The Wall Street Journal - 22 Apr 1992
Hilary Stout, Staff Reporter of The Wall Street Journal

That money is desperately needed, says foundation board member Peter Staley, because the government "is obviously not spending enough" to fight AIDS.

Yet others argue that in view of the many other serious health threats, the U.S. government is in fact spending enough on AIDS -- or even too much. "We're spending far more per death on AIDS than we are on these other killers" such as cancer and heart disease, protests Rep. William Dannemeyer, a California Republican.

Such divergent views reflect a growing debate over spending on the dread disease. Yet even as the issue becomes more politicized, there remains widespread confusion about how much truly is being spent and in what way.

There's no question that federal AIDS spending has gone up tremendously in recent years. President Bush's proposed fiscal 1993 budget calls for authorized spending of $4.9 billion, up from $4.4 billion in the year ending Sept. 30. The budget boasts of a 118% increase in AIDS spending authority since Mr. Bush took office in 1989. In research, the government now spends more on AIDS than on any other disease except cancer.

But the Bush budget exemplifies the AIDS-expenditures confusion. Documents and interviews with federal officials show that much of what the administration calls AIDS spending doesn't reflect investment in research, treatment or prevention but rather obligations under entitlement programs; such spending isn't included in government calculations of spending for other diseases, such as cancer.

The administration's budget proposal includes $2.5 billion for AIDS treatment in fiscal 1993, up 20% from this fiscal year -- and up 240% from the $737 million spent in 1989. But the vast majority of that money is projected spending for AIDS patients under Medicare, Medicaid and other government programs providing medical care to the poor and the elderly, the military ($61 million), veterans ($404 million) and federal prison inmates.

Entitlement spending also includes $570 million for income support in fiscal 1993. This mainly is in Social Security disability payments to AIDS patients and reflects the rising number of people stricken.

"Calling this AIDS spending is a deliberate and cynical sham," contends Rep. Henry Waxman, chairman of the House subcommittee on health and the environment. "The growth is because more and more Americans are dying of AIDS, and they are eligible for basic safety-net programs because they are elderly, disabled, veterans or poor."

James Allen, director of the National AIDS Program Office, a part of the Department of Health and Human Services, says the administration includes entitlement programs in its AIDS spending tally "because we feel, given the criticism that the federal government isn't spending enough, it is important to understand what this epidemic is costing the nation and what the treatment programs are putting into it."

Government health programs such as Medicaid are, in fact, crucial in helping AIDS patients get and pay for medical care. Medicaid pays for about 40% of all AIDS patients in the U.S. (for 90% of children with AIDS), picking up about 28% of all AIDS treatment expenses in the country, according to a Health Care Financing Administration official.

But of the $2.5 billion in the budget for treatment in fiscal 1993, only $340 million would go directly to expand health services to AIDS patients. That money is targeted for a federal grant program for states and communities to expand AIDS services. The legislation establishing the program, named after Ryan White, an Indiana teenager who died of AIDS, authorizes $875 million for the initiative. But Mr. Bush has never asked for -- nor has Congress appropriated -- even half that.

Moreover, for people facing AIDS, Medicare and Medicaid support comes very late. In order for childless adults between 22 and 65 years of age (which includes most AIDS patients) to get coverage under Medicare or Medicaid, they must meet the Social Security Administration's disability criteria. That means they can't be working and must have severe manifestations of AIDS. To be eligible for Medicare, a patient must have been receiving Social Security disability payments for 24 months. (And such payments begin only after a five-month waiting period following the filing of a Social Security application.)

Thus, it is almost impossible for most people to get federal coverage for treatment during the time between a positive blood test for the human immunodeficiency virus, or HIV, and falling ill with AIDS. Careful monitoring is critical during this time, doctors say, and some believe that such drugs as AZT can stave off infections and AIDS-related illnesses. While research is conflicting, a new study published last week found that people infected with HIV who take AZT live longer than those who don't take the drug until they develop AIDS.

Shortly after basketball star Magic Johnson learned that he was HIV-positive, he began taking AZT. But for people without money or insurance who depend on government aid to pay for costly prescriptions, that isn't a realistic option.

"The whole system hasn't developed an early-intervention system, between when you get tested and when you get care," complains Dave Cavanaugh, AIDS program coordinator for the National Association of Community Health Centers.

Apart from treatment, the largest spending category is research. The administration proposes to authorize spending of $1.2 billion, which eclipses that for all other diseases except cancer, at $2 billion. The administration would authorize spending of $772 million on heart disease, $100 million on stroke and $292 million on diabetes next fiscal year, according to the Department of Health and Human Services. More than 712,000 Americans will die of heart disease in calendar 1992, about 522,000 of cancer and 50,000 of diabetes, the government projects. About 51,000 will die of AIDS.

But overall cancer and heart disease rates are level, and declining in some categories, while AIDS is on the rise. For years, the Centers for Disease Control has been estimating that at least a million Americans are infected with HIV. As of January, 209,693 actual AIDS cases had been reported to the disease centers; by the end of 1993, CDC officials estimate, AIDS cases in the U.S. could double, to between 390,000 and 480,000. CDC officials believe that, because of underreporting by doctors, the actual totals are probably 15% to 20% higher. More Americans are expected to die of AIDS this year and in the next two years than in the past 10 combined. And the CDC has proposed expanding the definition of AIDS; if that happens, 160,000 additional HIV-infected people with certain symptoms will be added to the total.

Though the rate of new infections seems to be slowing among homosexual men, it is increasing among heterosexuals, both male and female. Still, in the U.S. the number of AIDS patients who have contracted the disease from a heterosexual partner who doesn't use intravenous drugs is still relatively small -- just under 3% of total cases, according to the CDC.

The Public Health Service calculates that by 1993, AIDS will surpass all other diseases in causing a loss of human potential. "It strikes people at a younger age than heart disease and cancer, and the numbers keep growing with AIDS while the others remain fairly stable," says a Public Health Service spokesman.

The scientific mobilization to combat AIDS, at least in recent years, has been the subject of praise. Fitzhugh Mullan, the author of "Plagues and Politics: The Story of the U.S. Public Health Service," says, ". . . the scientific apparatus of the government -- particularly NIH {the National Institutes of Health} and the CDC, has been extraordinary."

With federal research assistance, nine drugs have been approved for treatment of AIDS and AIDS-related conditions since the epidemic began about 1981, though no cure has been found. The Food and Drug Administration, under pressure from AIDS activists among others, has put AIDS drugs on a fast-track approval process. Yesterday an FDA advisory panel, at the urging of Commissioner David Kessler, recommended accelerated market approval of a new AIDS drug called DDC in combination with AZT, even though research on DDC isn't conclusive.

But the rise in AIDS research spending has slowed. For next year, Mr. Bush is asking for a 4% increase in funds for AIDS research, to $1.24 billion -- barely above the 3.3% inflation rate projected by his Council of Economic Advisers.

Anthony Fauci, the director at NIH's National Institute of Allergy and Infectious Disease , said under questioning at a recent House hearing that the proposed spending level would lead to a reduction in some NIH research teams and programs and "certainly will slow down" work toward a cure. "I think that we will be able to accomplish a lot," he said, while adding: "We will not be able to do everything that I think would be scientifically justified."

The administration also proposes to authorize spending of $661 million for prevention and education next year, a 5% increase from this year's spending authorization and 29% over the past three years. Some of the spending in the U.S. is for spreading the word, such as the America Responds to AIDS program, which puts out pamphlets and posters and broadcasts public-service announcements. But critics charge that political squeamishness has undermined the government's effectiveness. The government's newest and most ambitious education campaign consists of TV, radio and print ads that don't even mention sex (the way HIV is most often contracted) or condoms.

Some of the U.S. government's most creative prevention efforts aren't directed at the U.S. at all. In the past three years, the State Department's Agency for International Development has spent more than $3 million to buy condoms from an Alabama company. AID markets the condoms in Zaire "like Coca-Cola," says Jeffrey Harris, who coordinates the agency's AIDS program. The campaign uses billboards and T-shirts and has recruited prostitutes to promote the condoms in bars.

No such federally financed programs exist in the U.S., where Congress and the executive branch have had bruising battles over just what the government can pay for in AIDS education. The CDC, which is based in Atlanta, dispenses more than $200 million in grants to communities, state health departments and other groups to set up their own AIDS education and prevention programs. But the proposals must be reviewed by local boards for "offensive material" as a condition of funding.

As a result, some efforts have met resistance. An AIDS education coalition in Johnson County, Iowa, wanted to start a program for gay and bisexual men to educate them on how to protect themselves from AIDS through safer sexual practices. It decided to use a curriculum developed by the Gay Men's Health Crisis in New York, which was designed to "eroticize safe sex." But the state health department worried that the program's title -- "Hot, Horny and Healthy" -- would be considered too offensive to get federal funding. State health officials, says Margaret Skelley, the HIV/AIDS project director at the Association of State and Territorial Health Officials, "have become increasingly concerned about the turn away from prevention issues."

She wants Congress to concentrate on prevention. "We certainly need to see more money for treatment and research, but we can't fund it in lieu of prevention or we're going to be paying for treatment from here on out."

Gary West, assistant deputy director for HIV at the National Center for Prevention Services, a part of CDC, contends that federal restrictions are very light. "These local review panels have approved very, very explicit materials," he says. Moreover, he adds, the government has no rule against using federal money to distribute condoms; that is up to communities and states, he says. But others say the perception that they could lose valuable federal money has led some states, cities and groups to curb their own programs.

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David Shribman contributed to this article.
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