San Francisco Chronicle - Wednesday, June 7, 1989
Randy Shilts, National Correspondent

The recommendations may require public expenditures "well into the billions of dollars," said Dr. James Mason, the assistant secretary for health of the U.S. Department of Health and Human Services.

The joint guidelines of the National Institutes of Health and the U.S. Centers for Disease Control will set official standards for the use of treatments that recently have been found to prevent Pneumocystis carinii pneumonia, the major killer of people with AIDS.

The proposal calls for more aggressive AIDS testing of people at risk for the disease. Those found to be HIV-infected would be tested every six months for the status of the immune system.

Administration of prophylactic pneumonia treatments would be routine when the immune system began to fail, according to the guidelines.

Although the report merely formalizes medical care practices that already are routine among doctors familiar with the disease, it also contains a public policy bombshell.

A statement by the federal government that all people infected with the Human Immunodeficiency Virus (HIV) should regularly take expensive laboratory tests on their immune systems as well as expensive pneumonia preventions means that private health insurers and public health financers, such as the Medicaid program, will be under serious pressure to pick up the tab.

Nationwide, the CDC estimates that 1 million Americans are infected with HIV. Although estimates are imprecise, some federal experts believe that about 200,000 of these people have had their immune systems decline to the point where they are vulnerable to an attack of pneumocystis and likely candidates for preventive therapies.

About 40 percent of AIDS patients nationally end up having their care paid for by the federal Medicaid program during the course of their disease.

Mason conceded that the public cost of regular blood testing and early AIDS treatments would "presumably . . . go well into the billions of dollars." However, he said, he did not believe the government or private insurers could avoid the expense.

"It would be of great concern to me if drugs that might extend and improve the lives of people were denied to them because of cost," said Mason, who was attending an international AIDS conference in Montreal. "This is something that both private financers of health care and the government will have to face."

In a city such as San Francisco, where between 25,000 and 30,000 gay men are believed to be infected with HIV, the costs of such a program will easily run into the millions of dollars, local health officials said.

"If you figure (immune) tests are $60 to $70 apiece and you give them twice a year to 25,000 people, it adds up," said Dr. George Rutherford, director of AIDS Activities in the San Francisco Department of Public Health.

"Even if only 25 percent of these people get aerosolized pentamidine (for pneumonia prevention), that's a lot of people taking a $100-a-month treatment," he said.

Ultimately, experts agreed, these costs would be offset by savings in costs of treating pneumocystis. Most estimates place the cost of a typical pneumonia hospitalization at $10,000 per episode, and most AIDS patients usually have two to three bouts with the disease before succumbing.

A $1,200 annual cost in providing aerosolized pentamidine, therefore, would be compensated for by a savings in later hospitalization costs of as much as $30,000.

A supporter of the federal proposal, Dr. Robert Redfield of the Walter Reed Army Medical Center, said the Army had routinely been providing pneumocystis prophylaxis to HIV-infected military personnel since 1986. "We hardly ever see a case of pneumocystis in the Army," Redfield said.

"It's very difficult to justify the fact that 17,000 people died of AIDS-related pneumocystis last year when you consider that we can prevent it," he said. "I get upset when I realize it's still the leading cause of death from AIDS."

Congressional Democrats and leaders of AIDS advocacy groups worried that the Bush administration would not free the funds to follow through on the NIH-CDC guidelines.

"The public health experts should be talking to the budget makers now to explain why we need millions for the tests and preventive drugs today in order to save hundreds of millions tomorrow in hospital costs," said U.S. Representative Henry Waxman, D-Los Angeles, chairman of the House subcommittee on Health and the Environment.

"We have to assure that everyone has access to the treatments discussed in the recommendations," said Jeff Levi, executive director of the National Lesbian & Gay Task Force.

Mason said the potential costs will play no role in the decision to release the proposed guidelines.

Always watch for outdated information. This article first appeared in 1989. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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