HIV disease is a substantial cause of morbidity and mortality in the United States. The Centers for Disease Control estimates that 650,000 to 900,000 Americans are infected with HIV, and disease due to HIV is responsible for about 8% of all years of potential life lost in the United States. The HIV Cost and Services Utilization Study (HCSUS) indicates that about 335,000, or less than half of these, are seen by a medical provider at least every six months, and that about 13%, or more than 40,000, of all those under care are veterans. Extrapolation of VA’s Immunology Case Registry data suggests that the Veterans Health Administration sees nearly 40% of all HIV-infected veterans. Since optimal care for HIV-infected persons can cost up to $30,000 per year per patient, and since sub-optimal care is associated with more rapid progression to significant (and expensive) complications, VHA has a substantial clinical and financial stake in quality of HIV care.
Great strides have been made in the management of HIV. Many opportunistic complications now are largely preventable using chemoprophylaxis, and episodes that do occur generally cause much less morbidity and mortality than in the early days of the epidemic. The greatest improvements have come in the treatment of HIV itself. The ability to measure HIV activity directly with viral load testing and to often suppress viral replication with highly active combination antiretroviral regimens have revolutionized treatment. These regimens however include an expensive and difficult-to-use protease inhibitor or a non-nucleoside reverse transcriptase inhibitor. They are difficult to use because of a high incidence of adverse interactions with other drugs and because they require patients to adhere carefully to dosing schedules or risk viral resistance and treatment failure. Nevertheless, these therapies have diffused rapidly in the HIV-infected population: during 1996, use rose from one-sixth to.........
