Of Magic Bullets and Social Justice: Emerging Challenges of Recent Advances in AIDS Treatment

Article excerpt

HIV disease has now infected more than 1 million Americans and probably has affected an equal number of friends and family members who provide care or whose lives are otherwise markedly affected by the epidemic. This is a staggering impact for a social health problem identified only 15 years ago. AIDS and HIV have challenged and evoked ambivalent responses in all people and all professions. In response to the introduction of AZT as the first antiviral drug, Wright and Bodnar (1992) pointed out the need for a more focused social work contribution to the AIDS epidemic; this need has not changed substantially in the intervening years. Policies and programs for HIV testing and counseling, mental health services, service coordination and case management, and HIV prevention education have too often been designed and implemented by professionals in public health, nursing, medicine, and public administration and by the new hybrid, the AIDS service organization administrator. Although individual social workers have made unique contributions, social work as a profession has been slow to jump in and assume recognized leadership in the AIDS epidemic.

A new light is now illuminating the field of HIV care and services. The first phase of the AIDS epidemic was characterized by the unknown, by a lack of information. The second phase, beginning with the introduction of antiviral therapy, was associated with false hopes; the first antiviral interventions did not produce the magic cure that was initially expected. Now new drugs, the protease inhibitors, and diagnostic technologies to measure viral load are making possible the previously incomprehensible idea of managing HIV disease by keeping the virus at "undetectable" levels. Patients feel better and report reduced symptoms, increased energy, improved sleep patterns, better appetite, improved mental function, and improved quality of life in general.

HIV has not been cured, but the hope is offered that it is becoming a manageable (albeit complex) chronic disease. For how long no one knows. Studies reported at the Vancouver International Conference on AIDS last July showed that over 80 percent of clinical trial participants who received three drug combinations had their HIV burden reduced to undetectable levels (Chaisson, 1996).

HIV treatments include two components - first, prophylactic drugs to prevent and treat opportunistic infections and, second, antiviral drugs to directly reduce replication of the virus. Most of the increases in life span in recent years have been due to advances in prophylactic drugs. The most vivid examples are a variety of treatments that prevent Pneumocystis carinii pneumonia ranging from a simple dose of a sulfa drug to complex management using aerosolized pentamidine.

The major treatment innovation of the past five years has been combination therapies. These require complex monitoring and adjustment to avoid drug resistance and cross resistances. Typically, one antiviral drug is useful for a while, but over time, as the virus mutates, the body begins to resist the drug's effects or becomes intolerant of the drug. Thus, a kind of cat-and-mouse game ensues; beginning at the initiation of therapy, the physician prescribes multiple drugs and works with the patient to switch medications often enough to avoid periods when they lose their effect.

Taking these medications is complicated, involving many drugs that have different requirements in terms of timing and temperature and whether one's stomach must be empty or full. The person with AIDS lives by the timer and eats only in the "window periods" when the multiple drugs allow ingestion. All of the drugs have side effects and may need frequent readjustment. They clearly are not effective for all people living with HIV. Nonadherence (a more acceptable term than noncompliance) to a drug regimen can result in resistances to those and related drugs caused by mutations in the virus. These drug resistant viruses threaten the general public health as well as the identified patient, a situation now presented by multidrug-resistant tuberculosis. …