The HIV-infected urban poor should have access to protease inhibitors and other new antiretroviral drugs, says a group of UCSF researchers who study the homeless.

Contrary to what some may believe, many homeless can adhere to the complex treatment regimens required for HIV disease, and not to make them available would be discriminatory, according to the researchers. In order to give the new therapies a chance, however, the initial goal should be to tackle the basic problems of homeless living, the UCSF team advises.

"The first priority is to deal with essential needs such as food, shelter, and treatment for mental illness or chemical dependencies," says David Bangsberg, MPH, MD, UCSF research fellow at San Francisco General Hospital and the Center for AIDS Prevention Studies. "After these needs are addressed then it is appropriate to focus on antiretroviral treatment and the likelihood of adherence is much greater."

In a commentary, "Protease Inhibitors in the Homeless," in today’s issue of the Journal of the American Medical Association, the UCSF team emphasizes that health care providers who treat the homeless population need to be aware of their patients' life situations in order to treat them most effectively.

"Once the life situation is addressed, the caregiver can work up to the more complicated treatments," says Bangsberg. "Start with the basics, educate the patient about his or her treatment options, then layer the appropriate therapies starting with the simplest and most immediate needs."

The most immediate therapy is prevention of Pneumocystis carinii pneumonia (PCP) or tuberculosis, he adds, two common infections in homeless AIDS patients. Only when these are addressed should antiretrovirals be considered. Once the basics are dealt with, many patients in the homeless population, contrary to what some may believe, are able to adhere to the complicated schedules required of patients on three-drug regimens, according to Andrew Moss, PhD, UCSF professor of epidemiology and biostatistics and senior author of the commentary. Moss is the principal investigator of UCSF studies of HIV and tuberculosis in the homeless. Hotel residents and other more stable homeless patients can be good candidates for these drugs in many cases. "It is important to approach treatment with basic common sense and an open mind," Moss says.

The researchers outline a six-step plan for developing a treatment program for indigent patients. The goal should be to find the therapy that will benefit the patient the most, the researchers report.

In the case of a patient who remains in an unstable life situation but insists on taking the protease inhibitor therapy, the researchers recommend explaining the risks of not adhering to the rigorous treatment schedule. If the patient still requests the treatment, "we believe there is an obligation to prescribe if the patient is competent to decide and has indications for treatment," the researchers wrote.

By Alice Trinkl

1st appeared 7/02/97