Table Of ContentPsychosocial and
Public Health Impacts of
New HIV Therapies
AIDS Prevention and Mental Health
Series Editors:
David G. Ostrow, M.D., Ph.D.
Howard Brown Health Center and University of Illinois /Chicago School
of Public Health, Chicago, Illinois
Jeffrey A. Kelly, Ph.D.
Center for AIDS Intervention Research (CAIR), Milwaukee, Wisconsin
Evaluating HIV Prevention Interventions
Joanne E. Mantell, Ph.D., M.S.P.H., Anthony T. DiVittis, M.A.,
and Marilyn I. Auerbach, A.M.L.S., Dr. P.H.
Handbook of Economic Evaluation of HIV Prevention Programs
Edited by David R. Holtgrave, Ph.D.
Methodological Issues in AIDS Behavioral Research
Edited by David G. Ostrow, M.D., Ph.D., and Ronald C. Kessler, Ph.D.
Preventing AIDS: Theories and Methods of Behavioral Interventions
Edited by Ralph J. DiClemente, Ph.D., and John L. Peterson, Ph.D.
Preventing HIV in Developing Countries:
Biomedical and Behavioral Approaches
Edited by Laura Gibney, Ph.D., Ralph J. DiClemente, Ph.D.,
and Sten H. Vermund, Ph.D., M.D.
Psychosocial and Public Health Impacts of New HIV Therapies
Edited by David G. Ostrow, M.D., Ph.D., and Seth C. Kalichman, Ph.D.
Social Networks, Drug Injectors’ Lives, and HIV/AIDS
Samuel R. Friedman, Ph.D., Richard Curtis, Ph.D., Alan Neaigus, Ph.D.,
Benny Jose, Ph.D., and Don C. Des Jarlais, Ph.D.
Women and AIDS: Coping and Care
Edited by Ann O’Leary, Ph.D., and
Lorretta Sweet Jemmott, R.N., Ph.D., F.A.A.N.
Women at Risk: Issues in the Primary Prevention of AIDS
Edited by Ann O’Leary, Ph.D., and Loretta Sweet Jemmott, R.N., Ph.D.
A Continuation Order Plan is available for this series. A continuation order will bring delivery of
each new volume immediately upon publication. Volumes are billed only upon actual shipment.
For further information please contact the publisher.
Psychosocial and Public
Health Impacts of New
HIV Therapies
Edited by
David G. Ostrow, M.D., Ph.D.
Howard Brown Health Center and
University of Illinois / Chicago School of Public Health
Chicago, Illinois
and
Seth C. Kalichman, Ph. D.
Center for AIDS Intervention Research (CAIR)
Medical College of Wisconsin
Milwaukee, Wisconsin
Kluwer Academic Publishers
New York, Boston, Dordrecht, London, Moscow
eBookISBN: 0-306-47159-0
Print ISBN: 0-306-45973-6
©2002 Kluwer Academic Publishers
New York, Boston, Dordrecht, London, Moscow
All rights reserved
No part of this eBook may be reproduced or transmitted in any form or by any means, electronic,
mechanical, recording, or otherwise, without written consent from the Publisher
Created in the United States of America
Visit Kluwer Online at: http://www.kluweronline.com
and Kluwer's eBookstore at: http://www.ebooks.kluweronline.com
Contributors
MargaretChesney • UCSFCenterforAIDSPreventionStudies,Departmentof
Medicine, University of California, San Francisco, California 94 143
Susan K. Chuck • Department of Pharmacy Practice and Section of Infectious
Diseases, University of Illinois at Chicago, Colleges of Pharmacy and Medicine,
Chicago, Illinois 6061 2
David J. Greenblatt • Department of Pharmacology and Experimental Therapeu-
tics, Tufts University School of Medicine, Boston, Massachusetts 02111
Elizabeth Heitman • The University of Texas–Houston Health Science Center,
School of Public Health, Houston, Texas 77030
David R. Holtgrave • Division of HIV/AIDS Prevention, Centers for Disease
Control and Prevention, Atlanta, Georgia 30333
Seth C. Kalichman • Center for AIDS Intervention Research, (CAIR), Milwau-
kee, Wisconsin 53202
Kenneth H. Mayer • Brown University AIDS Program and Infectious Disease
Division, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island 02860
Lisa L. von Moltke • Department of Pharmacology and Experimental Therapeu-
tics, Tufts University School of Medicine, Boston, Massachusetts 02111
David G. Ostrow • Department of Research, Howard Brown Health Center,
Chicago, Illinois 606 13
Willo Pequegnat • Office of AIDS Research, National Institute of Mental
Health, National Institutes of Health, Rockville, Maryland 20857
Steven D.Pinkerton • Center forAIDS Intervention Research, Department of
Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee,
Wisconsin 53202
Judith Godwin Rabkin • College of Physicians and Surgeons, New York State
Psychiatric Institute, New York, New York 10032
BineethaRamachandran • Department of Psychology, Georgia State University,
Atlanta, Georgia 30303
v
vi Contributors
KeithA.Rodvold • Department of Pharmacy Practice and Section of Infectious
Diseases, University of Illinois at Chicago, Colleges of Pharmacy and Medicine,
Chicago, Illinois 606 12
Michael W.Ross • The University of Texas-Houston Health Science Center,
School of Public Health, Houston, Texas 77030
Peter A. Selwyn • AIDSProgram,EpidemiologyandPublicHealth,YaleSchool
of Medicine, Yale University, New Haven, Connecticut 065 10
Richard I. Shader • Department of Pharmacology and Experimental Therapeu-
tics, Tufts University School of Medicine, Boston, Massachusetts 02 1 1 1
Mike Shriver • The AIDS Research Institute/CAPS, University of California,
San Francisco, San Francisco, California 94105
EllenStover • Office of AIDS Research, National Institute of Mental Health, Na-
tional Institutes of Health, Rockville, Maryland 20857
Foreword
“AIDS is kind of like life, just speeded up.”
JavonP.,heroinaddictwithAIDS,Bronx,NewYork,1988
“Now I’m not so much scared of dying as scared of living.”
Mike D., heroin addict with AIDS, New Haven, Connecticut, 1998
Within little more than a decade, AIDS has been tranformed from an untreatable,
rapidly fatal illness, into a manageable, chronic disease. Most of this tranformation
has occurred in the past five years, accelerated by the advent of protease inhibitors
and the proven benefits ofc ombination antiretroviral therapy and prophylaxis against
opportunistic infections. For people living with HIV/AIDS, these developments have
offered unprecedented hope, and also new challenges. As reflected in the quotes
above, some of the anxieties and anticipation of premature dying have been replaced
by the uncertainties involved in living with a long-term, unpredictable illness.
The role of caregivers for people with HIV/AIDS has also changed radically
over this time. Earlier in the epidemic, we learned to accompany patients through
illness, to bear witness, to advocate, to address issues of death, dying, and be-
reavement. The arrival of more effective therapy has brought with it new capabili-
ties, but also new complexities, raising difficult problems concerning access to
care, adherence, and toxicity. Greater possibilities for success may also mean
greater possibilities for failure: “provider guilt” and victim blaming may become
more prominent as the vaunted promise of highly active antiretroviral therapy
(HAART) fails to be realized in some patients, while others thrive and have to con-
tend with rethinking their future lives. Perceptions of therapeutic efficacy may also
translate into decreased concerns about risk-taking behavior.
The ascendance of a virologic model of pathogenesis runs the risk of narrow-
ing the focus of HIV care; the advancement of science brings with it the danger of
reductionism. Our ability to elucidate the structure of the virus should not lead us
to ignore the important psychosocial issues that will continue to evolve with the
epidemic; indeed, the virus and its therapy have little meaning outside of the
human and social context in which these are expressed. This reality is particularly
important as the epidemic continues to advance in populations that are increas-
ingly disenfranchised, poor, and vulnerable. The availability of effective treatment
immediately raises challenges regarding access, affordability, and the emergence
vii
viii Foreword
of a “two-tiered” system of care, in which existing social inequalities of race and
class become further evidenced in the differential distribution of sought after HIV
therapies. Before the advent of HAART, there was a grim form of leveling that oc-
curred in the epidemic, a democratization of death in which all were affected
equally. The possibility of improved survival as a result of engagement and adher-
ence with complex HIV therapies has now resulted in a differentiation of out-
comes, with the risk that the hierarchy of survival will parallel the hierarchy of the
larger society. (This is already glaringly apparent on a global scale, in which it has
been repeatedly observed that 90% of the world’s HIV-infected population resides
in developing countries where virtually no one has access to any HIV-specific
therapies.)
Fortunately, this volume, Psychosocial and Public Health Impacts of New
HIV Therapies, edited by David Ostrow and Seth Kalichman goes a long way to-
ward addressing many ofthe emerging social, psychological, andbehavioral is-
sues that have accompanied the new therapeutic era. This collection of chapters,
from a diverse group of experts drawn from different disciplines, helps to define
the important theoretical, clinical, public health, and research themes that have
arisen in the era of highly active antiretroviral therapy. It will be an important ref-
erence for clinicians, policy makers, and public health officials attempting to re-
spond to the new chanllenges that accompany the new possibilities for changing
the course of HIV disease in infected individuals.
The book begins with a comprehensive overview of the pathogenesis of HIV
infectionandthearrayofcurrenttherapies,thenareviewofsomeofthecomplex
issues involved in the potential pharmacokinetic interactions between protease in-
hibitors and psychoactive drugs, including drugs of abuse. It then addresses theo-
retical and practical questions pertaining to the critical area of adherence with HIV
medications, rightfully characterized as the “Achilles Heel” of the new therapeu-
tics. Economic considerations and ethical issues are then explored, with implica-
tions for health services as well as clinical practice, and the important relationships
between HIV, mental illness, adherence, and risk behavior are discussed. This dis-
cussion shows convincingly why it is impossible to consider HIV treatment without
taking full account of the mental and physical comorbidities that often accompany
it, and the societal arena in which the dynamic interplay among host, agent, and en-
vironment is enacted.
The concluding chapters address the novel challenges in HIV prevention
raised by HAART’s success, including the unanticipated consequence that effec-
tive HIV therapy and the prospects for postexposure prophylaxis may contribute,
paradoxically, to increased risk-taking in sexual and drug use behaviors. This pos-
sibility may only increase over time, as prolonged survival increases both the like-
lihood of lapses in self-protection and the potential timespan over which viral
transmission may occur. Combining this with the recently demonstrated occur-
rence of the sexual transmission of multidrug-resistant HIV the ominous prospect
is raised of a self-sustaining epidemic of HIV infections, which will be less likely
Foreword ix
to be treatable by any existing “successful” therapies. These issues are clearly of
paramount and immediate importance.
The volume ends with a thorough analysis of the important issues for behav-
ioralresearchandinterventionintheHAARTera.Thelonglistofissuesisbothin-
triguing and daunting—making it clear that there will be ample material for an
ongoing research and prevention agenda in the years ahead. In the early years of the
epidemic, when we hoped and waited desperately for any treatment at all to fight
back at the virus, we talked optimitistically about looking forward to the time when
we would be able to treat HIV/AIDS as a chronic disease. That time has clearly ar-
rived, and, in parallel with our newfound treatment capabilities, we confront new
and unexpected challenges. Perhaps that is the best that we can continue to hope
for: it is still premature to look forward to a time when AIDS is only a memory, at
least not in the forseeable future. But we may hope to continue to face new prob-
lems that arise from our new and—if we are fortunate—ongoing successes.
PeterA. Selwyn, M. D., M. P. H.
Preface
Very few events have significantly altered the course of the HIV/AIDS pandemic.
Discovery of the virus that causes AIDS, the realization that most persons infected
with HIV would ultimately develop AIDS and die, the development of HIV anti-
body testing, approval of the first antiretroviral medications, and the use of anti-
retroviral treatments to prevent perinatal transmission of HIV are perhaps the most
significant achievements that easily come to mind. Of similar, or perhaps even
greater magnitude has been the advent of multidrug combination antiretroviral
therapies—most notably combinations of nucleoside reverse transcriptase in-
hibitors, nonnucleoside reverse transcriptase inhibitors, and protease inhibitors—
and the development of laboratory tests to measure the level of viral replication or
viral load.
Within weeks of their proclaimed success in reducing viral burden to below
measurable levels and improving the health status of people with HIV/AIDS, com-
bination therapies revolutionized the treatment of HIV. It soon became clear that
drug-resistant mutations could be suppressed through multidrug treatments and
that successful therapy lengthened the time people would live with HIV and im-
proved their quality of life. For the first time in over a decade, the words “cure”
and “eradication”e ntered the vocabulary of credible experts. For the first time in a
long time, there was good news about AIDS. By the time this book went into pro-
duction, just within 2 years of the widespread availability of protease inhibiting
drugs, people with HIV/AIDS were dying at a slowerrate than seen before and
people with HIV were more concerned about returning to work than selling their
life insurance policies. It truly became a whole new ball game in HIV/AIDS care
and prevention.
The hope and optimism of new HIV treatments, however, did not come with-
out caution and challenge. There were many questions raised in response to new
treatments: How do these new drugs work and how do they interact with other
treatments? How must clinical services and practice guidelines accommodate the
demands of new treatments? What are the psychological ramifications of new
treatments that offer such great promise? How do people adjust to an unexpected
life extension and how do they adapt to promising treatments that fail? How will
new treatments affect existing and future prevention efforts? Are the treatments
themselves of preventive value? What are the ethical implications of new treat-
ments that will not be universally accessible? How must care services change in
response to new treatments and what policies must be implemented to guide these
xi
