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Despite nearly 20 years of HIV prevention efforts, rates of new HIV infection persist at an alarming rate. As successful antiretroviral medications enable many HIV infected persons to live longer, healthier lives, interventions are necessary to support ongoing prevention and reduced risk behaviors. This article describes a survey that was used to assess the opportunities and challenges related to the integration of prevention screening into the work of HIV/AIDS case managers. The article describes the survey, reports the findings (N = 101), and concludes with a discussion of issues that must be addressed prior to incorporating prevention screening into HIV/AIDS case management.

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A substantial and increasing number of people have acquired HIV infections in their later years, as a result of male-to-male sexual contact or blood transfusion. However, heterosexual transmission also occurs, and substance abuse is often a factor. Health and service practitioners need to develop sensitivity to the needs of HIV-infected elderly people and their families. Prevention efforts and education should be incorporated as part of their initial assessment. Issues of treatment regimens, adherence, confidentiality, social support, and nondiscrimination are critical concerns when serving this population.

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Caring for persons with AIDS and HIV-related illness is extremely rare within long-term care facilities. A survey of 54 Illinois nursing facilities indicated that homes were reluctant to care for persons with AIDS due to concerns about cost, staff capabilities or resistance, and concerns about mix with other residents. Although nursing homes are often blamed for the limited care provided for persons with HIV infection, this study indicated that the demand on facilities to provide this care is quite limited to date.

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Hospital social workers were surveyed to identify referral efforts and outcomes for clients with human immunodeficiency virus (HIV) infection who required long-term placement. Over a three-month period, none of the 42 identified clients was admitted to a nursing home. In two-thirds of the cases, social workers contacted only one facility, and in about one-sixth of the cases, workers reported no placement attempts. Clients remained in the hospital a median overstay of eight days beyond acute care needs, representing 205 aggregate days that could have been spent in less intensive settings. Workers made few placement attempts because of beliefs that they would be unsuccessful or that nursing homes would not accept admissions. Increased communication and education both for referring workers and for long-term care facilities may improve the referral process, reduce costs, and decrease emotional distress for people infected with HIV.

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The feasibility of a state policy to permit home care agencies to hire kin as caregivers was explored by examining existing data on a state program that allowed relatives to be hired. Of 444 clients, 22% had kin as paid caregivers. Co-residence and kinship were associated with higher disability levels and a higher level of eligibility for services as determined by a functional assessment tool used by the state to determine care plans. The limited number of clients with paid caregivers who were kin suggests that there may be a natural limit to the demand for such an option.

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Home care agency administrators were surveyed to explore their views on hiring kin to care for their own relatives. The results suggest that formal systems may tend to view paid family caregiving in ways similar to policy makers who express concern about substitution for unpaid care and runaway costs. Many administrators expected that families may abuse the program and accept pay for work not performed. A major implication of the study is that implementation of family compensation through agencies could result in attempts to focus on controlling informal care.

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Agencies that provided home care services for the elderly were surveyed to identify the services that they provided to support family caregivers. More than one-third of the responding agencies provided various family supports, including referral information, training and support groups, counseling, and hiring of family members as caregivers. Agencies favored expanding concrete and psychosocial services rather than financial supports.

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The current approach in the United States to the provision of community care to the elderly interacts with the feminized structure of family care-giving to foster inequities for women, who provide the bulk of informal, unpaid care. The central concern of present policies with limiting eligibility and rationing benefits results in policies that reduce the choices of these carers, many of whom are already substantially disadvantaged by their economic position in society. What is necessary for gender justice is development of policies that address the needs and rights of carers and elders by providing necessary supports to families, including, when appropriate, adequate compensation to carers. We argue for an approach that takes into account the relationship of the adequacy of government support and the capacity of individuals to freely choose the caregiving role.

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Speaking disorders frequently result in serious consequences for mentally impaired elderly people. Two examples are presented illustrating the modification of both excess and deficit rates of talking via differential reinforcement procedures. Two men exhibiting verbal disorders severe enough to impair social interactions and lead to possible nursing home placement were treated by teaching their spouses to reinforce positive and ignore undesired verbal responses. Problem behaviors were reduced sufficiently to permit continued home care, and alternative positive behaviors were increased. These findings suggest that verbal behavior of the mentally impaired elderly can be affected by applying systematic consequences and can be modified by relatively simple procedures. These procedures provide an alternative to the negative effects of labels associated with either aversive or deficient verbal behaviors, promote more positive activities, and enable continued residence at home. Further, this research provides support for the generality of the utility of training spouses to serve as behavior therapists for the impaired elderly.

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