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http://www.nytimes.com/2002/07/16/health/16CASE.html

Beyond Temporary 'Miracles'

By ABIGAIL ZUGER, M.D.

ARCELONA, Spain, July 14 — A cynic wandering through the 17,000-person international AIDS conference here last week might have been tempted to point out that there were actually two conferences taking place under one roof, with remarkably contradictory messages.

One was devoted to establishing the need for AIDS drugs in poor countries devastated by the epidemic. The other was devoted to coping with the endlessly mischievous, sometimes life-threatening complications of these same drugs.

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Half the world is determined to put as many patients as possible on medication, it seems, while the other half is trying to take as many patients as possible off.

The drugs appear quite democratic in their benefits. Pilot studies presented here confirmed that the drugs seemed to work as well against the virus variants prevalent in Africa and Asia as they did against the common strain in Europe and North America. Descriptions of patients newly treated in Haiti, Africa and Malaysia were provided with the same awed tones that first described the miracles the drugs first wrought in Europe.

With few if any exceptions, patients from developing countries given AIDS drugs hopped off their deathbeds, began to eat again, filled out their skeletal frames, went back to work. They arrived triumphant back into their own lives.

Unfortunately, though, these drugs do not provide simply a bridge from death to life. After a few years, they tend to lead on out to a highway of complications and side effects so insidiously varied that the experts are still trying to keep track of them all.

And hence the other half of the conference here, with presentations on the health complications of AIDS drugs: heart disease, liver disease, diabetes, weakened and broken bones, the recurrence of skeletal thinness, or the onset of unnatural and equally stigmatizing plumpness, not to mention the nausea, diarrhea, headaches, rashes and allergies that plague patients, or the fact that in some studies drug combinations stop controlling the virus in as many as half the patients who take them, requiring new drugs (and new side effects).

While the AIDS drugs may be considered magic bullets, there are still no magic bullets against the health problems they provoke.

And so, AIDS experts in developing countries have begun to ask when it is safe to take their patients off AIDS drugs. Treatment guidelines endorse deferring treatment to increasingly later stages of illness.

At the conference, doctors and patients from North America and Europe crowded into sessions debating the merits of treating patients for only a few months at a time, or having patients take medication every other week. Some favored taking late-stage patients off medication completely for a few months. All called for more study of these and other options that will limit patients' exposure to the drugs and lessen complication rates.

There is little reason to assume that the drugs will be any less democratic in side effects than they are in benefits. Less-developed nations with increased access to these medications will undoubtedly soon experience for themselves the quandaries of medical care when a treatment turns into a poison.

A patient of mine went through his own miracle in 1995, when he had either the good luck or the bad to receive a diagnosis at the dawn of the availability of lifesaving medication. He rose from his sickbed, retrieved his appetite and his energy and went back to work right on schedule. The miracle lasted for a few years, but it has been downhill ever since.

His cholesterol has soared despite a spartan diet and endless exercise and, finally, medication. He has lost weight and become even more wasted than he was when he was still sick. His family looks at him strangely, he says. He has developed a serious case of diabetes.

Last month a set of routine blood tests showed his liver was suddenly on the verge of failing. Had he waited a few weeks to have his blood checked, my guess is that he would have needed a liver transplant. As it is, he needed a long vacation from his medications — his fifth combination of agents. They are not working very well at this point, but there are no alternatives for him.

Complications like his are hardly a reason to restrict any nation's access to these lifesaving drugs, but they are a reason to scold those who would turn AIDS treatment into a simple matter of raising money, paying for pills and watching miracles occur.

Instead, it is a long, expensive and technologically demanding road of medical monitoring and treatment. Buying the miracle drugs and passing them out is only the beginning.

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ALL INFORMATION, DATA, AND MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR LEGAL ADVICE.  THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH YOUR HEALTH CARE PROVIDER.