Mail and Guardian, 18 October 2002 , HIV/Aids Cover Doesn't Come Cheap

By Nawaal Deane

Choosing the best medical scheme plan is a life-and-death choice if you are HIV-positive and face long-term anti-retroviral treatment and extensive hospital bills.

Peter Stevens*, whose partner died of Aids, says: "When we changed over to another medical scheme we were promised full cover. But in the first three months the annual savings allocated for our anti-retroviral medication ran out."

He says the scheme only paid for the first eight days for his partner to be treated in a hospice. "But what did they expect me to do for the ninth day?"

He was forced to change to a scheme that offered more extensive coverage. "Yes, it is an expensive scheme, but now I feel secure that my anti-retroviral medication is paid for in full."

A study by the Centre for Actuarial Research (Care) at the University of Cape Town and the Treatment Action Campaign (TAC) found that medical schemes provide extensive coverage for HIV support services -- including counselling, testing, education and information -- but treatment is less adequately covered.

The study surveyed 77 open and restricted medical schemes with 5,29-million members.

Heather McLeod, director of Care, says the study found that most of the medical schemes it surveyed offer an extensive range of HIV/Aids benefits. The study says there is more emphasis on prevention and education than treatment, but most medi-cal schemes do cover at least some of the costs of anti-retroviral medicines, treatment to prevent mother-to-child transmission of HIV and post-exposure prophylaxis against HIV infection.

Coverage for HIV/Aids benefits is expensive, but the benefits may still not be adequate. The study recommends that the structure and extent of benefits be investigated.

It found that 81% of the options providing access to anti-retroviral medicines also offer monitoring of the treatment and counselling.

There has been a significant move towards triple-combination therapy as the optimal anti-retroviral treatment. The study says 90% of beneficiaries have access to triple-therapy treatment and only 9% have no access to any anti-retroviral medication. "However ... the size of the benefit is ... inadequate for a full year's supply of medication in many cases."

Therapy to prevent mother-to-child transmission of HIV is also extensively covered and 92% of beneficiaries have access to some form of anti-retrovirals. The combination therapy of AZT and 3TC, or Combivir, is the most frequently used treatment, but milk formula is provided to only 47% of beneficiaries.

The study says medical schemes should try to provide more anti-retrovirals. "The council of medical schemes should facilitate schemes to adopt a guideline on anti-retroviral therapy that stipulates triple therapy as treatment." It says generic medicines for opportunistic infections and generic anti-retrovirals are essential to reduce prices.

The study found disturbing evidence of low participation in the programmes, which Care attributed to the medical schemes' inadequate marketing.

Nathan Geffen, spokesperson for the TAC, says HIV-positive people should choose a medical scheme by carefully considering its benefits. They need to ensure that the scheme covers triple combination therapy that is not paid out of a savings account.

The scheme should provide about R1 500 for anti-retrovirals. "If they have a spouse or family member that is also on anti-retroviral treatment, then the scheme should cover them both."

* Name has been changed.