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City aims to halt spread of drug-resistant HIV


Hoping to prevent the spread of drug-resistant strains of the AIDS virus, the city Health Department plans to monitor patients to make sure they take their medications twice a day, every day.

Dr. Peter L. Beilenson, the city health commissioner, said yesterday that the department will initially enroll 200 patients, who will receive their drugs at either a van, a pharmacy or a public health clinic - all in West Baltimore neighborhoods devastated by AIDS. Health workers will watch the patients swallow all their pills.

The effort will be the largest of its kind in the United States, he said, and is patterned after a program of "directly observed therapy" that has been used successfully to fight tuberculosis in Baltimore for more than 20 years.

Beilenson said the department will begin Thursday to put out the word to people at the city's needle exchange vans and will then work to get patients into treatment as soon as possible.

People who express interest in the program will be evaluated by health professionals, who will perform medical tests and, if the patients qualify, write prescriptions that will be filled by pharmacies. The drugs will then be delivered to the treatment sites.

Acknowledging that the strategy is risky, Beilenson said aggressive action is needed to get more patients into treatment and to prevent drug-resistant strains that result when patients miss doses.

One of the chief risks, he said, is that the city will unwittingly make the problem worse by recruiting patients who will prove unreliable. Beilenson said he expects many, if not most, of the patients in the program to be drug addicts, a group that has proved notoriously hard to keep in regular therapy.

"We're trying something new, and we think it's a reasonable initiative," said Beilenson. "But it's certainly not a guarantee."

Researchers from the Bloomberg School of Public Health at the Johns Hopkins University will evaluate the program's success, using such benchmarks as the frequency with which patients show up at their assigned locations. The program will be expanded only if it works. Baltimore has about 6,000 residents living with AIDS, health experts say, and a significant number are not being successfully treated.

"We want to be able to demonstrate conclusively if something like this works," Beilenson said.

The program will cost the city $120,000 a year, which will go mainly toward salaries and purchasing a van. The prescriptions will be paid for through a state program that offers AIDS medications to low- and middle-income patients.

Though "directly observed therapy" has been used successfully against tuberculosis, AIDS poses some heftier challenges.

The AIDS drugs must be taken twice a day for life, and the disease is never cured. In contrast, the TB drugs are generally taken twice a week for six months - at which point the disease is often cured.

Because the city has a much smaller TB caseload - only 60 patients this year - city health workers are able to visit the highest-risk patients at their homes. Home visits for AIDS patients are impractical, given the twice-daily dosing and the number of people to be enrolled.

Beilenson said the idea of employing the strategy against acquired immune deficiency syndrome arose from conversations about a year ago with Dr. Robert Redfield, who directs AIDS care at the University of Maryland Medical Center.

Redfield said yesterday that 14 percent of patients who were diagnosed in the past year carry strains that are resistant to the medications that have prolonged the lives of thousands of people across the country. Many people give up on the drugs because of side effects and the complicated dosing schedules.

"If we do nothing, we're going to have more drug resistance," Redfield said. "Or we can develop alternative mechanisms and try to improve the delivery of care."

Redfield said a key to Baltimore's success will be enrolling patients who truly want go on medication, rather than coaxing people who are reluctant. But he warned that patients will succeed only if they take virtually all their pills. Those who miss 5 percent of their pills, for instance, run a 20 percent chance of failing in treatment.

The University of Maryland Medical Center will try to tackle the same problem next year by pairing new patients with mentors who have been successfully treated.

Other cities have launched programs of directly observed therapy of AIDS drugs, but on a smaller scale. Brown University, for instance, is delivering drugs to 20 patients at their homes in Providence, R.I. A small number of addicts are reporting to a Hopkins-run methadone center to take their medications. In many cities, including Baltimore and Miami, prison authorities watch inmates take their medications.

"There is actually very little data on doing directly observed therapy for HIV," said Dr. Gregory M. Lucas, an infectious disease specialist at Hopkins who has studied the issue. "But the worst thing you can do for people is to give them their drugs and not have a consistent course of medical care."

In Baltimore, patients will receive their drugs at the city's Druid Health Center at 1515 W. North Ave.; Fibus Pharmacy, 2103 W. Garrison Blvd.; or a van parked at the corner of Westwood and Mount streets. Medications will be dispensed seven days a week between 8 a.m. and 11 a.m. and between 7 p.m. and 10 p.m.

Mayor Martin O'Malley hailed the program yesterday as a key to fighting AIDS, which is the leading cause of death among young men and women in the city. "This is one program that can help us do better," O'Malley said.

Yesterday, the mayor announced that Associated Black Charities of Maryland will administer the city's share of funds from the Ryan White program, which provides care for low-income and uninsured people infected with the AIDS virus.

Since 1992, Baltimore has received $92 million for families through the program. The city is guaranteed to get at least $17 million next year.

Besides medical care, the program provides money for food and legal services.

"We are extremely excited about the opportunity to make a major difference for the community," said Donna Jones Stanley, executive director of Associated Black Charities. "We have the experience and the knowledge base and the cultural competence."

Sun staff writer Laurie Willis contributed to this article.

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