A PUBLIC HEALTH CONUNDRUM

Please forgive the inherent lack of humor in this topic, but
I’m trying to assimilate some information related to my job.  So I’m writing it out here. 

You probably know that there’s a drug treatment for HIV/AIDS
that significantly prolongs life and in some dramatic instances has brought
people back from the brink of death.  It
seems like a no-brainer to get that drug “cocktail” to as many people as
possible, here in the U.S.
and in other parts of the world, some of which have been utterly devastated by
the pandemic.

But is that the best approach, from a broad public health
perspective?

The widespread use of the cocktail in the U.S.
has brought about two serious, unintended consequences.

 1.      Because
public perception of AIDS has shifted from “death sentence” to “manageable
condition,” individual prevention efforts (safe sex) have been slacked off or
abandoned by many people.  This obviously
results in increased incidence of HIV and other sexually transmitted diseases.

 2.      The
drug cocktail regimen is complicated and difficult to follow (multiple daily
doses of multiple pills, and repeated follow-up visits with doctor to make
adjustments).  And there are often
unpleasant side effects.  Some people
cannot or will not stick to the drug regimen, for a variety of reasons.  They go on the meds, and then stop taking
them.  Or they take them
erratically.  As a result, the virus mutates
and they develop a drug-resistant strain of the disease which can then be
transmitted to others.

Now, say you are a health care
provider with an HIV+ patient we’ll call Joe Drug Addict.  Joe lives on the street and shoots up daily,
and therefore has a chaotic life, to say the least.  You feel quite certain that, if Joe receives
free medication (provided by your tax dollars), he will not be able to manage
the regimen.  You know that going on it
and off it may result in drug-resistance, thereby increasing Joe’s danger to
others with whom he has sex or shares needles. 
And you know that giving Joe the meds will suck health care dollars out
of the system that might be better spent on someone who could derive real
benefit. 

Can you ethically deny Joe
treatment?

Note that much of the problem
could be gotten around by also providing Joe with housing, counseling, treatment
for his drug addiction, and supervision with his medications. (That’s what my
agency does, on a small scale.)  But
those services may not be available, and even if they were, Joe would have to
consent to it.

For comparison, consider organ
transplant protocol.  Very sick people
who need new organs are often denied transplants because they are judged to be
incapable of adhering to the medication regimen required to prevent their
bodies from rejecting the transplanted organ. 
Since organs are few and far between, doctors reserve them for the
people who can best benefit from that precious gift. 

Now consider Africa.  There are millions of people on that
continent infected with HIV.  Even if the
well-meaning industrialized world could offer drug cocktail  treatment to
large numbers of them, could they, realistically, adhere to it?  And if not, would the resulting spread of
drug-resistant virus wreak further devastation? 

Well what do you think?  Who should get the drugs?  And how do we maximize our public health
efficacy?

_________________________________________________________________

Rick
asked if HIV incidence has increased.  The chart below shows an
increase for gay men, and modest decreases for other populations. 


It is
also worth noting that, due to the drastically decreased death rate in
the wake of the drug cocktail, there are more people than ever before
currently living with HIV/AIDS.

 

 

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32 thoughts on “

  1. Well, I think that the problem in the USA “….those services may not be available” is the root of the problem here. That problem needs to get solved. Give Joe a home and treatment, and maybe he will stick to the HAS the rate of NEW infection in the USA actually been increasing? I am talking about in the whole population and not specific subgroups.I am sadly not aware of the cost of these meds to manufacture (NOT what the companies sell them for) and the capacity for manufacturing. I know that there was a lot of talk of having these drugs available for cost, but i am unaware of how that turned out. If enough of the medicine be made, then nobody should be denied on their likelihood to follow the routine.

  2. I believe my primary concern would be with the danger of allowing or enabling a drug-resistant strain of the virus to develop.  I think that would be unethical.  We’ve spent too long trying to find a way to deal with this disease to let it mutate and regain ground now!!!  I have seen some documentaries about people who have been saved (if temporarily) by this kind of cocktail and it’s hard to deny people HOPE… Of course it’s impossible to tell who can or can’t REALLY adhere to the regimen.  I believe I heard something about some of the drugs needing refrigeration which is an issue in Africa. 
    I think a drug addict with no intent to clean up does not merit intensive and expensive treatment.  If Joe’s just going to screw up his meds and keep doing drugs, he’s making MORE of a problem AND costing me (taxpayer) money. 
    I would say that there should be some screening – as cruel as it may be to deny treatment.  There just is no good answer.  There will be some who are denied treatment who could have done right with the meds… and there will be some who pass the screening and still mess up their meds and end up with mutated stronger virus.  I do not envy your position.  It’s going to appear that the poor and uneducated are denied treatment because they are poor and uneducated.  That’s more-or-less unavoidable with this situation I’m afraid.

  3. Oooh, you ask the tough questions. I have one for ya…No, I don’t.  I do have my opinions, but I have a feeling they might not be popular over here.And you know me…I’m all about popular!

  4. If Joe wants to clean up and take his meds right, he should *ideally be provided with all the assistance he needs.  The decision is not entirely in the hands of the health care professional in that case.

  5. The sad thing is, even if you did provide Joe with housing, counseling, rehab, and supervision, you couldn’t provide him with self-control and self-motivation.  Of course you can’t *know* what a person is going to do or not do, which is why it’s so hard to say, “well, Joe looks pretty iffy, better not take a risk on him”–but people have an unfortunate tendency to be predictable in these situations.  Would it be ethical to insist on treating him when you’d be risking the public health at large?  It doesn’t seem like it.  But I hate to paint the issue with such a broad brush.  I think I ditto oceanstarr’s last comment.  Now I’m off to read something fluffy.

  6. That is really hard, I don’t know the answers, but maybe if you provide Joe with housing, counseling etc.., and he is proving that he is indeed making an effort to change his life then offer the medication, But then again, I really hate to deny anyone medication. I am always wishy washy with hard questions, I always see too many sides to an issue and then can’t decide.

  7. I think this all depends on what you believe our ethical obligation to these mebers of society is.  T the current administrations view seems to be, ‘well let them die and decrease the surplus population’ and that seems rather cold hearted.  The Drug companies seem to have the ‘what’s in it for us in terms of profit’ perspective, and the rest of the planet is just trying to get e handle on these things.
    As for us, again the dissolution of communities and ‘village’ mentalities where we all try to look after each other has been replaced by isloationism and defering things to the government for resolution, and we all see the benefits of that.
    So I don’t know either except to say that I wish the drug cocktail had been around soon enough to save my little brother.  HE was the funny one in the family.
    G.

  8. It sounds like the best thing you can do at this point is keep Joe supplied with clean needles and condoms.  Make it clear to him that the HIV treatment won’t work until he stops using drugs.  (This is true enough, since drug use is presumably what would prevent him from keeping up the regimen.)
    The money just isn’t available to house and treat all the Joes of the world.  Ironically, we’re spending it on the war on drugs. 

  9. 2 things to consider: As a health practitioner, one isn’t supposed to deny any one medical help. The other thing is, aren’t we “babysitting” too much, too often? If this Joe fellow contracted it through drugs and won’t quit even if he is being offered medication and help, thus increasing his chances of never being saved because of virus DNA mutation – do we really want to focus on such a group? I don’t think poor and uneducated is the problem; its our willingness to educate and the patient’s willingness to co-operate. Everyone deserves one chance to be treated and seen to, but if tax-payers have to spend millions of dollars re-habilitating some folks again and again someone has to blow the whistle.
    Its probably not so much of the re-habilitation stage itself; its the pre and post of it to ensure that genuine cases are seen to and progress at a better rate (with hopes we can come up with a good plan for that). Hard-core cases like Joe would probably benefit from an extended housing & counselling programme before even being put on medication to ensure he is prepared to stick to the regimen and loose his addiction. At least for a good while.

  10. It seems to me the real threat is the creation of drug-resistant strains of the disease.  On an ethical level, I’m not sure you can really consider the money unless there’s a genuine shortage of treatment (as in the case with organ transplants).  This is not a matter of who should or should not receive a highly prized treatment, but a matter of who should or should not be given the ability to turn his or her body into a weapon.  These drugs constitute a significant threat to the rest of the population if they are used incorrectly.  To me, that means you can only distribute them to people who can be trusted with them.  And I don’t think that has anything to do with “value to society.”  The brain surgeon who drinks a fifth of gin and smokes two packs of Camels every day and has unprotected sex with hookers would be as bad a risk as Joe Drug Addict.  The fact that the brain surgeon could buy the drugs on his own might be unfortunate, but it’s not your responsibility. 
    (Incidentally, I feel the same way about Africa.  If their lifestyle is not conducive to taking the drug responsibly and their doctors cannot be trusted to keep the drugs out of the hands of those who can’t or won’t take them responsibly then it’s too dangerous to send them there.  Weapons-grade technology can be used to make lots of things other than weapons that are of great benefit to a population, but you shouldn’t sell them weapons-grade technology if they can’t be trusted not to make weapons to use against you.)

  11. I have been thinking about this issue of viral and bacterial mutation evolution. This is not anything unique to HIV. Certainly this is the reason people are told to take all of their antibiotics. We do require provide moral “means testing” for people on antibiotics. Why should we do this with HIV?

  12. It is true that the individual initially makes the voluntary decision to use drugs. But once addicted, it is no longer a simple matter of choice. Prolonged drug use changes the brain in long lasting and fundamental ways that result in truly compulsive, often uncontrollable, drug craving, seeking and use, which is the essence of addiction. It becomes a more powerful motivator for that person than virtually any other. Once addicted, it is almost impossible for most people to stop using drugs without treatment. And sadly a lot of these addicts are turned away from treatment.
    My view is that we have no right to neglect a single person, we have to do all that is possible. Usually we can not achieve the best as the best method does not exist. We try to treat thinking that it is the best method but it is very important to remember that we cannot turn aside from the people and leave them to their fate. But again that is my view.
    This was a very good, deep-thinking post.
     

  13. The priorities of human care are all screwed up. Too much money focused on military spending. If we could just start at the beginning, where these problems are coming from, we can slow down the damage of what has been created. If we have something available to relieve suffering, it should be used without judgement.We cannot second guess anothers motivations.Victim blame harms everyone. Good post!

  14. Interestingly this is discussed a bit in the latest issue of Science.  One conclusion is that in order to treat HIV, patients need a depression screening and treatment.  Otherwise, just giving the drugs will  not work because as you have said, the treatment routine is rather rigorous & will be abandoned.

  15. I agree with Sunny – start with children.  emotional health, education, opportunities, mentors…
    but we’re so busy playing catchup on the other end – grownups already screwed up.. and military spending etc…
    It’s all a mess… stupid humans…

  16. You ask some difficult questions. I agree that it’s taking a terrible risk to provide drugs to someone who may not stick to the regimine, but I see a serious ethical problem in health care providers making decisions about who is “worthy” to receive treatment for a condition.

  17. It sounds awful, but I think the long term risk of mutated virus justifies careful dispensation of the meds.  One of those horrible things where you have to calculate future loss of life vs the needs of the individual patient

  18. That last point is interesting.  It illustrates so well why a treatment that prolongs life is so insufficient.  It’s good to have fewer people dying of the disease… but the cost is more carriers and more potential for further spread.  And that doesn’t even address the mutation problem.
    Bottom line:  There’s just no substitute for an actual cure.

  19. Wow…back in the ’70’s…I remember the controversy  about whether we should give heroin addicts methadone to help them detox from heroin.  Later, finding out that methadone was just as addictive.  Methodone would be legal and properly dispensed with clean needle, in a controlled setting, was the argument for.  The argument against was that Joe drug addict would fine a way to abuse the methadone and would end up worse than he was before. 
    As a paramedic we would roll on the scene of  a heroin overdose and we would inject  them with Narcan, the antidote.  We would provide the counseling, the housing and the methadone.  And for awhile “Joe drug addict” would do great. He would slowly detox from the methodone and clean his act up.  Six months later, as the paramedics rolled on the scene, guess who was overdosed ?  Joe Drug Addict!  I was all for making Methodone available, but not to the Joe Drug Addicts of the world.  How did we know whether they would be successful or not…we didn’t, that’s the problem with human nature.  Ethically we would not deny Joe treatment!
    As I read your post, I remembered the heroin addicts we worked with…at the time I really thought that providing methadone was the best approach, from a broad public health perspective.  I don’t know now!  In our 20’s we are a bit for optimistic about outcomes.
    I think if we found a way to screen the patients and the tool we used to screen those patients took into account all the social issues humans are faced with…..I say go for it.  But I don’t believe any tool to screen human nature is or ever will be available. 
    An Amazing well-thought out post!  Are you employed in the medical field?
     

  20. The following statement may appear callous:   I think all HIV/AIDS people should be given the “cocktail” and explained the regiment.  If they do not follow the treatment and spread the disease then their penis needs to be cut off. 
    It is sad how this disease is spreading.  I think it’s great that researchers are creating medicines that can help people with the disease.  I’m not sure how to make them stick to the regiment of the pills – threats might work. 

  21. A young West Virginian girl wanted to go to college at UVA. But her father said ‘ No Way! You’re going to By-God West Virginia Univ.’ Well she got her way and she went to UVA. The first semester went by, and she wrote home that she was getting married to, a man from Richmond, VA named Clarence. Her father said ‘ I’ll be damned if my daughter is marrying a man from Richmond, you’re marrying a By-God West Virginian boy.’ So he sent his two sons to UVA to get their sister. In a couple of days they returned. Dad said ‘ Where is your sister?’ They replied ‘ We were almost there Daddy and we came up on this overpass that had this sign that read ‘Clarence 13’6” so we turned around and got the hell out of there.’

  22. Thanks for your comment.  I responded at my place.  Funny how you can say you disagree with me completely, while I can say that *I* agree with *you,* albeit only partially.  I’ll also make the point here that it’s a huge lot harder to be apologetic, let alone respectful, after acts of violence have been perpetrated.  If you have a better idea, I’d be delighted to hear it.
    In friendship, always, Bob

  23. Give him the free drugs as long as he consents to follow the regimen (including having your agency monitor him and having him show up at your clinic at scheduled times to ingest said drugs.  If he misses too many appintments, then you have to cut him off.  That takes care of the mutation problem to a certain degree, no?

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