Health services research on HIV disease: what's new, what's unique?

The human and social costs of the human immunodeficiency virus are mounting rapidly in the U.S. and abroad. It is likely that this disease will help catapult us into health care reform in the current decade. Hopefully, health services research on HIV disease will contribute to the debate on what the nature of this reform should be. We need to understand the implications of access barriers facing those with no insurance as distinct from those with public insurance. We must grapple with and understand the implications for estimating the costs of AIDS, of open-ended, publicly funded acute care for persons with HIV. Furthermore, we must understand the long-term care needs of chronically ill AIDS patients with frequent periodic life-threatening acute events and the optimum structure(s) necessary to provide such care. Above all, we must be sensitive to the rapidly evolving treatments for HIV and the fact that these can make cost projections completely obsolete almost before they are made. Health services research on HIV disease must, of necessity, focus on many of the traditional themes of our emerging discipline. At the same time, the fact that it is an infectious disease with an observable transformation into a chronic condition has implications for the way we study it and how we define the emergence of clinical disease. This has implications for how we conduct health services research on the entity and may push us toward a new set of methodologies that borrow more from epidemiology than cost accounting.