As Epidemic Matures, the Battle Shifts

Unquestionably, the most important development in AIDS in the United States in the last two years has been the arrival of protease inhibitors, a new class of drugs that are used, in most cases, in three-drug combinations with other antiviral medicines.

Scientists now know that, despite the seeming quiescence of HIV in the early stages of a person's infection, the virus and the immune system are actually locked in all-out combat from the start. Every day, up to 10 billion individual viruses are made and killed off, with the immune system losing only after years of furious struggle.

"Triple therapy" can stop, or nearly stop, that cycle of virus replication. It is a treatment that, while probably unable to eradicate infection, nevertheless strikes at the source of HIV's pathological effects.

The Centers for Disease Control and Prevention estimates that between 650,000 and 900,000 Americans are infected with HIV. In only about two-thirds has the infection actually been diagnosed. Of the people who know they are infected, perhaps 200,000 are on triple therapy.

Like most new treatment strategies, this one was was first tried on the sickest patients. However, it may turn out that triple therapy's real promise lies elsewhere.

Almost certainly, the most famous American undergoing chronic treatment for this disease is Earvin "Magic" Johnson. The former star of the Los Angeles Lakers announced in 1991 that he was infected with the AIDS virus. A combination of antiviral drugs, Johnson and his doctors have said, suppressed the virus to levels below the ability to detect them in his blood. It appears the basketball star has been healthy throughout the course of his infection.

It is that state -- early, symptom-free infection -- that triple therapy may be able to maintain for long periods of time. Most AIDS specialists now believe that if an infected person comes to treatment early enough, he or she may never experience the ruinous assault of AIDS. The truly dramatic stories in the new world of AIDS may turn out to be those of people who led altogether ordinary lives after they became infected.

For the moment, the new treatment's obvious effects are in sick people suddenly made well. Its dramatic benefits are not always lasting, nor are they easy to achieve. (Triple therapy costs up to $ 12,000 a year, and its psychic demands on patients are equally large and unforgiving.) Nevertheless, there is a growing urgency to put as many people on triple therapy as possible, because its benefits appear to be so great.

AIDS was first described in 1981 among gay men. (It wasn't named acquired immunodeficiency syndrome until the next year.) Most of the victims were white and middle-class. That didn't change -- either in fact or in public perception -- for much of the first decade of the epidemic.

Now, HIV infection in America is rapidly becoming a disease of the poor and the nonwhite, of the socially unstable and the economically disadvantaged.

People of color, who were 39 percent of AIDS patients in the years 1981 to 1987, accounted for 57 percent of cases last year. Infections attributed to sexual contact between men have fallen from 64 percent to 44 percent. At the same time, infections attributed to injection drug use or heterosexual contact have risen from 20 percent to 38 percent. Women -- most of them drug users, or the sexual partners of drug users -- now account for one-fifth of AIDS patients.

Bringing good medical care to poor people, or people with unstable lives, has never been easy. Bringing them triple therapy is turning out to be similarly difficult. The new HIV treatments are now testing the limits of the nation's patchwork, and often charity-dependent, medical system. In that effort lies one of the biggest social and clinical challenges of the epidemic.