Many of the comments made since the arrival of highly active antiretroviral therapy-the HAART era-relate to the number of those with HIV infection able to return to work or remain active in the community, living with the virus as a chronic disease rather than as an acute, life-ending infection. Looking inside an inner-city hospital to consider the changes, if any, in hospitalizations over the period of rapid implementation of effective antiretroviral therapy makes sense. We expect changes, we think we know what they are, but without verification we would be making policy based on our best wishes or worst fears and not on reality.Hospitals matter and clearly so in inner cities where a public hospital may be the only door open to an uninsured or underinsured population with few resources. In our best post–HAART era dream, HIV-related hospitalizations evaporate as medication puts all symptoms at bay; the HIV-positive person is occasionally an inpatient, but for unrelated problems, such as injuries from an athletic event. In our post–HAART era nightmare, the number of hospitalizations remains high and even rises higher as the adverse effects of drugs and the resistance of HIV to treatment both take their toll on an already vulnerable population.The article by Pulvirenti and colleagues1 reporting on the experiences of one hospital in inner-city Chicago suggests that elements of both are true, and it points toward at least a dozen more studies. Is the drop in admissions of those with substance abuse problems the result of the success of our outreach and syringe exchange programs, or the continuing denial of the very existence of these people? Is the increase in the white population admitted part of a new shift in demographics in the epidemic, or of the demographics of those attracted to or welcome at this hospital? Is the increase of admissions of those older than 50 the result of the successful aging of those infected years ago, or are these new infections in an older population? Is the increase in internal medicine admissions the result of conditions that would have appeared anyway as folks aged, or is this increase an indication of complex, subtle problems caused by antiretroviral therapy over time?What about the push to keep people out of the hospital? Or to shorten length of stay? What are the predictable or planned changes in admissions when a new facility is built as a neighborhood changes? If those plans leave out some of those previously served, is there an organized attempt to ensure continuity of care?Finally, the focus on hospitals in isolation may well mislead policy makers. The early days of the epidemic taught us how important home- and community-based services were. Without a critical analysis, it is impossible to say whether this need has increased or decreased and whether something about other services is behind the reported changes in hospitalization.The arrival of the HAART era let some policy makers stop worrying about HIV, but this article shows us that the availability of effective antiretroviral therapy has not made the HIV policy options any easier. In fact, it leads to even more questions and more concerns about needed services and support, especially for those vulnerable populations most at risk for HIV infection and most likely to turn to public resources for their care.
