Letters

In 'The national lottery' (17 June) Mark Bellis and colleagues identify significant historical variations in HIV-related mortality across the UK, and suggest these may be attributed to different per patient funding allocations to health authorities.

They draw on mortality data from 1995-97. Evidence indicates major discrepancies in access to optimal anti-HIV therapy combinations during this period, particularly outside London. But after successful campaigning, the availability of combination therapies has improved significantly. There is now little evidence of major access difficulties to drugs themselves (the same is not true of diagnostics).

However, treatment strategies have to be planned effectively. Expertise in clinical care correlates strongly with mortality in HIV. Although regional centres of excellence exist, patients commonly travel out of regions for expert care, often in London (where most people with HIV receive treatment). Higher caseloads and more diverse casemixes contribute to the developing expertise. While differences in HA allocations may raise an equity issue, they cannot easily be identified as the only or major causes of differential clinical outcomes.

In some HAs a significant proportion of HIV funding is not spent on HIV services. This further complicates identifying HA-level funding as the cause of differential mortality rates.

The impending national HIV strategy offers the opportunity to address these issues. It should promote effective service networks that maximise accessibility to expertise, and promote evidence based practice and training across the UK. Such networks should be supported by strategic HIV commissioning and funding structures to deliver agreed standards of care. The strategy should also address other factors that impact on the health outcomes and quality of life of people with HIV, such as social support and culturally appropriate services.

Ideally, standards for treatment and social support services should be set out in a national service framework for HIV.

An effective HIV strategy should ensure that HIV funding is spent on HIV services, and can be monitored and accounted for so that people with HIV living across the UK are able to get the treatment and care services they need.

Dr Mike Youle Royal Free Hospital London trust Derek Bodell Director National AIDS Trust Nick Partridge Chief executive Terrence Higgins Trust Colin Nee Director NAM Publications Steven Fouch HIV development officer The Haemophilia Society