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Is the AIDS Epidemic Over?

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from: Jon Cohen
to: Dr. Jerome Groopman

Posted Tuesday, Dec. 17, 1996, at 3:30 AM ET

I, too, see both false hope and true hope in the passages I have flagged. That's my criticism: Why introduce false hope at all?
There's an interesting article in the Dec. 23 issue of The Nation that underscores many of the points I've been making. Just to tick off a few of them:
If patients take their HIV medications 75 percent of the time or less, Dr. Scott Hammer (who works across town from you at Beth Israel Deaconness Medical Center) suggests they risk the emergence of resistant strains of HIV taking over, which would render the drugs worthless. The article also notes that physicians routinely consider "normal compliance" for patients on long-term therapy to be in the 70 percent to 80 percent range.
The good news about drug advances may already be encouraging people at high risk to practice unsafe sex.
It's only a matter of time before strains of HIV that are resistant to the latest protease inhibitors begin spreading from infected to uninfected people.
"Large-scale resistance" may develop in the people who are most likely to infect others, namely injecting drug users who are notoriously noncompliant and care little about condom campaigns and the like.
The dramatic results from studies of the latest treatments are in idealized patient groups that were healthier and more likely to have positive responses to the drugs.
San Francisco AIDS clinician Marcus Conant says "a significant number" of his patients aren't being helped by the new treatments at all, primarily because they've already become resistant to the older drugs in the triple-combo cocktail that's made the most headway.
Mike Isbell from Gay Men's Health Crisis reports that they surveyed several dozen doctors "and found no consensus on how to use the drugs."
As Gabriel Rotello, the author of the Nation article, concludes, "Misguided optimism was certainly the rule in past epidemics."
The exaggerations and oversights in Sullivan's and Sanford's articles that I have been highlighting are not petty snipings. Both of these writers are delving into prediction journalism (albeit with caveats), which I think works better when writing about a political race than a scientific truth. If their hopes (and mine, for that matter) come true, and new treatments allow even some people to truly survive AIDS, neither of them will have been perspicacious. They will have been lucky. What I worry about is what happens if they're unlucky, and the way they have described their hopes sets the hopes held by their readers too high.
And speaking of the Talmud, there is a story about a man who visits his rabbi and says he is going to leave his wife and three children because his mother-in-law has moved into their two-bedroom home. The rabbi tells the man to move a chicken into the house. The man returns a week later and says, "Rabbi, this is crazy. I now have three kids, a wife, a mother-in-law, and a chicken in my house." The rabbi tells him to move two sheep into the house. The man returns the next week and says he absolutely cannot take another day of this. The rabbi says to move a cow into the house. When the man returns the next week, insane with rage, the rabbi says, "OK, now move all the animals out of the house." The man does so, and finds that living with his mother-in-law is tolerable after all. The progress now being made with the anti-HIV drugs is analogous to driving the animals out of the house. Yes, it will be easier than it was when there were no effective drugs, and, in many cases, I'm confident that disease and death will be delayed. But the mother-in-law is still there. Which means living with HIV likely is going to continue to be difficult, I suspect, for most every infected person, just not as difficult as it used to be.

--Jon Cohen

dialogues
entries
123456
from: Jon Cohen
to: Dr. Jerome Groopman

Posted Tuesday, Dec. 17, 1996, at 3:30 AM ET
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Dr. Jerome Groopman is a professor of medicine at Harvard Medical School. Jon Cohen covers AIDS for Science magazine and wrote the story "AIDS Isn't Over" for SLATE.
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