Poverty Entangles Promise of Powerful Treatment
By David Brown
BALTIMOREWe're back from the front lines now, away from the places where patients know their viral loads and CD4 counts by heart, and ask, by name, for drugs that aren't yet on the market.
Or could it be that this is the front line in America's war on AIDS?
Barbara Worrell leans forward in the chair of the examining room. In a while, when the methadone kicks in, she will lean back and put her head against the wall. The doctor knows he has to work fast. But not too fast.
The woman looks all of her 56 years. She carries a black, knobby walking stick. Her ankles, visible at the end of pink sweat pants, are slightly swollen. Human immunodeficiency virus (HIV) infection is just one of her medical problems.
The doctor, Chukwuemeka Ufomadu, begins with her medicines. She's on 10. He goes over them with her, making sure that what's in her inch-thick medical chart on his desk reflects what she's actually putting in her body every few hours, every day of the week. Of the three drugs intended to quell the virus in her blood, she can identify only one. This doesn't bother the doctor, who knows plenty of people who take a medicine for years without once being able to pronounce it correctly.
But the names, at this point, don't matter anyway. Ufomadu's seen the most recent lab test results. The three antiviral drugs aren't working. Soon, she'll be on three new ones.
"Today you are complaining of what?" Ufomadu asks her, the words short and musical in his Nigerian accent.
"I just feel chills all the time. And diarrhea."
"How long have you been having this new diarrhea?"
"It comes and goes. This time three weeks."
And so they proceed.
As much as anyone, Worrell represents the typical AIDS patient in the United States. Her problems are rapidly becoming the mainstream-not the marginal- problems of AIDS medical care, as well.
Last year, the proportion of American AIDS patients who were black exceeded the proportion who were white for the first time. The fraction who were women reached 20 percent, an all-time high, and more than double what it had been a decade earlier. The fraction infected through intravenous drug use was 26 percent, half-again higher than in the early years of the epidemic.
Those groups-blacks, women and IV drug users-are poorer than the population of gay, white men who were the majority of AIDS sufferers in the 1980s, numerous studies have shown. They also tend to have less education, and are more likely to be without medical insurance, than people infected earlier in the epidemic.
Accompanying this demographic shift has been a revolution in the treatment of people with HIV disease. Three antiviral drugs (one of them usually from the potent "protease inhibitor" family), taken every day, can prolong the lives of most AIDS patients. This treatment can restore many to something approximating good health. Whether it can permanently halt the disease is uncertain.
What's certain, however, is that for "triple therapy" to make a big impact on the epidemic, it will have to work in people like Worrell, and at places like Liberty Medical Center, where she's treated.
Here, taking care of people with HIV involves not only physical exams, blood tests, prescriptions and return appointments. It frequently also means drug treatment and social work, free meals and bus tokens. It means picking up patients at home, getting to know their families and creating a spiritual milieu in which AIDS becomes only one of many problems to be overcome.
The hospital's AIDS clinic is called the Imani Center; the name comes from the Swahili word for "faith." Its clients are, almost exclusively, low-income black city people. Some are saddled with addictions or are suffering from serious illnesses apart from HIV infection. Many are chronically underemployed. Some frequently change residence or are in and out jail. Often, their knowledge of AIDS is slight.
Bringing triple therapy to the Imani Center's clients-as to all AIDS patients-comes at a price, and with some risk.
There's the literal price-about $12,000 a year, on average, for three antiviral drugs and the lab testing that goes with them. There's the price in effort and psychic burden, for HIV-infected people can never forget their disease. On triple therapy, a person must take some pills twice a day and some pills three times a day. Some on an empty stomach, some when the stomach is full. For one of the newer, better drugs, one dose consists of six pills, twice a day. And the patient has to remember to put the bottle in the refrigerator in between.
The risk concerns the bad things that might happen-to both the patient and other people-if the rules aren't followed.
In an untreated AIDS patient, about 10 billion viruses are born each day (and a similar number die off.) Triple therapy suppresses that completely, or nearly completely. However, if a person forgets to take the medicine, or decides not to, there's no lid on virus growth. It starts up again, and the viruses that manage to survive and multiply in such a situation are much more likely to be resistant to the drugs than if a person had said no to treatment in the first place.
© 1997 The Washington Post Company