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INTRODUCTION
The human immunodeficiency virus (HIV) epidemic will present major challenges to the U.S. health care system in the coming decade. By the end of 1990, more than 160,000 people in the United States were reported to have acquired immunodeficiency syndrome (AIDS) (Centers for Disease Control, 1991). An estimated $50 billion will be spent in the 1990s for HIV health care (Pascal et al., 1989). Recent developments in the epidemiology and treatment of persons infected with HIV also bear important consequences for the health care financing and delivery system. Survival time has increased since the early years of the epidemic (Harris, 1990; Lemp et al., 1990; Seage et al., 1990). Improved therapeutics offer the promise of delaying the onset of debilitating symptoms and of longer survival (Hellinger, 1988; Pascal, 1987). Treatment of persons with HIV disease is shifting from the acute care inpatient hospital setting to outpatient and community-based modalities (Arno and Shenson, 1990; Hellinger, 1988). AIDS is now considered to be part of a spectrum of HIV disease and, accordingly, HIV health care models must also incorporate a range of settings for the delivery of services.
In this context, long-term care for persons with AIDS (PWAs)(1) is an important policy issue. As the nature of the disease shifts from the acute to the chronic, interest has arisen in the provision of home health care as a more humane and less costly alternative to long-term institutionalization. There is increasing recognition that HIV health services should be organized along a continuum incorporating both the acute care and the chronic illness management needs of persons with HIV (Benjamin, 1988). As prevalence and survival continue to rise, the direct and indirect costs of HIV will also increase. Home and community-based long-term care is therefore looked to for potentially providing both the cost effectiveness and the continuity of care required. Little is known, however, about the cost, delivery, and quality of home and community-based services for persons with HIV. In order to make informed policy decisions, there is a need for more analysis of the issues involved and of actual experience to date in providing long-term HIV care.
This article discusses the policy context of long-term HIV services and reports on an empirical study of the Nation's first...