San Francisco Chronicle - Monday June 19, 1989
Randy Shilts

Top officials from the U.S. Department of Health and Human Services undoubtedly will be offering many acts of contrition to Bush administration budget officials this week, even as HHS has maneuvered to get public pressure behind an ambitious plan to provide early AIDS treatments to the hundreds of thousands of HIV-infected Americans.

The future of federal AIDS policy started Friday with the release of the latest issue of the federal Centers for Disease Control's official publication, the Morbidity and Mortality Weekly Report.

The little article seemed innocuous enough - "Guidelines for Prophylaxis Against Pneumocystis carinii Pneumonia" - and most of the article was devoted to recommending procedures for administering aerosolized pentamidine to prevent Pneumocystis pneumonia, long the major killer of AIDS patients.

Buried away in an editorial footnote, however, is the proviso, "All persons found to be infected at HIV testing and counseling centers should be referred for further medical evaluation including a measurement of their CD-4 cells. Centers should develop networks of medical care providers sufficient to evaluate and care for the infected persons they identify."

From a medical point of view, there's nothing controversial here. Now that interventions exist that can keep HIV-infected people from getting one of the most virulent AIDS killers, it only makes sense that all HIV-positive people be referred somewhere for the immunological tests and drugs that can help keep them alive.

From a policy point of view, the problem is that the "networks of medical care providers" called for in the guidelines do not yet exist. And creating such networks will cost money. Piles of it. At this point, nobody is sure where it's going to come from.

Although private health payers will reimburse the costs of the tests and treatments for those who are insured, the federal government now bears about 40 percent of all AIDS-care costs nationally.

But if AIDS care is expanded, the federal government probably will have to assume an even larger financial burden since the bulk of HIV-infected people who would make use of the new treatments are impoverished intravenous drug users and their sexual partners, most of whom rely on federal Medicaid programs for health care.

Add to this the cost of setting up the hundreds of clinics that would be needed to screen the estimated 1 million people who the federal government says are HIV-infected.

And for those who are healthy enough to not need the pneumonia prophylaxis right away, the guidelines recommend immunological tests - at $100 a shot - every six months.

Dr. James Mason, assistant HHS secretary for health, conceded last week that the costs "could well go into the billions of dollars."

Leaders of several leading AIDS lobbying groups were incensed when Mason leaked word of the morbidity and mortality report at the international AIDS conference in Montreal two weeks ago. They reasoned that it was irresponsible for the government to call for massive immunological screening and treatments without first figuring out how it would be paid for.

"What clinics are ready to meet the demands for health care that will come from this?" asked Jeff Levi, executive director of the National Lesbian & Gay Task Force. "This policy must be put in the context of the whole public health package that will be needed to implement it."

Mason countered that he could not responsibly hold up government scientists from releasing information that could help doctors save lives.

The assistant secretary is no stranger to Washington, however, and the release had a political context as well. By simply issuing the treatment guidelines, the HHS leaders undoubtedly hope a groundswell of support for treatments will force the Bush administration to shell out the billions it would otherwise not be happy to spend.

Even though health officials might end up begging for forgiveness, such a strategy would undoubtedly have greater success than asking permission from budget officials earlier in the game.

Moreover, they know the pentamidine issue is only the start.

Expecting that AZT may soon be shown effective in delaying the development of AIDS in HIV-infected people, HHS is working on estimates of what widespread distribution of the drug would cost. The preliminary government price tag for AZT, aerosolized pentamidine and the necessary immunological tests for those who need them: $4 billion a year.

Of course, this money would mean huge savings when compared with the federal hospitalization costs that would pile up if all these hundreds of thousands of people get sick. However, that still may not stop some Bush administration budget officials from wanting to hold the line on AIDS spending.

The battle over this level of spending will make earlier disputes over issues such as antibody testing look as mild-mannered as a Barry Manilow concert.

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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