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Bitter Pills

The new AIDS treatments may be the magic bullet for some. But for others the cure may be worse than the disease.

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"I'll tell you why I'm not taking my medicines today," Sonja says, lighting up a Marlboro and settling into one of the few pieces of furniture she owns, a fuzzy green sofa she bought last week at a hotel liquidation sale. "I'm not taking them because a couple of days ago I woke up and saw spiders all over the walls of my apartment. I had to close my eyes and wait for them to disappear."

Sonja has AIDS. Among the half dozen drugs she's decided not to take today is ritonavir, a powerful new protease inhibitor. Pills identical to the ones Sonja tosses into my lap in disgust appeared on the cover of Newsweek last fall, dramatically lit underneath a bold teaser: "The End of AIDS?" According to Time, "Everywhere they turn these days, doctors and patients are hearing good news about AIDS." Time even named Dr. David Ho, one of the leaders in protease inhibitor research, as its man of the year. Ever since July's International AIDS Conference in Vancouver, when the results of many small-scale protease inhibitor studies were announced to the world, it's been difficult to avoid stories in the press of people putting on weight, checking out of hospices, returning to work, or going back to bodybuilding, thanks to these drugs. The AIDS crisis, so the story goes, is just about over.

But people like Sonja are conspicuously absent from that story. For her, and thousands like her, protease inhibitors bring their own sets of crises. Since starting on the drugs six weeks ago--a regimen consisting of about 20 pills a day with an annual price tag of around $15,000--her life has become much worse. And seeing spiders isn't the half of it.

"When I first took the drugs, I thought I was going to die," she says. "Really. I spent the first two days in the bathroom. I had to buy an extra phone cord so it could reach." Within an hour of taking her dose--six oversized white capsules of ritonavir twice a day, along with two other antiviral medications, a prophylaxis against pneumonia, an antidepressant, and an occasional Tylenol 3--she's hit with severe nausea, diarrhea, and fatigue. When she ventures out of her apartment, a subsidized unit in a south-side residence for people with HIV, she's out of breath after walking two or three blocks. "Sometimes I can't even leave the house," she says. "It's too embarrassing to have to go throw up or have diarrhea. It's always one end or the other."

Sonja isn't surprised that the drugs are making her sick. For one thing, her doctor at Cook County Hospital warned her about such symptoms. "I've heard a lot of horror stories from people whose doctors didn't tell them what to expect when they started the drugs," she says. "At least my doctor got me ready for it. I could cancel my plans."

Since being diagnosed as HIV positive a little more than a year ago, Sonja has had a hard time tolerating whatever drugs her doctors have prescribed. She says she's just about ready to give up. She learned she was infected in January 1996 while in Dwight Correctional Center, where she was serving serving six months for drug possession. The doctor immediately put her on a combination therapy of two antiviral medications, a regimen that was switched three times before her sentence ended, either because the drugs weren't working or because Sonja developed such severe migraines and fatigue that she couldn't stand to be on them any longer. Since leaving Dwight, she says, her medications have been switched five more times. One of her kitchen cupboards is stuffed with medications she has stopped taking.

"I'm taking all this shit that makes me feel like crap," she says with a laugh. "And I'm supposed to take my ritonavir with food, even though it makes me throw up, so how much sense does that make?" She takes a long drag from her cigarette as though drawing sustenance from the smoke. "I didn't go through anything this bad even when I was doing heroin. And the thing is, ever since I started on these drugs, I've had a lot more thoughts about relapse. I know I can go out and get a bag that will make me feel good. I mean, I know what that will lead to, and I don't want that. But it's even in my dreams."

Sonja understands that by skipping her dose today--not the first time she has done so--she runs the risk of developing resistance, making the drugs ineffective against the HIV in her system. She also knows that the symptoms she's experienced for the past six weeks are likely to diminish as her body learns to tolerate the daily, massive infusion of toxic drugs. She already feels better than she did two weeks ago. But like so many people with HIV, Sonja has been worn down by a life of recurrent chaos and crisis: raised in foster homes, hooked on cocaine by 16, hooked on heroin shortly thereafter. Two of her children were taken from her by DCFS, and she voluntarily surrendered the third for adoption. She ended up in prison, then spent nine months in a shelter concurrent with nine months in a drug-rehab program and seven months battling Social Security to get her disability benefits. Now, finally, she has a bit of stability in her own clean, quiet apartment. She finds herself living a life she never thought possible, and these days are so precious to her that she wants to enjoy them without the fear of throwing up on a street corner every time she leaves the house, even if that means surrendering ten years of her life. "You've got to think about quality as opposed to quantity of life. You know what I mean? I don't take drugs, I feel great. So right now I'm wondering if they're worth it."

Just before Sonja started taking protease inhibitors, her viral load--a measure of the amount of HIV in her blood--was 180,000, up from 53,000 a month before, both troublingly high numbers. In two weeks she goes back for another viral load test, her first since starting on protease inhibitor therapy. "If I don't see a dramatic improvement, I'm just gonna stop altogether," she says. "I know I could try switching to a different protease inhibitor, but I just can't adjust to that again."

With the back benefits Sonja received from Social Security, she paid for a cruise to the Bahamas, which she will take in May. "I've never done anything nice for myself," she explains. She's also paid for her own cremation.

The success of protease inhibitor therapy is the subject of intense debate among AIDS service workers. These drugs are even the subject of a daylong conference at John Marshall Law School next Tuesday. Certainly, protease inhibitors have produced dramatic benefits for some. "We all have our miracle patients," says Dr. Richard Novak, a virologist with the University of Illinois at Chicago's HIV clinic. One of his miracle patients once suffered from multiple infections and severe weight loss, his T cells bottoming out at 16 (an AIDS diagnosis comes when T cells fall below 200; an intact immune system typically has 1,000 or more). Triple-drug therapy including a protease inhibitor brought his T-cell count up to over 350, and all his symptoms disappeared. He has now returned to work with a new lease on life.

John Weekly sees similar results every day. He runs a support group for gay men on protease inhibitors at the Howard Brown Health Center. The group was designed with an eye toward helping formerly disabled men to make a transition back to work, and as far as Weekly knows it's the first such group in the country. "We put one quarter-page ad in Gay Chicago magazine, faxed a notice to a few doctors' offices, and the group filled up almost immediately. We had to add a second group."

Most of the people in the group are living what one AIDS therapist in town describes as "the New York Times version of AIDS." One group member was on TPN, an intravenous diet given to people in the final stages of AIDS who no longer have the ability to eat. Another spent time in a hospice. Now they're both thinking about going back to work. If protease inhibitors continue to improve their health, then indeed a minor medical miracle has taken place. On the other hand, one member of the group died. As Weekly points out, "I read there are about 100,000 people on protease inhibitors right now. But look at the total number of people with HIV or AIDS in the nation [estimated near a million]. We're talking about a small percentage who are on the drugs. And how many of the people on the drugs are developing resistance or can't tolerate them?"

In most of the protease inhibitor studies around the country, resistance develops in 10 to 15 percent of research subjects. Dr. Philip Loy, a biophysicist with American Viatical Services in Atlanta, has completed medical reviews of some 4,000 people on the drugs. He estimates that 30 percent of these patients become intolerant to one or more medications, while another 15 to 25 percent fail to adhere to the drug regimen. If his sample is representative of the larger population of people on protease inhibitors--and his sample is three times larger than the largest clinical study designed to test the drugs' effectiveness--then these drugs may fail in half of the people who take them.

If you want to see Weekly bristle, suggest to him that protease inhibitors will make AIDS as manageable for the men in his group as diabetes or hypertension, comparisons used repeatedly in the media. "How many people are fired from their jobs, or kicked out of their apartments, or abandoned by their families because they're diabetic?" he responds immediately. "How many people are told that diabetes is their own fault? How many people have had their lovers break up with them because they're hypertensive? Are protease inhibitors going to solve all these problems too?"

In Weekly's view, the recoveries he sees in his group can be credited to class and culture as well as the pills. "The guys are all white, they all have primary physicians who are HIV specialists, they're all hooked up to support systems, and they're all self-motivated people, the kind who see an ad in the paper and call right away. They're not representative of a lot of people with HIV. I feel like they are the exceptions."

Jeff, then, is an exception to an exception. Like the men in Weekly's group, Jeff is white, gay, self-motivated, and well-connected. His primary physician is one of the most highly respected AIDS specialists in town. Though Jeff is on disability leave from work, his employer has agreed to keep him on its group insurance plan "in perpetuity," a highly unusual arrangement that pays for all of Jeff's drugs. He lives in a comfortable high-rise condominium light years from Sonja's subsidized south-side unit, which is surrounded by abandoned buildings and vacant lots. Protease inhibitors have worked for Jeff--sort of. Ritonavir, in combination with the older antiretrovirals d4T and 3TC, has brought his viral load down from 460,000 to 8,000. And there it stays. His T-cell count has risen from a dangerously low 65 to a slightly less dangerous 200. And there it stays. "For me, the drugs represent a freezing of the situation, rather than being the cure or the answer," he says. "I am not improving as much as other people are improving. And at any time the infection could break through and the bottom could drop out."

He started his triple-drug therapy in November 1995. When I met him the following summer, he was pale, thin, barely spoke above a whisper, and had the first telltale signs of the AIDS face rarely described in the press these days--his skull slowly rising to the surface. Now nine months later Jeff seems a different person, sturdier, more animated, filled out. With the dramatic reduction in the amount of HIV in his system, he says, much of his former energy has returned. He's even able to work out and swim, activities he thought he'd given up for good a few years ago.

But Jeff can't entertain thoughts of returning to his former life as a graphic artist and art director, in part because, like Sonja, the drugs' side effects hit him hard. "The first time I took it, it was like my body screamed," he recalls. "I felt this weird chemical rush, and within an hour I was running to the bathroom with diarrhea. It's a stomach killer, the drug is. What we ended up doing--my doctor and I, because I got so sick on it--was cutting back to one twice a day, then two twice a day, and gradually building up to the six.

"But still I don't have a normal GI system. I constantly have acid indigestion. It's really worth it, for what the drug has done for me. I know I wouldn't be alive today without it. But you always know that the drug is in your system. I have diarrhea. I chew Tums constantly."

Moreover, Jeff can no longer take medication for depression, something he has battled off and on since long before he was diagnosed as HIV positive. His antidepressants are strongly contraindicated with ritonavir. For now he's coping well. But he's worried. "I'm really not a very stable guy," he says with a disarming laugh.

Jeff was one of the first people in Chicago to get on protease inhibitors after they were approved by the FDA. "My health was pretty stable with d4T and 3TC the year before. But my doctor was anxious. That whole year, he knew the protease inhibitors were coming. He said, 'They're coming out soon enough so we can hold on. But as soon as it comes, we're going to do it.'"

It turns out that such fast action may have left Jeff at a disadvantage. "We now know that it's best to start with two new drugs," he explains. "In other words, I was on d4T and 3TC, and my doctor added ritonavir. It would have been smarter to change the d4T to another drug like ddC or ddI and add the ritonavir. But no one knew this back then, and in the rush to get people on the drugs, they just did it. Looking back, a lot of people have similar regrets to mine."

Failing to change two drugs in his cocktail may account for its diminished success, a reality that hit home in January when he was flipping through the New York Times. Graphs accompanying a front-page article titled "With AIDS Advance, More Disappointment"--one of the only stories to profile people for whom the drugs don't work--charted three case studies of people on protease inhibitors. The cases were labeled "When Therapy Works Well," "When It Works Somewhat," and "When It Fails." Jeff saw himself reflected almost perfectly in the second case, right down to a nearly identical T-cell count and viral load. "It was the first time I saw on paper that things aren't as good as they could be," he explains. "And then the doctor starts talking about if the viral load starts going up, what do we do? Which sounds to me like any day it can break through. So I'm just sitting on pins and needles about that, and feeling like I've got a little more time, how much I don't know, maybe two years."

With so much uncertainty, one of Jeff's biggest problems is sticking to his drug regimen. Like Sonja, he takes six huge pills twice a day--pills that smell and taste terrible--always with food, along with two smaller pills. "It's not just the AZT popped in the mouth like it used to be," he says. "Now it's a major event." The experience of taking so many pills with such irritating side effects every day has begun to overwhelm everything else in his life, as he articulated in a recent painting. Spread across the canvas is his dosage blown up to monstrous size, and behind the pills lurk tiny emblems of his former life. Books lie half visible behind a huge capsule. A male dancer in the middle of a joyful leap is almost completely obscured. In the center of the painting the Dalai Lama sits in a lotus position, his head blotted out by a gargantuan ritonavir. "That's what it's like for me. It pervades everything."

It's a sentiment Sonja understands well. As she wrote in a diary recently, "Every time I take my medication it's a constant reminder of my limitations. Days like today I just lay around and dream I had a normal life. I'm sick of taking medicine. Great life--I have no life!"

Even without troubling side effects or an uninspiring prognosis, compliance with such a demanding regimen can be difficult. Just ask John. He's perhaps the ideal candidate for protease inhibitors. Not only is he an organized, self-motivated person with a solid career, good insurance, and a stable home life, he started on the new drug cocktail almost immediately after becoming infected. If the ultimate goal of protease inhibitor therapy is to eradicate the virus from the body, John is in the perfect position for success, since HIV had almost no time to replicate before being suppressed by the drugs. Currently his viral load is undetectable.

John takes a protease inhibitor called indinavir, along with 3TC and AZT. He tolerates the drugs well, though he started protease inhibitor therapy last July on a different drug that crippled him with diarrhea, vomiting, and extreme anxiety for seven and a half weeks. "I got to a point where I thought, 'I don't care if this is going to save my life. I don't want to live like this,'" he says. After skipping two doses--just looking at the pills turned his stomach--he asked his doctor to change his prescription. Now, instead of eight pills twice a day, John takes four pills every eight hours. But even without side effects, holding to the regimen is trying.

"The papers all say that the regimen is difficult," he says, "but people have no idea. First of all, I have to take the drugs at 8 AM, 4 PM, and midnight, every day, without fail, for the foreseeable future. And I have to take them two hours after eating, when my stomach is empty, and I can't eat for another hour after I take them. So that means I have two three-hour periods every day when I can't eat. I can have maybe a piece of toast or a cracker; that cuts the absorption rate to about 98 percent. If I take them on a full stomach, the absorption rate is only 23 percent. So what happens? It's three in the afternoon, I'm at work, it's somebody's birthday, and there's a cake. That's too much fat, so I have to say no thank you. It's a little thing, but little things like that add up, they intrude into your life all the time. Your life is not your own.

"It may not sound like much, but you try taking your life and regimenting it every day. What if you want to sleep more than eight hours? A lot of people with HIV have chronic fatigue. It's summer, you're out with your friends in the afternoon, they want to go for ice cream, you can't have any. It's a reminder every day that you're infected.

"My job has very regular hours. But what do you do if you're a flight attendant, or a construction worker, or in a business where you're schedule isn't set? I know a doctor who told me he won't prescribe protease inhibitors to one of his patients who is an attorney, because the patient's schedule is so hectic. What if you're homeless? Where do you refrigerate your drugs?

"And here's the thing. I have supportive friends, a supportive lover, a supportive work environment. In my office, I can pop pills or run to the bathroom whenever I need to. I'm a very organized person with a very scheduled life. And I'm sitting here with 1,477 T cells. If it should be easy for anyone, it should be easy for me."

But John admits that the temptation to skip dosages is real. "Some days I just don't want to put up with it. I don't want to be reminded that I've got HIV."

The better protease inhibitors work, the more likely people are to skip doses. "The problem is, people who are asymptomatic don't reliably take medicine," says Dr. William Paul, director of the Chicago Department of Public Health's tuberculosis program. "From poor, homeless people to doctors and nurses. Research shows that it's quite common to have up to 40 percent of individuals miss their prescribed medicines." And skipping even a few doses of protease inhibitors can allow HIV to mutate into a strain resistant to those drugs.

Noncompliance with protease inhibitors' demanding regimen stands to create an even more menacing health problem, if history is any indication. Thirty years ago Americans were led to believe that the TB crisis was over, thanks to multidrug therapy. That regimen is not nearly so difficult--and not a tenth so expensive--as the new AIDS cocktail. According to Paul, the standard course of treatment for an uncomplicated case of TB is four different antibiotics taken for two months, then two antibiotics for the final four months. These drugs typically do not produce any serious side effects.

Yet due in part to people's inability to adhere to this regimen, the tuberculosis bacillus was able to mutate into strains resistant to these drugs, leading to the appearance of multidrug-resistant TB in the 1980s--a killer that we are nearly powerless to cure. A 1992 survey in New York City, one of the U.S. cities hardest hit by TB, showed that more than a third of the strains tested were resistant to at least one TB drug, and nearly a fifth were resistant to the two most powerful TB drugs, rifampicin and isoniazid. According to the World Health Organization, cases of TB in New York City have increased by 150 percent since 1980.

With protease inhibitors the problem stretches beyond noncompliance. Some people develop resistance to the drugs even while complying perfectly. Others can't comply through no fault of their own. Brian Gleason, case manager at the Evanston-based social-service group Better Existence With HIV, tells of one client who was diagnosed as HIV positive while in a psychiatric ward at a local hospital. His doctor prescribed protease inhibitors. "He called me the day before he was going to be discharged," Gleason recalls. "It was the hospital's policy not to discharge patients with medicines--they're not allowed to take drugs from the hospital. This guy was a veteran, so he wasn't eligible for a medical card through Public Aid. He got his health care at the VA hospital, but there was a two-week wait just to get an assessment. So he had this two-week period when he was in great danger of becoming resistant. I called his nurse in the psych ward and advised her about prescribing medications to someone who couldn't possibly adhere to the schedule."

If resistance to one protease inhibitor develops, people can sometimes switch to another (four are FDA approved). But those who develop a resistance to one protease inhibitor may have developed a resistance to all of them. One recent European study suggests that taking the antiviral 3TC may promote the development of HIV strains resistant to protease inhibitors. One activist who recently started on the cocktail confides, "Someday we'll figure out that we're all just growing mutant HIV in our blood."

And resistant strains of HIV, which are already developing, will most certainly spread. Currently about 10 percent of new HIV infections are from AZT-resistant strains of the virus, suggesting that some people on AZT are still engaging in unsafe sex. And given the reports of protease inhibitors' success in all but eliminating HIV from the body, there is every reason to believe that condom use will fall along with viral loads. Jeff Moore, an administrator with the Chicago Department of Public Health, says there is already evidence that gay men are becoming less vigilant about safer sex. Last month Moore convened a focus group of HIV prevention workers, who all agreed that some men are using the news about protease inhibitors as justification for reducing condom use. One participant said he has encountered men whose concern about becoming infected has decreased because they believe that in a few years taking protease inhibitors will be as easy as chewing gum.

As the stories of people with HIV springing back to life spread, AIDS may begin to recede from our collective consciousness, just as TB did three decades ago. Perhaps this has already started. Mary Lake, a client services representative from Howard Brown, says, "I can't tell you how many people have said to me, 'Isn't AIDS over? I heard there was a cure.'" It's hard to find anyone working in the AIDS service world who doesn't have a similar story to report. Recently Deborah Steinkopf, executive director of Better Existence With HIV, met with funders who have given her agency several thousand dollars each year. This time they said they weren't sure they wanted to give any money. "They said they had read all this stuff in the papers about these drugs," Steinkopf recalls, "and they asked, 'Are you going to be around in a couple of years?' They were operating under the assumption that the kinds of services we provide--prevention education, counseling, case management--wouldn't be needed soon. Or at least wouldn't be funded."

"From a public health standpoint," Paul concludes, "the biggest problem may be declining interest."

Sonja had her viral load test done two weeks ago at Cook County Hospital, but the results aren't back yet. She did learn that her T-cell count has climbed to over 300, up from 181 in November. The side effects of her drugs continue unabated, though they don't have the same overpowering psychological effect they had on her a month ago. "The doctors told me that in three to eight weeks my body would get used to the drugs," she says. "And that's exactly what happened. The diarrhea hasn't stopped, but now I'm used to having it every day. I'm dealing with it. It's normal now to throw up every morning."

Nonetheless, things are looking up for Sonja. She now works part-time at a collection agency, making $5 an hour. On the days she works she gets up an hour early so she can take her medicines and vomit before heading to the office. That office is located in the basement of a residential house in her neighborhood and is owned and staffed entirely by recovering addicts. "This isn't a usual job," she explains. "If I'm not feeling well I can just go upstairs and lie down. The owner is very understanding. He'll stop business in the middle of the day and hold an NA meeting if people want one. I get to work four days a week and pick my own hours. I miss days for being sick or going to the doctor, and he doesn't care. Where else could I get away with all this shit?"

Perhaps the side effects of her drugs will gradually diminish in the coming months, along with the chronic gynecological problems, erupting skin boils, and migraines that have plagued her for the last two years. Perhaps the drugs will work so well for her that by the fall she will be able to work full-time and begin a "normal" life. It's tempting to think that Sonja's personal AIDS crisis will then be over. But it's more likely that she will find herself in an even more precarious situation.

Let's say she's ready to work full-time in September. Her current employer doesn't offer health insurance, so Sonja gets a different job with a downtown collection agency, a position that offers $7 an hour, or just over $14,000 a a year before taxes, along with health insurance. Her income disqualifies her for Medicaid, which currently pays for all of her drugs. So she signs up for her new company's insurance policy. But that policy classifies her HIV infection as a preexisting condition; it won't pay any HIV-related claims for a year, by which time she has been off protease inhibitors for so long she has developed resistance. By returning to work, she loses access to the very drugs that keep her healthy enough to return to work. Considering that Medicaid currently covers an estimated 50 percent of Americans with AIDS, tens of thousands of people stand to inherit this crisis if their protease inhibitor therapy is successful.

But wait. Sonja gets her job after July 1, when the Kennedy-Kassebaum Act goes into effect. That law says that anyone who has been continuously covered by a single insurer for at least 18 months prior to getting a new insurance policy cannot have pre-existing conditions excluded on that new policy. So it would seem that her new coverage must cover HIV-related claims. Unfortunately, the law specifically exempts time spent on Medicaid and Medicare from counting toward those 18 qualifying months.

Still, Sonja qualifies for the Illinois Drug Reimbursement Program, which provides a number of AIDS drugs, including protease inhibitors, free of charge. To be eligible for that program her income must not exceed 200 percent of the federal poverty level, or about $15,000 annually. (The income eligibility ceiling was lowered from 400 percent of the federal poverty level last spring when IDRP began paying for one protease inhibitor, saquinavir. The Illinois Depart-ment of Public Health, which administers the program, also had to eliminate about 70 percent of the other drugs that IDRP used to provide. Some of those drugs were restored on April 1.)

However, beginning June 1, IDRP's maximum monthly benefit will be $1,000 per individual, leaving Sonja with perhaps a hundred dollars in unpaid prescription costs each month. Because her income has more than doubled since getting off of Social Security, the rent on her subsidized apartment doubles as well. With rent, medicines, groceries, utilities, transportation to and from work, regular doctor visits, and viral load tests ($100 a pop at minimum), she is going into the hole every month.

Still, the drugs continue to work so well for Sonja that she shines on the job, and within six months she is promoted to manager. She now makes $16,000 a year--roughly the annual cost of her drugs--making her ineligible for IDRP. She tries to apply for the Illinois Comprehensive Health Insurance Plan, a state-mandated quasi-public insurance plan that provides insurance to the commercially uninsurable. But when she receives ICHIP's application information in the mail she reads that "the benefits of this plan will not be payable for expenses incurred during the first six months after the effective date of your policy for any preexisting condition."

So somehow she buys her own individual insurance policy (which in reality is nearly impossible for anyone already infected with HIV who can't pay exorbitant premiums). Luckily that policy doesn't have limitations on preexisting conditions (as unlikely as her being accepted onto the policy in the first place). Still, she's in trouble, because it turns out her million-dollar lifetime policy caps AIDS benefits at $100,000. Sonja's good for four years.

Sonja ends up in the same situation as five people who called the AIDS Legal Council of Chicago and the Lambda Legal Defense and Education Fund last month. They all have million-dollar health insurance policies with AIDS caps: three have caps of $100,000, one has a $25,000 cap, and the last has a cap of $10,000. Four of the five polices are written by one of the largest insurance companies in the nation. According to Julie Justicz, executive director of the AIDS Legal Council, it may be possible to challenge these caps in court, as they appear to violate the Americans With Disabilities Act, which prohibits disability-based discrimination in "public accommodation." But one of the policies also contains a $5,000 annual prescription-drug cap. Since that cap doesn't limit benefits for specific illnesses, there seems to be no way to challenge its legality. Even if that cap were lifted, the policy includes a clause that precludes any benefits for the treatment of sexually transmitted diseases.

It's nearly impossible to find anyone working in the AIDS service world--whether in social services, health care, or policy analysis--who believes that the AIDS crisis is anywhere near over. "Sure, there is good news out there, but the downsides are being hidden," says Steinkopf, echoing sentiments often expressed by her colleagues. "The focus in the press is always on people who are getting better. They are the only ones who are real." And the only real problems, it seems, are those that medical science can address. For people on the front lines of the fight against AIDS, the epidemic is not only about T-cell counts and viral loads but also about fear, ignorance, and intolerance. HIV has created enormous rifts within American society and exacerbated others that already existed--rifts that no number of pills will heal.

That divisiveness is particularly acute in the gay community, where too often infected and uninfected men split into camps and stare at each other across a wide political divide. Unrealistic reports about the success of protease inhibitors may drive another wedge into our neighborhoods. On a balmy summer night in the not-too-distant future, it's not difficult to imagine an emaciated man stumbling into Roscoe's or Sidetrack with his walker. The heads of the robust patrons, many of whom are knocking back pharmaceutical cocktails along with their alcoholic ones, will stare in disbelief. Doesn't he know the AIDS crisis is over? they will whisper to one another. What is he thinking?

Art accompanying story in printed newspaper (not available in this archive): Illustration by Dorothy Perry.

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