Originally created 11/30/97

Therapy causing conflict



The days of the cancerous sores and the bed-ridden death wishes are long gone for Thomas. Because of combination drug therapies, the HIV in his body is dwindling and his strength returning.

But his good health soon could cost him crucial coverage of the incredibly expensive drugs he credits with saving his life. As area advocates gather Monday to begin celebrating World AIDS Week in Augusta, recent developments point to a growing problem that could put thousands of people in Thomas' position.

Despite some early optimism the virus could be eradicated by the "drug cocktail" that includes protease inhibitors, recent studies show the virus may lie dormant inside cells in the lymph nodes and central nervous system. That means patients could have to take the drugs for several years to maintain their health.

And as more HIV-positive patients live longer, the strain on services and government to pay for the therapies could lead to widespread rationing of the kind that some states are already trying.

For Thomas, 38, who asked that his name be withheld for fear of reprisals, it is still worth it.

"I've been doing great," he said, though two years ago he was waiting to die. His immune system was nearly gone and he was covered with cancerous Kaposi's sarcoma. He is doing so well now, in fact, that his T-cell count is approaching 500, showing his immune system has bounced back.

Right now, his $16,000-a-year protease inhibitors, of which he takes two, are being paid for by the drug companies through what is known as a compassionate access program for those who can't afford the treatment.

"If your T-cell count goes over a certain amount, 500, they can't allow you to continue," Thomas said. "I don't know what they'll do now."

And while sitting around the house was fine when he wasn't feeling well, now it bothers him. But working could threaten his eligibility for some programs and threaten his Social Security disability payments.

"The lifeline that's keeping me afloat is not working right now," he said.

What to do with the thousands of Thomases out there is a question the government and medical leaders have yet to come to grips with, argues Dr. David Haburchak, infectious-disease specialist at Medical College of Georgia. In a recent article in the AIDS reader, he estimated that the longevity and expenses added by the protease inhibitors could mean as much as $1,000 more per month per patient.

Even if the patients live the same number of years, it would nearly double the cost per AIDS patient to $227,278. If the drugs helped the patient live 36 extra months, it could be as much as $280,000, though Dr. Haburchak notes this cost is less than what other life-saving measures, such as coronary artery bypass surgery, cost per year of life added.

The success, as well, may attract those who had not been tested before for fear there was nothing that could be done, Dr. Haburchak said.

"Before, if someone had a CD-4 (immune cell) count below 50, they had 22 months or less to live. I can't say that anymore," Dr. Haburchak said. "The downside is you're going to have to take these medicines all the time. And they're not easy to take."

And more and better drugs are coming out, said Cheryl Newman, an infectious disease specialist at MCG who is testing a different kind of drug, known as a nonnucleoside reverse transcriptase inhibitor. The hope is the drug will target the virus's enzymes more specifically and reduce the toxic impact on other cells that can cause side effects. Some of the newer drugs also can be taken once a day, making the regimen easier to comply with, Dr. Newman said.

That difficulty in following a regimen could explain why Augusta has experienced about a 50 percent success rate with the protease-combination therapy, compared to 75 and 80 percent in its clinical trials.

And the cost of the drugs themselves is an issue yet to be addressed.

"I don't think anybody is ready to face the economic issue," Dr. Newman said. "It comes down to is it worth giving this patient some extra years? (But) you could say that about any illness. You could say that about hypertension. You could say that about diabetes. (To cut costs) what would we do, let 'em die in a diabetic coma?"

But some states like Kansas and Florida already limit the number of people who can get the protease inhibitors, and Missouri is prepared to limit the drugs and use a lottery to determine who gets them, Dr. Haburchak said.

Augusta AIDS Council Chairman Brad Littleton has a quick answer to the cost-benefit argument.

"Wouldn't it be (worth it) to you?" he asked. But then he adds, "It is expensive. Can we afford that? I don't know."

While those like Thomas are feeling better, the public may not be prepared to carry the heavier burden of helping them feel that way, Dr. Haburchak said.

"The long-term prognosis is not as rosy," he said.