Commissioner's perspective; Mr John H James

Mr John H James, Chief Commissioner, Kensington and Chelsea & Westminister Health Authority

The advent of combination therapy as an effective treatment regimen for HIV and AIDS caught health authorities and the main AIDS/HIV centres very much on the back foot. We were well aware of the significance of the trials and of the expectation that the Vancouver Conference in 1996 would give strong support to the general introduction of combination therapies. We did not anticipate, as arguably we should have done, how great the costs would be.

For Kensington and Chelsea & Westminster - which receives about one-quarter of the national AIDS treatment care budget in recognition of its responsibility for the services provided by St Mary's Hospital Trust, Paddington, and the Chelsea & Westminster, which between them manage an active patient caseload of 3,200 - was one of the first authorities to have to decide its position on the matter. Knowledge of the trial results was at a high level, particularly through an internet facility at the Chelsea & Westminster, and significant numbers of patients were already receiving combination therapy as a result of being included within the trials.

The health authority quickly formed the view that it should support the principles common to both PACT and BHIVA guidelines - that is, that the treatment should be available to anyone with a CD4 count below 350 and a viral load count above 10,000. We also fairly quickly recognised the need, prima facie, to be sure that the patient would be compliant. We anticipated that the forecast of 70% of individuals meeting these criteria taking up combination therapy might well be substantially exceeded in both centres.

Finding the additional resources was a substantial task for us, as for other health authorities. The Government's reinstatement of the 1996-97 seven and a half percent cut provided some relief and we froze all other HIV initiatives. Ultimately, both trusts made substantial savings, some from ending the inappropriate use of HIV funding as a subsidy for other services.

We also made savings in other HIV areas, particularly through collaboration with other inner London health authorities in relation to the voluntary sector. A collective approach to Government undoubtedly influenced the additional resources made available for 1998-99, but provided no help with costs in the current year. The health authority therefore finally bridged the gap through the use of mainstream non-recurrent resources.

The topic illustrates the need for better anticipation of new treatment regimens, a clear set of protocols for access to treatment and clear guidelines as to responsibility for payment. These should ultimately be based on residence-based funding, but interim arrangements will be needed in 1998-99.