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DURHAM, N.C. - The statistical data surrounding the HIV
virus have changed significantly in recent years.

Five years ago, being diagnosed with the virus that causes
AIDS was, in essence, the equivalent of receiving a death
sentence. But improvements in medical treatments have allowed
HIV patients in the United States to live longer, healthier
lives.

The types of people who are now contracting the virus also
are changing. While once a disease that primarily afflicted gay
men, it now is increasingly found in women and people who also
have substance-abuse and mental-health problems.

As a result, a federally funded study coordinated by the
Duke University Center for Health Policy, Law and Management is
about to be launched in 15 eastern North Carolina counties.
During the five-year study, about 500 people triply diagnosed
with HIV, substance-abuse and mental-health problems will have
their treatments coordinated by existing agencies in an effort
to measure whether such an integrated approach is
cost-effective.

Dr. Alison Heald, assistant professor of medicine at Duke,
said about one-fourth of all new HIV-positive patients seen at
Duke's infectious disease clinic also suffer from mental-health
and substance-abuse problems.

"Treating people who are triply diagnosed with HIV
infections, substance-abuse and mental-health problems is a
real challenge," Heald said. "It's a lot more difficult than
just getting them to the infectious disease clinic and getting
them to take their medications, because there are so many other
things in their lives that have priority over basic medical
care. For them, having a place to live, having a way to get the
clinic, having their substance-abuse and mental-health problems
in control, all of those things need to fall into place before
you can talk about treating them with medications.

"This project would allow us to treat the underlying
barriers to their care, to treat the mental-health problems, to
treat the substance abuse and, with that in place, then we'll
also be able to treat the HIV infection."

Many of the participants will be from rural areas, which to
date have not been included in any study largely because of the
logistical difficulties involved in treating people who can't
easily make it to appointments.

Kate Whetten-Goldstein, assistant research professor at
Duke's Center for Health Policy, Law and Management and the
study's lead investigator, said the $4 million federal grant
funding the study will help assure that patients can get the
care they need and that case managers can provide support for
patients to receive treatment.

Whetten-Goldstein said integrated treatments have been
"fairly effective" in treating triply-diagnosed people in urban
settings. "What we don't know is whether we can do it in a
rural area, and what we also don't know is if it's
cost-effective," she said. "Depending on our results, we may be
able to show to society at large and, particularly, to other
rural areas that there are some savings to be gained in
treating people in an integrated fashion. We also may find that
there aren't savings to be gained, but at least we'll know what
the true costs of providing care are and then payers such as
Medicaid, the state, third-party payers can decide whether they
want to treat people in an integrated fashion."

Among those agencies taking part in the study are the
infectious disease centers at Duke and the University of North
Carolina at Chapel Hill and the Southern Regional Area Health
Education Center in Fayetteville, which will provide HIV
primary care; the Cumberland County (N.C.) Mental Health Center
and the Duke Alcoholism and Addictions Program, which will
provide 12 months of integrated outpatient mental-health and
substance-abuse services to participants; and a network of HIV
case managers in 15 rural counties who will be cross-trained in
mental-health and substance-abuse management and who will
frequently visit patients to ensure they are adhering to their
treatments.

Heald said this integrated approach can potentially save
money "because if you treat HIV early and prevent problems, in
the long run you end up ahead. The medications are expensive,
so there's an upfront cost. There's an upfront cost, too, to
providing for the mental-health and substance-abuse care, but I
think it's a worthwhile investment and that we'll reap the
benefits in the long run. Patients will have fewer
complications, fewer acute hospitalizations, fewer disasters
down the road."

Vince Wagner, managed care director for Cumberland County
Mental Health, said there are now 16 to 20 people in his county
who are triply diagnosed with HIV, substance-abuse and
mental-health problems, and treatment for these individuals is
scattered. "Any one of those three is difficult to deal with.
With all three, you can imagine the problems for the system,
let alone for the individual.

"This is a more practical model," he noted. "We're always
looking for a better mouse trap." Bengie Hair, HIV care
coordinator at Cape Fear Valley Medical Center in Fayetteville,
thinks the greatest good could come from the fact that rural
clients won't have to travel so far for treatment. "Having a
substance-abuse or mental-health provider within the community
who is knowledgeable about HIV issues means there are greater
possibilities for intervention. I'm excited about this. It's a
new effort to meet the challenge of HIV in the state."

Heald agrees that this project potentially could do a lot of
good.

"I think the main reason this project is important is it
addresses a population that clearly has a need that has not
been met previously. That is folks who are dealing with three
diagnoses: HIV, mental-health problems and substance abuse.
This population previously, because of difficulties in getting
to the clinic, because of difficulties in getting their
personal lives in order, would often not be treated as
aggressively. Or there would be sort of this farce, where
doctors would prescribe the medications and the patients
wouldn't take it but would tell the doctors that they
were."

HIV patients who take their medication haphazardly run the
risk of resistance to further treatment, Heald noted. And
because of advances in medication, HIV patients are living
longer, healthier lives, which makes it more important than
ever that patients adhere to their treatment.

Heald said it is not known what the life expectancy is for
people with HIV.

"Five years ago, we would predict that people would become
ill and die from HIV in a five- to 10-year period," she said.
"These days, with the new medications, the estimates are very,
very difficult to give. Optimistically, 15-20 years. Who's to
say? And during this time period, perhaps we'll find a cure or
something that will enable doctors to prolong that period even
longer."

The five-year project begins Jan. 1. It is funded by five
different federal agencies: the Substance Abuse and Mental
Health Services Administration (the lead agency); Health
Resources and Services Administration; National Institute of
Drug Abuse; National Institute of Alcoholism and Alcohol Abuse;
and National Institute of Mental Health.