Over the past 30 years, the New York community has united in unprecedented ways to combat the AIDS epidemic. NGOs have brought communities together to advocate and expand access to care, private companies have worked with providers to decrease the cost of medications, and government has committed millions of dollars to treat affected individuals.
However, most of these efforts have focused on delivering medical solutions after patients have already seen a doctor. PReP (Preventative-Exposure Prophylactic) and HAART (highly active antiretroviral therapy) treatments for preventing and managing HIV/AIDS are highly effective and can prolong life for decades, but in 2012, only 44% of New York’s 1 million HIV-positive individuals had a suppressed viral load. If these medications are so effective, why don’t more people use them consistently?
The answer lies outside of the doctor’s office and in the communities where people live, work and play. To bend the curve of the HIV/AIDS epidemic, funders and activists need to focus on wraparound care – the non-medical services that that increase the availability or effectiveness of HIV/AIDS treatments. Wraparound care works to link, retain, and support in care those who may need help taking their medications regularly, getting to their appointments on time, or coping with the psychological and emotional stresses surrounding their diagnosis. It can include housing support, transportation, child care, emergency financial assistance, therapy, substance abuse assistance, and mental health resources. The right combination of these services for each patient can provide stability and offer a safety net so that unexpected events do not have long-lasting negative health consequences.
In 2005, Utah’s government made a bold case in favor of using wraparound services to improve outcomes and lower costs. Utah’s Housing First program calculated that emergency room visits and jail stays cost the state $16,670 per person annually, but providing a free apartment and a social worker for each individual only cost $11,000. The state also did away with previous standards that homeless individuals with substance abuse problems must cease drug or alcohol use before applying for housing. Traditionally, housing assistance programs have operated under the assumption that clean and sober people would be better equipped to seek housing, but researchers found that the reverse was true: people living in a stable home are better equipped to seek treatment.
This progressive strategy found an unlikely champion in the conservative state of Utah, but the results speak for themselves. Since the state began providing free housing and social work services eight years ago, chronic homelessness in Utah has fallen 72%. Since then, similar studies in Denver and New York City have confirmed Utah’s findings – paying to house high-risk individuals actually reduces costs in the long term. One of the largest areas of cost reduction is in emergency medical care.
Despite this clear evidence, shifting the actual models of care is a slow process. Existing support services often are only funded for the extremely poor or extremely ill, reacting to conditions once they have intensified rather than preventing them before they advance. New York’s HIV/AIDS Services Administration (HASA) department is one such program – the Administration provides housing and emergency support, but only after patients have verified with a litany of forms that they suffer from HIV and its severe complications. Rising initiatives spearheaded by the Bailey House and other outreach organizations seek to expand this service, using a “HASA for all” approach to expedite access to housing for every HIV+ patient, regardless of their comorbidities. These initiatives could be expanded and mimicked for at-risk populations with other costly and chronic conditions.
Without housing, many homeless individuals are unable to seek treatment. Similarly, without the socioeconomic support that several HIV+ patients need, many cannot take their medications regularly or are never linked into care at all. The challenge lies in encouraging governments, companies and donors to invest in wraparound care. The effectiveness of antiretroviral therapy is backed by a litany of peer-reviewed studies, but similar studies on the effectiveness of providing social counseling or emergency support have yet to be conducted on the same scale. In addition, even when the literature does support wraparound care, it can be hard to shift deeply ingrained paradigms of treatment and practice. Bending the curve of the AIDS epidemic requires funders and providers to remember that lowering the barriers to treatment in patients’ environments will increase the effectiveness of those treatments in the patients themselves.