摘要：To strengthen the quality of HIV care and achieve improved clinical outcomes, payers, providers, and policymakers should encourage the use of patient-centered medical homes (PCMHs), building on the Ryan White CARE Act Program established in the 1990s. The rationale for a PCMH with HIV-specific expertise is rooted in clinical complexity, HIV’s social context, and ongoing gaps in HIV care. Existing Ryan White HIV/AIDS Program clinicians are prime candidates to serve HIV PCMHs, and HIV-experienced community-based organizations can play an important role. Increasingly, state Medicaid programs are adopting a PCMH care model to improve access and quality to care. Stakeholders should consider several important areas for future action and research with regard to development of the HIV PCMH. Combination antiretroviral therapy (ART) is critical to the management of HIV/AIDS because it improves survival of HIV-infected persons 1,2 and reduces rates of both sexual and mother-to-child transmission of disease. 3,4 Adherence to ART decreases the average mortality rate in people living with HIV (PLWH) by one half, 2 reduces sexual transmission of HIV-1 in serodiscordant couples by 96%, 4 and reduces the frequency of mother-to-child transmission to below 2%. 3 Because of these clinical and preventive benefits, increasing access to ART and retention in care remains an important public health strategy. Unfortunately, the Centers for Disease Control and Prevention estimates that of the 1.1 million people living with HIV disease in the United States in 2012, only 37.0% were retained in HIV care. 5 Only 25.0% of PLWH have achieved viral suppression (defined as a sustained viral load of ≤ 50 copies per mL). 5,6 The Centers for Disease Control and Prevention considers ART with durable viral suppression key to a comprehensive HIV prevention strategy. 7,8 Recent estimates show that increasing the HIV diagnosis rate (i.e., the percentage of individuals aware of their infection) to 90.0%, achieving 80.7% viral suppression in care, and obtaining full funding of behavioral interventions for PLWH could avert nearly 180 000 new infections by 2020. 9 Difficulties in accessing ART and achieving viral suppression stem from delayed diagnosis and other challenges to engagement and retention in care, such as substance use, unstable housing or homelessness, psychiatric disorders, language barriers, and incarceration. 10,11 Regular adherence is crucial for long-term viral suppression, and missed doses or significant variation in dosage timing can lead to viral resistance that may portend treatment failure. 12,13 Serving PLWH through a patient-centered medical home (PCMH) may be a successful strategy for increasing the number of people who remain in care and achieve viral control. PCMH models, which have evolved over decades, focus on whole person care coordinated across all the elements of the health care system and the patient’s community. 14 Both the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act include the PCMH as a valued strategy for accomplishing key goals of improving quality of care and cost containment. 15–17 The national rate of 25% viral suppression reflects a need for development and refinement of the PCMH specifically designed for PLWH, or the HIV PCMH. Stakeholders across the health care system—including providers and payers—should ensure that a growing proportion of PLWH enroll in a PCMH with specific HIV expertise that comprehensively meets their needs. An alternative policy direction would be to enroll PLWH into traditional PCMHs that address the full spectrum of primary care, although that alternative is suboptimal.
