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.