Pulling Back An Aids Lifeline
The good news from the AIDS front is that new combination therapies--potent cocktails of drugs taken together--are far more effective at keeping the HIV virus in check than previous treatments. The U.S. death rate from AIDS declined for the first time last year, dropping 13% in the first six months from 1995. The bad news: At a yearly cost of $12,000 to $14,000 per patient, states say they can no longer afford to cover all the afflicted who apply for help under a program to assist the uninsured. That's leading to hard decisions about who will get subsidies for the life-lengthening regimen.
STRETCHING FUNDS. The extent of the crisis became evident in April. That's when directors of the AIDS Drug Assistance Program (ADAP), a federally funded plan that picks up drug costs for 80,000 AIDS patients not covered by Medicaid or private health insurance, calculated that the budget would fall short by an estimated $68 million for the fiscal year ending in October. This despite a fourfold jump in annual funding since 1995, to $380 million. The problem: a 77% increase in the number of clients, many of whom are seeking treatment for the first time precisely because the new drugs are so effective. But the combination therapies cost roughly seven times as much as AZT, the earlier treatment of choice.
All 50 state ADAP programs are facing steep rises in both costs and caseload. And in the past year, 34 states have limited their programs to stretch funding--restricting access to new drugs such as protease inhibitors, or capping the number of people allowed in the program. Representative Nancy Pelosi (D-Calif.) unsuccessfully proposed an emergency funding bill to bail out ADAP this spring, and is now hoping for the White House to propose a budget rider. "This is an emergency," she says.
Ask Justus Upton, 29, a hotel clerk in North Jackson, Miss., who is HIV-positive. Until 18 months ago, when he started combination therapy, Upton had been surviving on disability checks. He now takes 14 drugs daily to check his infection. The virus levels in his blood have plunged to near-undetectable levels and he hopes to return to work.
But last month, the Mississippi Health Dept. notified Upton and 662 other HIV sufferers that they would no longer receive payments for many of the ingredients in their cocktails. The state is wrestling with a 38% increase in clients in its ADAP program and a startling 411% increase in costs. "Please know that all of us regret having to make these heartbreaking decisions," says the letter. Small solace for Upton. "I got all this great news and thought I might have a normal life," he says. "And then it was like--no, you can't have that."
Medicaid is not an option for most ADAP clients because their new drugs have made them too healthy to qualify for disability; many are even returning to work. So, in addition to the human toll, cutting off the drug subsidy could raise the overall bill for AIDS. Warns Pelosi: "These new drugs are expensive but they ultimately result in decreased costs [for] treating opportunistic infections and expensive hospital stays."
As more state ADAP programs limit access to drugs, AIDS professionals foresee a system in which only the rich will get medication. "We've got people that have a terminal illness. We have a number of drugs that can prolong lives," says Dr. Nancy Tatum, a medical ethicist at University Medical Center in Jackson, Miss. "But the bottom line is, you have to decide how to ration." An ominous conclusion for the Justus Uptons of the world.