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In addition, Joey has a case manager at Shanti House, a social service and hospice program, who has helped him obtain furniture for his hotel room and provided him with discounts at local art classes. "They provided me with a social life," he says. And an AIDS Foundation counselor is helping him figure out his finances.
Late last month, TARC hired Joey as its receptionist and he and Goldhammer went looking for a house in Berkeley to rent together. The same week, Joey decided to give Crixivan a try.
Joey's new job at TARC has provided him with more than a paycheck. But one thing the shoestring nonprofit can't provide is health insurance. The organization's plan contains more co-payments than Joey can afford.
So, like half of the people with AIDS in California, Joey has his health care paid through Medi-Cal. And that includes his Crixivan protocol.
Funding drug treatments for people like Joey is no small matter in San Francisco -- still with the highest infection rate in the nation. According to the 1996 annual report from the S.F. Health Department's AIDS Office, at least 50 percent of the 3,400 people diagnosed with AIDS in 1994 and 1995 have no private insurance. Five-and-a-half percent are homeless. (Currently, 7,346 people in San Francisco are living with AIDS, according to the 1996 report.)
The uninsured have two ways to pay for the new treatments, Medi-Cal, federal money spent by the states, and the AIDS Drug Assistance Program (ADAP), a federal program administered by counties for people who don't qualify for Medi-Cal. But Medi-Cal cuts in the budget President Clinton proposed this month and a plan by Gov. Wilson to redistribute ADAP in the state threaten those programs at the same time that demand is increasing dramatically.
The stress on ADAP funds was brought into stark relief last year when the city ran out of the drug money early. Heading into fiscal year 1997, the city faced a $5 million ADAP shortfall. Rep. Nancy Pelosi (D-S.F.) saved the day by wringing $100 million more out of Washington for ADAP budgets nationwide.
But now that that problem has been averted, another has cropped up. Gov. Wilson wants to take away $12.9 million from the nine counties hardest hit by AIDS -- S.F. is one of them -- and spend that money where he pleases. That would mean a $3 million cut in the city's AIDS budget.
At the same time, general AIDS dollars are also shrinking compared to previous years. Last fiscal year, President Clinton granted a 31 percent increase in AIDS funding. This year, he has proposed only a 3 percent increase. This comes at a time when the nation is still experiencing 40,000 new HIV infections each year.
With the arrival of protease inhibitor-based treatments, the demand for ADAP money has increased, placing an entirely new stress on the budget. Two thousand people in San Francisco are on ADAP-funded drug protocols, a dramatic increase since the arrival of protease inhibitors last year. Meanwhile, the demand for services -- typified by those 3,000 people with AIDS on a housing waiting list -- has kept pace. This two-way pressure makes the debate over how money is spent all the more fierce.
But S.F.'s top AIDS doctor, Mitch Katz, director of the Health Department's AIDS office, isn't worried. "I view it as a healthy dialectic," he said in an interview. "This is how we resolve issues. I don't think this debate has hurt anyone or been particularly destructive."
Katz says that everyone in S.F. who seeks the new triple-combo treatments will be granted them -- regardless of ability to pay. "Anyone who has a prescription for a treatment will get drugs," he says. However, if money grows too tight, prioritizing drugs means "it's possible that some [AIDS] service cuts will occur.
"In an ideal world," Katz says, "the drugs will prove as successful as we think, the price will drop as it usually does, and the level of institutional care will drop, and we will use the money to pay for treatments." But if just one piece of Katz's "ideal" picture fails to jell -- and more than one probably will -- the abstract debate over funding priorities stands a good chance of becoming a full-blown civil war.
In fact, the Battle of Fort Sumter of the AIDS civil war -- the first shots fired in anger -- may well have occurred last year when Pelosi won the $100 million ADAP supplement. When service providers -- Pat Christen included -- heard the new money would be spent exclusively on drugs, they lobbied Pelosi to split the appropriation evenly between drugs and services.
When the 50/50 deal was made public, all hell broke loose. At the most extreme, charges flew that greedy service providers were stealing lifesaving drugs from the dying in order to pay their salaries. Though that overstates the case, the service providers erred by acting arrogant and entrenched.
Their arguments that services must be maintained for those who won't benefit from the new treatments has merit. But the pandemic is changing. By grabbing $50 million from drug money at the very time the treatments were showing such success, they showed a myopic insistence in sticking with the AIDS strategies of the past -- when effective new drugs were part of the equation.
AIDS Foundation head Pat Christen's salary is $131,000 a year. And that drives some AIDS activists crazy. "That is just so far over the line," says Matt Sharp of ACT UP Golden Gate, noting that his annual pay is $22,000 as head of a discount buyers club for AIDS drugs called Healing Alternatives.
The AIDS Foundation's budget, in excess of $15 million a year, drives them just as batty. "AIDS Inc.," many activists call it. And they want it downsized. The city's oldest and most prominent gay newspaper, the Bay Area Reporter, has joined the crusade. On the cover of its Jan. 2 issue it ran a copy of the "Fat Cat Pat" sticker, this one with a legend reading: "AIDSPHOBIC, UNION-BUSTING, SFAF EXEC GETS SIX-FIGURE SALARY."
