Twenty Years into the HIV Epidemic, Do We CARE Enough To Manage It Well?

• Human immunodeficiency virus infections
• Disease outbreaks
• Health services accessibility
• Quality of health care
• Health policy

Since the first case of AIDS was reported 20 years ago, maintaining broad access to high-quality HIV-related health care has been a major challenge of the HIV epidemic. This continues to be the case as the number of low-income persons who are HIV seropositive increases. This challenge is attenuated, however, by the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (Public Law 101–381), which was enacted by the U.S. Congress in 1990.

The Act comprises four Titles. Title I provides emergency relief grants for health care and support services to 51 eligible metropolitan areas (EMAs); Title II provides grants to states and territories to improve the quality, availability, and organization of health care, medications, and support services; Title III supports early, outpatient-based intervention services; and Title IV aims to improve the system of services for children, youth, women, and families affected by HIV infection or AIDS (1). A portion of the funds for each of the Titles is earmarked for case management, a core feature of the Titles that allows impoverished HIV-infected persons to be guided through a highly fragmented health system. No federal bureaucracy has evolved to micromanage the Title programs. Instead, in keeping with the belief of current federal leaders that “government closest to the people governs best” (2), much of the management of CARE programs is decentra zed and involves cooperation between local governments and community representatives.

From 1991 to 2001, the funds allocated for the CARE Act to the Health Resources and Services Administration of the Department of Health and Human Services increased from approximately $2.2 million to approximately $1.8 billion. The steady increase in federal funding for CARE programs has kept pace with …