HIV medication: Patients get someone to watch over them

City program makes sure lifesaving pills get taken

January 28, 2003|By Jonathan Bor | Jonathan Bor,SUN STAFF

A city health worker opens a plastic case and dumps a pile of pills into the outstretched hand of Antoine Chester, a slender man with an easy smile who has been battling HIV infection for five years.

With a few swigs of water, Chester downs the colorful assortment - blue, orange, yellow, red and white - that arms him against the deadly disease. If he takes the pills twice a day, every day, he might live a long time.

In a patient's struggle against a virus that could rebound with the slightest lapse in treatment, that's a huge "if"- and the principal reason that Bernard Cure knocks on Chester's door every morning and night with a package of pills and some encouraging words.

"He'll come by and say, `It's not so bad,'" says Chester, who lives in a section of West Baltimore that for years has had the state's fastest-rising rate of HIV transmission. "I'm not an irresponsible guy, but sometimes I need someone to watch over me."

In an experiment that faces some stiff challenges, Cure and other workers from the Baltimore Health Department hand-deliver medications to 27 patients who are considered unlikely to stay in treatment if left to manage on their own. The department is gambling that the program will restore the patients' health and stem the spread of drug-resistant strains that can develop when people take some but not all of their medicine.

Many of the patients are drug addicts, recruited directly from the city's needle-exchange program. But not all are. Chester, who is in his mid-20s, says he contracted his infection through unprotected sex and was referred by the health clinic where he has been getting his care.

The program, one of a few such efforts around the nation, is surely one of the most labor-intensive in public health.

Here, counselors load their vans with prepackaged medications and drive from one client to the next - visiting them at their homes, shelters, Narcotics Anonymous meetings or even on prearranged street corners. They watch their clients take every pill, listen to their problems and review the day's challenges. Sometimes, they drive them to medical, dental or psychiatric appointments.

It's a job that requires the skills of a social worker and the know-how of a police officer.

Health workers who don't find their clients at home learn to find them with friends or relatives. In August, when Chester was new to the program, Cure often had to pound on the man's door to rouse him, even after giving him a wake-up call a half-hour in advance. Now, he finds his client dressed and ready.

"He's one of my best clients," says Cure, meeting Chester one day last week in the program office on Garrison Boulevard.

"I wasn't one to have someone knock on my door at 8:30 and tell me to get up," says Chester, who was a cashier in a fast-food restaurant before a bout of AIDS-related illness put him out of work last year. "I had an attitude with it, but I had to adjust."

TB program is model

The program is called "directly observed therapy" because health workers literally watch people take their pills. It is modeled after the highly successful way Baltimore has kept tuberculosis under control since the 1970s.

That program, which was pioneered here before becoming a mainstay of TB control nationally, was designed to keep the highly infectious disease from spreading rapidly, which it can when it goes untreated.

That program stemmed from the recognition that patients who don't take all of their pills can become resistant to treatment and trigger a public health nightmare by spreading nasty strains to others.

Last year, city Health Commissioner Peter L. Beilenson said he would use a similar strategy to combat drug-resistance among hard-to-treat patients with HIV infection. But he was quick to add that HIV posed a more formidable foe.

Though the city has fewer than 100 cases of active TB, it has more than 12,000 people who are infected with the human immunodeficiency virus, relatively few of whom can be served by a home-delivery program. Also, TB pills can be taken twice weekly; most HIV regimens have to be taken twice daily .

And tuberculosis can be cured with six months to a year of therapy; HIV is still regarded as incurable. That means that anyone who begins treatment must look ahead to a lifetime of therapy with few lapses.

"You have to be 95 percent compliant with multiple medications twice a day, all the time," says Beilenson. "If not, you're at risk of developing multiply drug-resistant HIV, which is disastrous to yourself and the community."

With a first-year budget of about $120,000, Beilenson initially hoped to serve perhaps 200 people, but less intensively. The plan was to have patients report twice daily to storefront centers where they could receive their medications. That effort was short-lived.

"Folks were much sicker than we anticipated," says Dawn Laforce, Beilenson's chief of staff. "They were not making appointments to show up at their designated spots, so we ended up having to chase them down anyway."

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