Playing the Long Game

Years ago, racing to develop a cure for infectious diseases seemed to be the end game. Then we started worrying about drug costs and the difficulty of effective distribution. While neither of these hurdles has been overcome, a new conundrum now has us questioning our treatments, even those we don't yet have. The rise of drug-resistant strains of diseases such as tuberculosis and HIV has centered attention on the harmful effects of administering treatments without policies in place to ensure the long term effectiveness of the drugs. We are learning about the elaborate infrastructure needed to sustain treatments; this framework relies heavily on education and human support, resources we are currently sorely lacking.

To get a better idea of what this looks like, we can examine the new “test and treat” approach in San Francisco, California, operating under the basic premise that the earlier people discover their positive status, the sooner they can receive treatment and vastly improve their life expectancy and quality of life. Seek treatment at the San Francisco General Hospital (SFGH) Emergency Department for a broken bone or stomach pain, and your nurse will probably ask you if you want to be tested for HIV. The result? Nurse Diane Jones of SFGH reports that about half of people who test positive “never perceived themselves at risk,” and a not insignificant four percent of people tested in the SFGH ED have been HIV positive. Take one of these patients, Darnell Hollie, a 47-year old woman who found out she was HIV positive at age 25. She had battled a strong heroin addiction until age 32, when she realized being HIV positive didn't have to be a death sentence, and entered Dr. Monica Gandhi's treatment and support program at SFGH. After fifteen years of support from family, friends, and health workers at SFGH, Hollie maintains a strict routine with taking her antiviral medication, and is enjoying a healthier lifestyle.

This is an inspiring success story, as Hollie was not only able to overcome her drug addiction, but also battle HIV head on. But shift across the globe to Cape Town, South Africa, where health workers are implementing this “test and treat” approach with less gratifying results. It will be common here to see people getting tested at roadside tables, with HIV positive patients immediately receiving antiretroviral therapy. The US Health Resources and Administration reports that clinical trials have demonstrated that patients receiving HIV treatment are less likely to pass on the infection to others. The reasoning then, is that “test and treat” can act as a preventative measure in addition to a quick, large scale treatment effort. However, patients in Cape Town might not be able to experience Hollie's success, because they are not integrated into a long term support group or associated with a physician who can track their progress, and, most importantly, ensure that they are taking the appropriate doses of medication at the right times. Without this attention to detail in handling HIV medication, resistant strains can easily emerge and compromise individual and global health. In addition, support groups and physicians act not only as informational resources, but also outlets where patients can feel comfortable with their condition and can then envision a brighter future. This aspect of treatment must be underscored as patients need motivation and encouragement to keep up with their regimen. The absence of this support and education in the Cape Town testing environment transforms the battle against HIV into a widespread, yet independent process, where patients' lack of guidance jeopardizes the effectiveness of developed drugs, constantly sending us back to the lab, and thrusting us into a vicious cycle.

However, it remains difficult to argue for an “all or nothing” approach, by which testing and treatment is delayed until the region has an adequate system for long term treatment. Context is key here. This U.S. “test and treat” program is concentrated in health care centers, such as SFGH, where patients can more easily connect with physicians and support networks. It might be necessary for a Cape Town program to focus its efforts near a hospital or health clinic, perhaps compromising the extent of outreach, but ensuring the sustainability of antiviral treatments. If current trends continue, the opposite policy strategy, with its efforts directed toward numbers – quantity rather than quality – will give rise to a larger biological predicament that we may not be able to extricate ourselves from.