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The experience of San Francisco illustrates how a city can mobilize to effectively fight the AIDS epidemic. San Francisco was one of the first cities to report HIV infection in 1980. The city has a large gay population and by 1995, about one-third had contracted HIV. However, the incidence of HIV infection in the city peaked in 1992 and has been dropping since then. In San Francisco, the gay community took an active role in shaping public policy and has worked openly with the local government. There is still much work to be done to educate young gays and gays of color.

The use and total costs of services provided by Medicaid to AIDS patients were examined in individuals on Medicaid in New York and California who died between 1985 and 1986. The average lifetime costs were approximately $30,000 per individual in New York and $20,000 in California. Ninety-three percent of the costs in New York and 86 percent of the costs in California were due to hospital care. Care was more often obtained in the hospital in New York, while it was more often obtained on an outpatient basis in California. The individuals in the study were classified into different risk populations: men who used drugs, men who did not use drugs, women and children. The differences in costs and use of Medicaid services between the states were still present even if risk groups, clinical manifestations of disease, and income levels were taken into consideration. In California, women used more inpatient services and the costs were higher than for men. In New York, women and men who used drugs had a greater use of both inpatient and outpatient services and the costs were higher than for men who did not use drugs. Inpatient care and costs were higher for children in New York than adults, with the average number of days in the hospital for children being 85 compared with 55 days for adults. The differences in costs and use of services among the risk groups were due to differences in clinical manifestations of disease and income level. Thus, the economic impact of AIDS can vary among states and depends on how services are used. (Consumer Summary produced by Reliance Medical Information, Inc.)

Individual states set criteria for eligibility for the financing of care and treatment for individuals with AIDS by Medicaid. The criteria include the categories of individuals that are covered and financial limits. How these criteria affect individuals with AIDS was examined in 1,314 individuals with AIDS from California and 6,273 individuals with AIDS in New York between the years 1982 and 1987. Both New York and California do not have strict criteria for eligibility for coverage and the importance of higher financial limit and the availability of an optional coverage, known as medically needy coverage, to the AIDS patients is clear. Medically needy coverage is a type of coverage where individuals become eligible for Medicaid if their medical expenses exceed their incomes. Many individuals' annual incomes are too high to make them eligible for Medicaid, yet too low to pay for private heath care insurance. Medically needy coverage is optional for each state. Two thirds of the individuals with AIDS that are financed by Medicaid in California and one third of the individuals on Medicaid in New York are covered by this option, demonstrating a strong need for this type of coverage among persons with AIDS. Individuals who are enrolled under medically needy coverage generally have other health care coverage and use Medicaid only in the later stages of the disease (such as when they may become unemployed and their health costs rise). The lifetime costs of individuals with this type of coverage are less than for those who are fully covered by Medicaid, as these patients use Medicaid for shorter periods of time. The study also showed that many AIDS patients from both states experience difficulties in obtaining eligibility status for Medicaid, which can be a stressful experience for those who are sick and need financial assistance. Improvements must be made. Some of the costs of care and treatment of persons with low incomes may be covered by the federal government, as well as by the state. Thus states, including New York, may lower their costs by using all options available from the federal government. (Consumer Summary produced by Reliance Medical Information, Inc.)

The demographics of persons with AIDS being cared for under Medicaid in New York and California from 1983 through 1986 were analyzed. There were approximately three times as many Medicaid cases in New York (7,541) as in California (2,495). The number of persons with AIDS on Medicaid increased tremendously during the four years of the study. The increase was 298 percent in New York and 595 percent in California. The increase occurred primarily in the young adults between 21 and 44 years old. The largest number of cases were in counties containing large cities, such as New York City, Los Angeles and San Francisco. However, the epidemic was spreading to other counties as well. Differences were seen between the two states. The proportion of cases of patients with a history of drug use was greater in New York (40 percent), compared with 12 percent in California. Drug users are generally poor and depend on Medicaid funding for treatment. The proportion of cases among other groups of adult males, e.g. homosexuals, was greater in California. The majority of homosexuals with AIDS have higher incomes and often depend on Medicaid only later in the course of the disease. A much higher proportion of patients with AIDS in New York were women (30 percent of all AIDS patients) than of those in California (5 percent). There were also more cases of AIDS in young children in New York. These data support the evidence that transmission of AIDS occurs in the heterosexual population living in urban areas via sexual encounters with infected drug users. This type of analysis is necessary for determining policies for Medicaid at both the federal and state level. (Consumer Summary produced by Reliance Medical Information, Inc.)

A report was complied on the costs of health care for 36 patients with AIDS who lived in Los Angeles, California and received care during 1987 and 1988. The costs considered in the report included medical and nonmedical services. The average number of times the patients were hospitalized was 1.6 times per year, with 17 days of hospital care. The average costs for the first year after diagnosis were $22,272 for inpatient hospital care and $22,850 for outpatient care, with the overall medical costs averaging $45,122 per year. Lifetime costs were estimated to be from $50,000 to $60,000, and were based on the average life expectancy for patients with AIDS of 13 to 15 months. Approximately one-third of the costs were for drugs, including zidovudine (AZT), which is used to control HIV infection, and aerosolized pentamidine, which is used to prevent pneumonia due to Pneumocystis carinii. The average cost for nonmedical services, such as volunteer services and counselling, was $9,276. The health care costs for AIDs patients in the Los Angeles area were similar to those in other regions of the United States. This study suggests that a large portion of future costs will come from outpatient services and drug treatment. Because many of the newly discovered drug therapies are not covered by health insurance, a large majority of these costs will be passed on to the patients themselves. Since there has been a shift in the treatment of patients with AIDS from hospital-based care to outpatient care, and since new drug regimens are being used, there is a need for policy changes that will lower the financial burden on the patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

At the end of 1985 there were approximately 4,705 cases of AIDS in California. This number increased to about 22,228 cases by the end of September 1989. California has the highest percentage of AIDS cases of any state, with 23 percent of all US cases. In 1988, the California Academy of Family Physicians (CAFP) conducted an AIDS survey that highlighted practice experiences, physician's knowledge of AIDS, and demographic information. The survey was mailed to 3,449 active CAFP members; 1,774, or 51 percent, responded to the 52-item questionnaire. One in five of the respondents were treating at least one patient with AIDS or ARC (AIDS-related complex). It was found that, in general, experience with AIDS has increased. The average family physician in California treats at least one or two patients with AIDS. However, compared with data obtained in a similar study in 1986, physicians' knowledge about the disease has not increased. Areas in which they were lacking included knowledge of symptoms (the inability to name more than three symptoms of AIDS), failure to take adequate patient sexual histories, and not having a working knowledge of AIDS screening tests. Family physicians are especially relied upon to treat AIDS-related illness in smaller areas, as opposed to larger cities. While the number of AIDS-related cases in practices in large cities may be higher in than in smaller areas, the percentages are lower. For example, an average of 23 percent of patients of family physicians in larger cities have AIDS or ARC. In smaller areas, the percentage is closer to 30 percent. There is a need for family physicians to take part in continuing education curricula focusing on AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.), In the last few years there has been a dramatic increase in the number of acquired immunodeficiency syndrome (AIDS) patients. The total number of cases in California increased from 4705 [...]

The number of deaths and years of potential life lost before the age of 65 was determined for residents of San Francisco from 1979 to 1986. The number of deaths that were related to AIDS increased from 5 (0.1 percent of all deaths) in 1979 to 534 (6.6 percent) in 1986, with a total of 4,509 deaths related to AIDS during the seven years. AIDS-related deaths included deaths from infection with cytomegalovirus and cryptococcus, pneumonia caused by Pneumocystis carinii, cancer of the skin, and immune deficiency. Of the deaths caused by AIDS-related diseases, 84 percent (1,032 out of 1,225) were among men who were 20 to 49 years old. Between 1979 and 1986, AIDS-related deaths increased from 0 to 44 (25 percent of all deaths) among men aged 20-29 years, 0 to 257 (44 percent of all deaths) among men aged 30 to 39 years, and 0 to 150 (35 percent of all deaths) among men aged 40 to 49. In 1986, for men living in San Francisco, AIDS-related diseases were the third leading cause of death and the leading cause of years of potential life lost. Because of the only moderate improvement in survival rates and the number of reported and projected cases of AIDS, the number of deaths due to AIDS is projected to increase. The demands on the health care systems and the community in San Francisco, in terms of medical costs and psychological and social impact, is enormous. (Consumer Summary produced by Reliance Medical Information, Inc.)

Human immunodeficiency virus (HIV) is the causative agent of acquired immunodeficiency syndrome (AIDS). HIV is a virus that attacks the immune system and reduces the ability of the immune system to fight infection. Therefore, patients with AIDS are at risk for developing opportunistic infections. The most common systemic bacterial infection in patients with AIDS is Mycobacterium avium complex (MAC). Infection with MAC is found, at autopsy, in approximately 50 percent of the AIDS cases. MAC causes tuberculosis in the lungs of patients with AIDS. Since the beginning of the AIDS epidemic, there has been an increase in the number of lung specimens containing MAC. This increase may be due to an increase in the number of AIDS patients with MAC infection, or may be caused by contamination of the lung specimens with MAC that is present in the air. To investigate this further, medical records of AIDS and non-AIDS patients with MAC infection, hospitalized at the San Francisco General Hospital between 1984 and 1987, were reviewed. The records from 1984 indicated that MAC was present in lung specimens from 6.5 percent of the AIDS patients and in 0.3 percent of the patients without AIDS. By 1987 the incidence of MAC infection was 8.8 percent and 0.3 percent, respectively. The difference in prevalence of MAC infection between the two groups was statistically significant for both years. It is concluded that MAC infection is rare in non-AIDS patients, and that the increase in MAC infection observed in lung specimens from AIDS patients is not solely caused by contamination of the specimens by MAC present in the environment. (Consumer Summary produced by Reliance Medical Information, Inc.)