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Frerichs, R.R. Response to comment on HIV and health insurance.

SEA-AIDS Network, October 9, 1996

R.R. Frerichs Posting

Mr. John James (message not available) has raised an important point regarding insurance plans, and the willingness of Californians to impose restrictions on the insurance industry.

In California, the rate of AIDS cases per year is sufficiently low (33.5 per 100,000 during the most recent reporting interval, July 1995 to June 1996) and the cost of general health care is sufficient high that the financial burden to group insurance plans attributed specially to AIDS is not an important considerations. When cost is elevated due to higher case finding (i.e., detecting the 40-60% of HIV infected person who don't know they are infected), higher treatment costs of newer drugs, or increased incidence and prevalence, it is not clear how the people of California will respond. Here in Los Angeles County, local politicians have already condemned AIDS care organizations for wanting more money to extend the life of AIDS cases. Our efforts to promote earlier detection of HIV with simpler and more accessible forms of testing (i.e., home HIV tests and rapid clinic-based tests) have not been accepted with universal enthusiasm, possibly due to the cost burden that early detection would place on the care system. But these are our problems in California, and not necessarily those of Asia.

When HIV transmission is more common, as it is in certain regions of India, Myanmar, Thailand, Southern China, Cambodia, and Vietnam, the issues of detection, treatment and who will pay, become more complicated. If people avoid thinking about the future, the best strategy from an economic point of view is to not offer widespread test, provide no special care for AIDS cases, and to not allow testing for insurance coverage or other reasons. Stigmatization of HIV/AIDS benefits this shorter-term view by keeping HIV/AIDS cases hidden and out of the health care system until sudden death ends the drama.

Yet such social blindness does nothing to promote the longer term goals of the nation or region, and avoids the central public health mandate of preventing disease transmission. To control HIV in higher prevalence regions requires money and sacrifice, but not of the few who have medical insurance, but of the many who live and work in the country. Ordinary citizens in high prevalence regions will need to continue to support current efforts to decrease high risk contacts with commercial sex workers or with intravenous drug users. Such control efforts are well described by experts at UNAIDS, NGOs and other international organizations.

More important to halting the epidemic, however, they will need to reach out and find HIV infected persons early in the infection, an action that has not yet been widely advocated by international organizations. Local public health workers will then need to work with such infected persons to limit further transmission (especially to their "high risk" spouses and newborn children), and offer them hope and care to extend their lives.

Avoiding the social responsibility of providing care or preventing further transmission by ignoring the problem or forcing private insurance plans to offer medical care for those later discovered to have AIDS will not stop the epidemic. Instead, a more open approach is necessary, keeping in mind the principles and mandates of public health.