Francisco reports that "because of large city and state budget deficits...there will be fewer related public health programs, most notably mental health, prevention, and community based programs."
  • New York City mentions the “sheer scale of the epidemic here” in addressing the adequacy of
  • local resources.
  • San Diego: “Both state and local government [are] in extreme financial distress.”
  • San Juan: “Every day, cases increase. The proportion of new [financial] sources does not increase at [the] same rate.”
  • Anaheim: “The anticipated future caseload will produce a demand for services that will not be met with the current level of funding.”

 

Looking for Funds to Meet Future Demand

 

Seventy-two percent of survey respondents were not able to identify a source of funding for future needs. Survey respondents often cited federal resources as a source for coping with future caseloads. Baltimore, Boston, Chicago, Dallas, Jersey City, and San Diego specifically refer to Ryan White CARE Act funds as a needed resource.

 

[Page 35]

  • Baltimore will look to state and federal medical assistance, research money, and Ryan White CARE Act Title I funds to cover needed expansions.
  • Boston has no identified source of funding future needs but rather states that “only limited federal funds have been identified through the CARE Act. With the potential dismantling of state Medicaid optional services (as proposed in the current state budget) services will be cut, not expanded.”
  • Lauderdale: “Ryan White [funding] will keep us at the current level of services.” Ft. Lauderdale has 2,632 current AIDS cases and estimates there are an estimated 6,175-30,876 HIV infected in Ft Lauderdale.
  • According to Chicago, “the Ryan White CARE Act provides much needed funds; however, without full appropriations, service needs will remain unmet.”
  • Cleveland: “Unless funds from federal and state governments increase in this area, Cleveland will be hard pressed to financially maintain the needed resources. Local funds have already begun to plug gaps created by state and federal cuts. This cannot continue.”
  • Dallas identified Ryan White CARE Act funds, state HIV services grants, other federal programs, as well as city-county and private contributions as possible sources of funding.
  • Jersey City looks to Ryan White CARE Act funds as well as The Robert Wood Johnson Foundation.
  • San Diego will look to funds “partially through CARE Act Titles I and I.” San Juan identifies federal and private foundation funds.
  • Seattle: “The estimated revenue from all sources for all AIDS/HIV activities within the health department in 1991 is $10,364,494. The projected revenues for 1992 are currently estimated at $8,161,778 which represents a 21 percent decrease in funding. Meanwhile, surviving AIDS cases are estimated to increase by 26 percent by the end of 1992.”

 

Planning for the Future

 

As the epidemic continues, cities have undertaken a range of planning approaches in dealing with increasing numbers of AIDS cases as well as persons with asymptomatic HIV infection. These plans are often developed in a consortium with community service providers and often seek to address early intervention needs of persons not showing signs of HIV-related illness.

 

  • In Baltimore, a major new initiative is “to practice early intervention in STD clinics where approximately 600 new HIV infections each year are diagnosed.” San Francisco has developed plans which integrate and consolidate HIV prevention messages with that of other STD programs.
  • Boston: “Plans are being developed to establish early intervention/prevention services and integrating primary care with drug treatment; further plans have been developed to expand home based services. Lack of funding is a major barrier to expansion.”
  • Los Angeles: “Through federal CARE Act funds, we are establishing and strengthening early intervention and outpatient care facilities in diverse geographic areas of the county. We are also strengthening the referral network from HIV testing to treatment and social services.”
  • Houston reports that “limited funding for early intervention services [is] to begin in summer 1991."
  • Philadelphia: “Comprehensive geographic planning is ongoing to link outreach and prevention efforts with direct medical services, along with enhancement of psychosocial support network.”
  • Tampa: The county health department plan for care involves individuals diagnosed with HIV cared for in Primary Care Clinics; those with AIDS/ARC cared for in the specialized Patient Care Clinic.
  • In San Juan, the emphasis is on home care and ambulatory services rather than inpatient care. Case management services as well as increased prevention education activities for IV drug users, gay/bisexual men and women are planned.

 

[Page 36]

THE UNITED STATES CONFERENCE OF MAYORS

1620 Eye Street, Northwest

Washington, DC. 20006

(202) 293-7330

Files

Citation

“[1991] Impact of AIDS on American Cities,” OKEQ History Project, accessed March 1, 2024, https://history.okeq.org/items/show/698.