Inside the European Union: A French Lesson

Antiretroviral treatment is projected to cost France 1.2 billion francs in 1997, compared with 830 million in 1995. This will be the highest expenditure on HIV treatment in the European Union and, worldwide, is surpassed only by the United States. How can France cope with these costs amidst burgeoning unemployment (11 percent compared with 4 percent in the US) and an aging population?

This cost of HIV treatment is borne cheerfully by the French state. Dr. Pierre-Christian Soccoja of the Ministry of Health told me that wide and fair access to free treatment governed attitudes towards access to therapeutic innovations. The French believe financial resources are a means, not an end, to healthcare, he added.

For a country which appears insouciant over the cost of treatment, the French Ministry of Health has the most impressive collection of data in the world on the use of antiretrovirals by its HIV-positive population. French health officials can say with certainty that the most prescribed combination in France in January 1997 was ZDV/3TC (14.1 percent), very closely followed by 3TC/d4T/indinavir (13.7 percent) and ZDV/3TC/indinavir (10.3 percent). Twenty-five other combinations of antiretrovirals are being prescribed to French patients. French hospitals now see 73,400 HIV-positive patients each quarter, compared with 55,000 in 1993, and the proportion of asymptomatic patients has grown from 34 percent to 48 percent. The number of patients on antiretroviral drugs has grown from 30,000 in 1993 to 48,000 in 1996, of whom 18,000 are receiving protease inhibitors; 43 percent of those on antiretroviral therapy are receiving three-drug treatment. These data are gathered from over 200 French hospitals, which must make quarterly reports.

At the Fourth Conference on Retroviruses and Opportunistic Infections the French Ministry of Health produced the most impressive fruits of its dirigiste approach: evidence of the real-life cost-effectiveness of triple combination antiretroviral therapy. The French Federation of AIDS Reference Centers presented data on 7391 patients treated at nine reference centers during the 12 months ending September 1996. In September 1995, of 2720 patients receiving antiretroviral therapy, only 25 were receiving a triple combination including a protease inhibitor. By September 1996, a total of 5047 patients were on therapy, 1284 of whom were receiving triple antiretroviral therapy.

Centers were divided into two groups: those which saw no decrease in AIDS-defining events, and those which saw an average two-thirds decline in the event rate. Protease combination use was 12 percent and 21 percent respectively. In the group where the AIDS event rate was unchanged, costs increased by $125,000, but in the group with a two-thirds fall in the event rate, costs fell by $650,000 a month.

The major difference between the two groups of centers appears not to be the number of patients prescribed three-drug therapy, but the time when such therapy was initiated. This study is the first to demonstrate a real saving in treatment costs with early and intensive antiretroviral therapy. Based on such findings, the French Ministry of Health is projecting a 20 percent reduction in hospitalization, a 30 percent reduction in deaths, and a reduction in new AIDS cases in 1997.

The countries which provide the starkest contrast to the French approach are Italy and the United Kingdom, although for different reasons. The Italian problem is cash starvation, while the British problem is a complete abdication of governmental responsibility. In the rhetoric of Britain's Conservative government it's called "returning power to local communities," but many physicians see it as a crude bid to devolve responsibility for spending cuts and healthcare rationing onto local authorities. Neither the Italian nor the British Health Ministries have made attempts to set a standard of care in HIV disease, with the result that innovations in treatment are being diffused unevenly.

The health costs are obvious. In Edinburgh, the UK's second-worst-affected city, the local health authority told hospitals that no money was available to fund any antiretroviral therapy for new patients. The authority relented after high-profile protests in the Scottish media and from local AIDS organizations. Similar things are happening throughout the UK and Italy. The potential gains of triple-combination therapy are being squandered by short-sightedness at a time when the financial burden of AIDS threatens to become catastrophic for some societies.

Keith Alcorn is a regular contributor to AIDS Treatment Update, published by NAM Publications, 16a Clapham Common Southside, London SW4 7AB; phone 44 171 627 3103.

©1997, Medical Publications Corporation