When, in the summer of 1996, reports were released on thesuccess of protease inhibitors in treating AIDS, both thegovernment and clinical direc- tors were faced with new problems ofdistribution. Protease inhibitors were used as part of a drugcocktail that can drive the HIV virus below the level of detectionand lead to a great increase in disease-fighting immune cells. Butno one knew if the drugs could wipe out HIV lurking in the lymphnodes. Indeed, little had been published. Attention had beenfocused on dramatic turnabouts, but less attention had been paid tofailures, or resurgences of the virus. Since that time many moreeffective and costly drugs have been duced that are prescribedusually in combination. To date, these treatments have never beenproven curative. Treatments developed would cost between $10,000and $20,000 year at retail. The exact price would depend on theother drugs used in the cocktail. Although most private healthinsurance and managed care programs cover the treatment, some arerestricting its use to the advanced stages of the dis- ease. Thedecision to treat is usually based upon laboratory tests that showthe depression in the immune system (CD4) and the amount of viruspresent (viral load). Indeed, there is debate as to when it is bestto begin treatment with the newer cocktails. Early treatment mightmake HIV cells drug-resistant and leave the patient with no drugswhen the virus re-emerges. Waiting for even the first symptoms toappear might take five to ten years, making clini- cal trialsdifficult. Even today many infected individuals have no insuranceor are under- insured. Clinical directors estimated that they wouldhave to double their income in order to meet the demand for the newtreatments. National es- timates put the total cost of treating HIVin the billions, with the average total cost of HIV care being near$20,000 per patient per year. There are, moreover, problems withthe treatment. The patient must many per day on A very tightschedule along with dietary restrictions. In most cases the treat-ment will last for the rest of the patient’s life. There is seriousdoubt about the ability of drug users, alcohol abusers, and manyrootless people to main- tain such a regime. This fear isreinforced by the side effects of some of the cocktails: nausea andheadaches at the start of treatment. These effects cause some tostop treatment. If the patient starts and then stops, there may beserious social consequences. Specifically, a new drug-resistantform of HIV may develop and spread through the population. Alreadythere are cases of patients who have sold their protease inhibitorsin order to purchase street drugs. Newer, once-daily regimens offera greater likelihood of compliance, but the issue remains.Even aside from the discipline required for the treat-ment,should the government increase payment for these new antivirals?What health care services or general public services should bereduced to provide this extra money? This is a political and socialquestion that involves the opinion of the whole society. Shouldclinic directors refuse to treat those who do not appear to havethe discipline to carry through with treatment? If they do treatthem, how can they justify the risk of producing new drug-resistantstrains of HIV? How are the answers to these questions affected ifthe clinics receive no new funding?
