A bitter pill?

The new combination therapies should be good news for people
with HIV. But because there’s no new money in the pot, their
provision could mean other HIV support and care services are cut
back Rhonda Siddall reports.

The future is looking brighter for people diagnosed with the HIV
virus. Combination therapies – using two or more different drugs to
slow down the reproduction of the virus in an infected person – are
now the most effective way to attack HIV. Research has shown that a
combination of two or more drugs that attack HIV has a more
powerful effect on viral activity than one drug alone. Combination
therapies can successfully reduce the level of HIV in the blood and
can dramatically improve health. The result is that people with HIV
can live longer and benefit from a higher quality of life.

But because combination therapies are hugely expensive – one
person’s triple combination therapy costs about £10,000 a year
– health commissioners are having to take a radical look at the
provision of HIV services. This comes at a time when the long-term
effects of the combination drugs remain to be seen and we do not
yet know whether the improvements people are currently experiencing
will be sustained over several years.

Two weeks ago, NHS managers in London launched an urgent review
of HIV and AIDS services across the capital, identifying a budget
shortfall of around £10 million caused by the increased use of
combination therapies. The Inner London HIV Health Commissioners
Group, a group of seven inner London health authorities, has asked
the Department of Health to make up the shortfall.

But if there is no new money for the next financial year,
savings would have to come from the existing overall budget of
around £130 million for 1998-9. In anticipation, the group has
started a wide-ranging stocktake of HIV and AIDS services. It will
formally announce its purchasing intentions in September, but the
voluntary sector looks likely to be hit.

Will Huxter, the group’s chairperson, says: ‘The shortfall will
affect preventive work, and treatment and care. Much of the money
we will have to save will come from hospital-based care but we are
also having to look at the voluntary sector.’

Rumours and speculation abound about which organisations are
going to be affected. London Lighthouse, a charity that provides
care and support, and which has seen its funding fall over the past
five years, is worried. A spokesperson says: ‘The benefits
experienced by many people taking combination therapies may lead to
health authorities placing greater emphasis on medical treatments.
This could mean less money for other forms of care and support for
people living with HIV and AIDS, both for those taking new
treatments and for those who choose not to take combination
therapies or who are unable to tolerate the side effects.’

The arrival of combination therapies represents a major
breakthrough in the treatment of HIV infection, and health
authorities have a moral responsibility to ensure people who wish
to take such treatment have access to it. All this at a time of
stretched NHS funds.

But the news that some HIV services face cuts – and possibly
closure – is not a simple story about harsh cuts in a climate of
cash shortages. Combination therapies herald a new era in the field
of HIV infection and thus demand a rethink of how funds can best
support the services that sufferers are now most likely to
need.

James Fitzpatrick, development officer at the National Aids
Trust, says: ‘This is not about bad commissioners versus good
providers. The fact is that, more broadly, the NHS is not able to
deal with the cost of new treatments and meet the challenge of a
reconfiguration of services. It’s about going back to the
principles of community care. Providers and commissioners are
working together to identify what need is there and what range of
services can be purchased and provided to meet that need.’

This rethink follows hard on the heels of last year’s 7.7 per
cent cut in the HIV treatment and care budget by the DoH.

The NHS receives two pots of money to fund HIV services. The HIV
treatment and care budget – which is not ringfenced – funds
hospitalisation and drug costs. The HIV prevention budget – which
is ringfenced – supports preventive work. The 1997-8 allocations
for England were £199.6 million and £52.5 million
respectively.

The cut in the treatment and care budget was imposed after
government figures projected a fall in the incidence of HIV
infection. However, it was reversed after indications showed
projections about the size of the HIV epidemic were inaccurate.
Fitzpatrick says the government has responded to one part of the
epidemic – the incidence of the disease – but has failed to address
the management of the epidemic properly.

He adds: ‘The indications have been for some time that
combination therapies would have a dramatic effect on the
management of HIV infection. But the financial consequences are
only just beginning to be addressed.’

Huxter refuses to pinpoint those voluntary organisations that
might be affected by September’s announcement. He adds: ‘We are not
going to rip up the voluntary sector but we have a responsibility
to look at how best to spend the money we have.’

According to Huxter, commissioners are considering:

· How many providers are needed to provide an appropriate
range of services?

· Is the current volume of providers too great?

· How many hospice and in-patient beds are needed?

· Is there a need for the current number of drop-in
centres?

When the DoH announced last year’s 7.7 per cent cut, three
organisations bit the dust. The Fountain, a south London support
centre for people with HIV and drug-related problems, the
Positively Irish Action on AIDS group and the Black HIV/AIDS
Network were forced to close their doors to clients.

This year, it is likely that some voluntary sector organisations
will merge or work collaboratively in bidding for contracts.
Fitzpatrick explains: ‘There is scope to look at efficiencies in
the voluntary sector and a willingness among providers to work
together. We are going to have to work in an environment where
there are fewer contracts, less service volume, and where
management costs are greatly reduced.’

But he concedes some services will go altogether. ‘My guess is
that buddying and befriending services, support groups and
complementary therapies will not be funded from the public purse,’
says Fitzpatrick.

This view is largely based on an argument about parity with
services for people with other conditions. The Inner London HIV
Health Commissioners Group will be looking at whether various
services for people with other diseases, such as cancer, are funded
from the public purse. Where they are not, funding for comparable
HIV services is likely to be hit.