Strip Mall Medicine

Will a flood of new AIDS patients break the system's back?

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Tucked away at the edge of a ramshackle strip mall on the black side of town in Montgomery, Ala., there's an AIDS clinic. When I was last there, in 2005, the mall featured just a couple of weather-beaten shops—a dollar store, a beauty parlor—and this nondescript clinic, quietly declaring its presence without using the word AIDS in its marquee. Staff there tell stories about handing meds out the back door to patients too scared to come through the front, so the discretion is warranted.

The fact that such profound fear lingers a quarter century into the AIDS epidemic is one of the many complexities doctors must untangle in order to provide quality care in black communities. But the more notable challenge for this little clinic is its jurisdiction: At the time, it was the only AIDS clinic serving uninsured patients in the entire southeastern quarter of Alabama. There's the emergency room, of course, and there are private infectious disease specialists for those with insurance. And for everybody else, there's the strip mall.

"For a lot of people, we're able to patch together an amazing amount that works," one harried doctor told me, "but there are a lot of holes." Her statement succinctly describes what AIDS treatment looks like in a growing number of black neighborhoods today: A frayed patchwork of care providers triaging an expanding epidemic with diminishing resources. And by all indications, it's about to get worse.

The Bush era has been marked by ideological wars over science and public health—from stem cell research to abstinence-only sex education. But outside the glare of these high-profile debates, the administration has also presided over an exploding AIDS treatment crisis. After seven years of neglect, the AIDS safety net that stopped American deaths in the 1990s is bursting at the seams. And like most things, it's a problem most acutely felt by African Americans. Two-thirds of blacks suffering from HIV/AIDS depend upon public insurance programs to pay for treatment; 60 percent of those who turn to clinics like the one in Montgomery are people of color.

The pressure is most obvious down South, where more than half of all new HIV infections are now logged. Most southern communities still lack the infrastructure that AIDS activists long ago built in the big northern and western cities where the epidemic began. So year after year, treatment waiting lists develop across the South as the programs that finance AIDS meds for the uninsured simply run out of money.

But the problem stretches above the Mason-Dixon Line as well. Even in places like Chicago, Detroit and Washington, D.C., service providers report having to turn patients away. We hit a nadir in 2004, when there were more than 1,600 uninsured Americans on treatment waiting lists.

None of this should come as a surprise to policy makers. The federal Centers for Disease Control and Prevention (CDC) announced in 2005 that the HIV/AIDS epidemic had grown larger in the U.S. than ever before. Today, an estimated 1.2 million Americans are HIV positive; a whopping half of them are black. You'll look in vein for similar growth in resources to meet that demand. The primary federal vehicle for funding programs like the one in Montgomery has seen little new investment since 2001. Its budget inched up $300 million between fiscal years 2001 and 2006—which is about the same amount we were spending every month in Iraq that year.

Now the pressure on the system is about to ratchet up.

The CDC estimates a quarter of Americans who are HIV infected don't know it—including more than half of HIV-positive blacks—and it says that these undiagnosed infections are driving the epidemic's growth. So the agency has launched a massive campaign to get everybody in America tested. In late 2006, it issued new guidelines urging hospitals to test every patient between the ages of 13 and 64 who doesn't explicitly reject it.

The CDC points to New York City's public hospital consortium for proof of how well this sort of aggressive testing policy can work. The consortium cranked up its HIV testing program in fiscal year 2005; by fiscal year 2006 the number of new HIV diagnoses it logs had nearly doubled. But the burning question is who will provide treatment and care to all these newly diagnosed people? There's no room at the clinic for this kind of growth.