Many individuals also have pre-morbid chemical dependency and/or mental illness diagnoses which complicate their treatment and adaptation to their illness. Addressing psychosocial stresses and lifestyle readjustments is an essential part of the treatment process and thus facilitates the effective use of a costly treatment program, and can maximize rehabilitation potential.

The reductions in hospital admissions has created an increased number of patients in care and has changed the focus of care from one of preparing to die to helping people live quality lives. While there is much hope for people with HIV since the development of new treatment protocols, people are still faced numerous personal crises that impact on their overall well-being. Patients who once had to deal with imminent death are now faced with numerous choices of how to live their lives; usually with the aid of rigorous and intensive treatment protocols.

Alicia is the mother of two children and has been followed in the clinic for 2 years. She is considering one of the new treatment protocols, but is reluctant because she has had side effects from previous treatment regimes. She is appealing her SSI re-evaluation which states that she is now able to work.

Social workers, always having been on the front line of the epidemic are now faced with fewer resources to assist patients living with HIV. Alicia was managing well until the problems with SSI started. Prior to her diagnosis she was living on the streets, prostituting. She started to get her life together 2 years ago when she began coming to the clinic. She entered a Methadone Maintenance program and got her children out of foster care. Now while she is considering a new treatment which could extend her life significantly, SSI finds her to be able to work. Alicia does not have marketable skills and until now has only focused on living with the disease until death. The social worker's role is to assist Alicia with her current financial needs while linking her to job training programs. The greatest challenge is to work with Alicia around relapse prevention and stress reduction.

Pedro was released from prison shortly after he was diagnosed HIV+. He had no place to live, no entitlements nor health coverage; all he was given upon release was the number to the clinic and medication.

It is not uncommon for people to be released from prison without appropriate services. HIV positive, Pedro is returned to the streets. He requires assistance with housing and entitlements. The social worker arranges for him entitlement assistance from a local agency specializing in work with the recently incarcerated. Pedro is wary of social service agencies and difficult to engage. He does not understand the treatment regime he is on and his lack of housing makes it difficult for him to take the medications as prescribed. The social worker's role is to assist Pedro with integration into the clinic system and to assist the medical and nursing providers to understand why he seems so resistant to their interventions. Counseling is focused around his feelings of anger, frustration and developing trust.

Alvin is dying from AIDS. He has been in the hospital for 4 weeks and wants to go home to die. He finds out from a friend that his apartment has been broken into and trashed. The social worker, concerned about his safety upon discharge, arranges to go to the home to assess its condition before he leaves the hospital.

Despite the new hope for AIDS patients, people are still dying. The reductions in hospital admissions and lengths of stay does not result is less suffering and death. Many patients who are hospitalized are sicker and more likely to die than a year ago. AIDS social workers on inpatient units once could have a mixed caseload of relatively well and seriously ill patients, thus creating some sense of balance in doing the extremely difficult work of watching patients die and helping their families. There may be less of a need for inpatient social workers but the work is more intense and therefore the risk for burnout greater. Many times the social worker becomes the sole source of support for patients like Alvin who have minimal supports in the community. Doing a home assessment may be rare for an inpatient social worker, but when the patient repeatedly asks to go home to die the social worker will often do what there is no one else to do. The social worker arranged to have the locks changed the day she visited the apartment and then subsequently gathered a group of volunteers from local agencies to clean it up. The patient went home with 24 hour home health services, content to be in familiar surroundings.

John and Julie are new to the clinic. They have been married three years and John was found to be HIV+ during a recent hospitalization. Julie is anxiously waiting for her HIV test results. Their relationship is under a great strain. She is angry with John being HIV+ and possibly infecting her. She states that she will leave him if she is positive.

The gift of new treatment regimes does not relate to transmission prevention. Social workers have a vital role to play in counseling patients around risk reduction including safer sex. John and Julie will have a bumpy ride ahead of them. Couple and family counseling are fundamental services that are provided by social workers both in clinics, inpatient units and community agencies.

The Bridge Project

Since earlier monitoring and treatment is recommended with many of the treatment protocols the Bridge program was designed to assist people infected HIV make decisions about medical treatment soon after the diagnosis rather than wait for another medical crisis. Those newly diagnosed are often isolated and suffer alone with turbulent emotions and defer treatment because they feel 'fine'. The Bridge Social Worker reaches out to these individuals for counseling and practical assistance. Once engaged and the crisis subsides the individual can make some decisions about treatment facility, medical provider and begin the task of rebuilding a life.

Managed Care

In many ways, social workers have always "managed care" for their patients. As the health care system shifts towards managed care it is important that social workers participate in the design and function of these new entities. All social workers can help to insure that these "new care models" appropriately serve patients while maximizing precious resources. The New York State Department of Health is currently developing a Request for Proposal for HIV Special Needs Programs (SNP). Hospitals, community based organizations, and the private sector HMOs are competing for these managed care contracts. Social workers in these settings have an opportunity and a responsibility to influence and, ideally, manage the process.