Why AIDS Drugs Can’t Help Those at the Highest Risk

SAN FRANCISCO —  The woman with the ponytail is homeless, mentally ill, addicted to crack cocaine, sick with AIDS--and a perfect example of why the latest AIDS-fighting drugs will not wipe out the disease.

You can’t get better unless you take the drugs. And health officials say many people at highest risk for AIDS are those least able to follow a careful regimen of medication.

“We’ve done educational programs. We talk about viral-load testing and protease inhibitors,” said Ken Shigematsu, a social worker at the San Francisco AIDS Foundation.

“But for some of our clients, finding something to eat or someplace to live takes priority over saying, ‘What’s my mealtime plan so I can take my protease inhibitors?’ ”

The foundation and other social-service agencies give out housing vouchers, clothing vouchers, even daybooks to help people keep track of time--anything to restore a measure of order into chaotic lives.

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Without such efforts, the vaunted new drugs could prove instead to be a menace. Protease inhibitors work best in combination with older drugs, such as AZT, thus undercutting HIV’s ability to mutate into drug-resistant strains. If people can’t stick to the schedule, they may create a multidrug-resistant strain of HIV.

“We could have a whole new epidemic on our hands,” said Derek Gordon, the AIDS Foundation’s communications director.

The woman with the ponytail is an especially hard case. She won’t give her name, but is willing to tell her story, partly because it gives her a few more minutes in the warmth of the AIDS Foundation office.

Age 38, she says she has seven children, all farmed out to relatives. She says she’s been off crack cocaine for four days.

Her purse is stuffed with bottles of pills prescribed for psychological ailments. Sometimes she takes them; sometimes she doesn’t. It would be the same with protease inhibitors, she concedes.

“I’m not real good on the schedule,” she says.

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She called her oldest daughter recently, and the 16-year-old said: “Don’t die, Mom, I love you.” She laughed and told her daughter she wouldn’t die, but she wasn’t really sure.

“It hurts,” she says quietly. “I’m very, very, very scared. I’m scared to death about dying.”