IHV In the News

Drug deliveries bring hope to AIDS patients

In person: An effort in Baltimore that makes therapy routine is being introduced in sub-Saharan Africa.

Baltimore Sun
November 5, 2004
By Jonathan Bor
Sun Staff

Every day, Dorothy Murray files into a downtown clinic, raises a glass of grape juice and downs three pills under the eye of a pharmacist. It has been her routine since March, when she left the hospital after nearly dying from an AIDS-related infection that reduced her weight to 70 pounds.

"I was an intravenous drug user, but I didn't like taking pills," said Murray, 38, who's back to 100 pounds, which sit well on her diminutive frame. "I figured this was the only way I'd take my medication."

Preventing drug resistance - in a region where a third of the population in some countries is infected - was a major topic of discussion at an international conference on AIDS held this week by Dr. Robert Gallo, the institute's director.

In Malawi and Nigeria, specialists from the institute are training local health workers to pay weekly visits to villages where patients live. Doctors from the Johns Hopkins schools of medicine and public health are doing similar work in Kampala, the capital city of Uganda, as well as in a rural district without a major hospital.

Fighting the stigma

Before introducing medications in those countries, doctors educate families and village leaders about the nature of the treatment and the need to the fight the stigma that can drive people with AIDS from even being tested. Health workers who visit patients at home count pills to see if they're missing doses, and they make sure that relatives and friends remain involved.

"We think treatment is sustainable once the community is with us," said Dr. Athanase Kiromera of St. Gabriel's Hospital in Malawi, which serves patients within a 16-mile radius, in an area that lacks roads. The hospital gets help from the Baltimore virology center, which is part of a consortium that won a $335 million, five-year federal grant to deliver medications in Africa and the Caribbean.

St. Gabriel's began educating village chiefs and residents two years ago, before the hospital had drugs to deliver.

On both continents, doctors say the AIDS epidemic is too widespread to provide such intensive supervision for a lifetime. Instead, the goal is to help patients on a daily or weekly basis during the first months of therapy - then ease off as patients and families take charge.

Dr. Robert Redfield, who heads the clinical AIDS program at the University of Maryland, said those early months are critical. If patients can drive the virus to undetectable levels early on and keep it there during that period, the odds are good that they can tolerate occasional lapses later.

Although drug-resistant strains of the AIDS virus can turn up any time, the odds are greatest when patients miss doses early in their treatment. This forces doctors to substitute drugs that might not work and cause harsher side effects.

Experts say the issue is more acute in Africa, where drug shortages might not allow patients to switch from one regimen to the next.

"You get it right for a lifetime," said Redfield, the leading force behind the university's AIDS programs in several African countries. "You've got to move away from the thinking that, 'If I fail the first regimen, I'll move to the next.'"

Long concerned about the threat of drug resistance in Baltimore, Redfield started what is formally known as the Jacques Initiative in the spring of 2003. The program is named for Joseph Jacques, a Baltimore man who helped scores of people with HIV infection before he died of AIDS in 2001.

When the program began, the staff offered patients several options: get their pills at the clinic, have somebody deliver them, or buddy-up with an experienced patient who could spur them on. To the staff's surprise, most patients chose to come in.

"We thought that people wouldn't want to be inconvenienced," said Derek Spencer, a nurse practitioner who directs the Jacques program. But patients liked the idea of coming to a familiar place where people know their names and are willing to listen. Perhaps, said Spencer, people who lack structure in their daily lives gravitate to a place that has plenty of it.

Another key, he said, is that three of the six people who work there full time are infected and know firsthand what it's like to battle the illness. "It's one thing to tell people that they can live being HIV-positive," said Spencer. "It's another to show them."

Faced with a choice

Kathy Bennett, a treatment specialist who tested positive nine years ago, recalled wanting to stop therapy because of wrenching side effects. It was Redfield who told her she had a choice between sticking with treatment or giving up and facing the consequences.

Bennett said the side effects subsided after a few weeks. Her immune system rebounded, her "viral load" became undetectable, and she stopped thinking about death.

"I give my patients a shot of hope," said Bennett, a mother of two who sees 33 clients a day.

With 141 patients enrolled in the program, the early evidence is encouraging. In September, a study found that 82 percent were taking their pills 36 to 40 weeks into therapy. Elsewhere, studies have found compliance levels well under 50 percent.

Patients who report to the clinic on a daily basis - a strategy known as directly observed therapy - are expected after six months to begin taking pills on their own. The clinic is still there for them. They can participate in support groups, meet with counselors and help others.

Despite tens of millions of dollars flowing into AIDS programs in sub-Saharan Africa, the battle has come late. According to the United Nations, 25 million adults and children live with the virus there - two-thirds of the world's total.

Dr. Thomas Quinn, a Hopkins professor involved in programs in urban and rural Uganda, said Africa offers a significant advantage - "a family structure that is sometimes lost in inner-city Baltimore."

That, he said, makes it possible to enlist families in the struggle. This is particularly important because the epidemic's scope makes it impossible for health workers to monitor patients daily.

Though the Bush administration pledged $15 billion over five years to fight global AIDS, and foundations are pouring in millions more, Quinn worries about the future. Unless governments and private donors maintain a commitment for years, he said, it will be difficult to keep patients in therapy and control the problem of drug resistance.

"We can prevent resistance if we go about it in the right way, at least in the short term," he said. "The long term could be the problem.

Copyright (c) 2004, The Baltimore Sun