The Wall Street Journal - 10 October 1996
Michael Waldholz, Staff Reporter of The Wall Street Journal

Data from medical centers that treat large numbers of HIV-infected people are preliminary and largely anecdotal, but they provide the first indication that the new drugs may generate long-term health savings that could offset their cost.

Medical officials say that if the trend emerging in recent weeks continues, it could force government and private agencies to start shifting some of their spending from medical care to the new drug therapies, including increasing hospitals' outpatient services to provide the drugs and the close monitoring that the drugs' use requires. The combination therapies can cost $16,000 a year per patient, but a federal study conducted before the therapies were available estimated that a patient infected with the AIDS virus generated $24,000 a year in hospital costs from the date of infection until death.

"As a group, my patients aren't anywhere near as sick -- or sick as often -- as they were," says Peter Ruane, a physician with a large AIDS practice in Los Angeles. "We may be in the midst of the most radical medical change in our field since the first arrival of drugs for [tuberculosis] in the 1950s."

Doctors and hospitals in New York and California, where AIDS services are clustered, say they are seeing the most significant decline in acute-care services since the epidemic exploded over 12 years ago. St. Vincent's Hospital in New York's Greenwich Village says AIDS-related admissions are down 8% this year, and the length of each hospital stay is down, too.

Midway Hospital Medical Center in Los Angeles says that on an average day only about 10 patients are using its 40-bed AIDS unit, down from a typical daily census of about 30 patients last year. Midway just laid off one-quarter of its AIDS unit nurses and is considering shifting the unit's focus to cancer.

Just two weeks ago, Chris Brownlie House, a 25-bed Los Angeles hospice that had provided care for dying AIDS patients since 1988, shut down operations. "The demand for the hospice beds is radically diminishing," says Michael Weinstein, president of AIDS Healthcare Foundation, a large, private program in Los Angeles that ran the hospice. Adds Charles Farthing, one of the foundation's doctors: "For really the first time I have discharged patients home from AIDS hospices who prior to commencing therapy were bed bound and waiting to die."

Most doctors agree that while several factors may be at work, the principal reason for the trend is the new combination drug therapies. Largely due to the addition of new protease medicines, which block the action of an enzyme critical to HIV replication, the drug therapies are reducing levels of the virus in patients' bloodstreams by as much as 99%, allowing besieged immune-system cells to rebound. That reduces the patients' need for intensive, hospital-based services.

David Senecheck treats about 600 people in San Francisco infected with the virus. He says that until earlier this year he was hospitalizing about three patients a week, but he has ordered just five hospitalizations for all of this year.

One of his patients, 42-year-old Marcus Wonacott, was in and out of the hospital regularly, fighting off an AIDS-associated skin cancer called Kaposi's sarcoma, a serious liver abscess, and cytomeglovirus, which can cause blindness and death. In January, Mr. Wonacott began taking a three-drug combination that included Roche Holding Ltd.'s protease drug, Invirase, until he was switched to Merck & Co.'s protease drug, Crixivan. By spring, Mr. Wonacott says, the amount of virus circulating in his blood was undetectable and his immune system cells had risen somewhat. What's more, he says, the cytomeglovirus is now gone and the cancer "has almost completely disappeared."

Mr. Wonacott hasn't been in the hospital since last winter. His only complaint, he says, is that he must swallow 21 pills every day or risk a swift increase in the virus in his blood.

In fact, getting patients to adhere to the complicated, costly and sometimes toxic regimen isn't easy. "The greatest problem we face right now is compliance," says Roy Gulick, a physician researcher at New York Hospital.

While hospital use can be expected to continue dropping as long as the new combination therapies are effective, doctors who prescribe the new drug therapies say figuring out precisely which combinations of the nine drugs available work best for each patient has required an increase in time and expertise.

"I used to say that AIDS patients should be treated by primary-care physicians if possible," says Michael Saag, a leading AIDS researcher and doctor at the University of Alabama in Birmingham. "But all that's changed. These days I'm telling people that the best care can only come from doctors who really understand the nuances of the different drugs."

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The Price of HIV

Current estimated lifetime cost of treating HIV (prior to introduction of new triple drug therapies

Total Cost $119,000

HIV infection to AIDS 50,000

AIDS to death 69,000

Source: Fred J. Hellinger, Agency for Health Care Policy and Research, U.S. Public Health Service, 1993

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