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July 2, 1997, Vol 278, No. 1 >
ARTICLE | July 2, 1997

Protease Inhibitors in the Homeless FREE

David Bangsberg, MPH, MD; Jacqueline P. Tulsky, MD; Frederick M. Hecht, MD; Andrew R. Moss, PhD
[+] Author Affiliations

Reprints: AndrewR. Moss, PhD, San Francisco General Hospital, University of California, San Francisco, Box 1347, San Francisco, CA 94143-1347 (e-mail: andrew@cygnus.ucsf.edu).


JAMA. 1997;278(1):63-65. doi:10.1001/jama.1997.03550010077044
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Article
References

Homeless people are often thought not to adhere to therapy. Should we try to make protease inhibitors available to them? The new therapies for human immunodeficiency virus (HIV) infection are expensive, and their use may lead to the development of drug resistance. Do these drawbacks outweigh the ethical imperative to make effective drugs available to an underserved population?

In late 1995, the first protease inhibitor was licensed by the Food and Drug Administration for persons infected with HIV. In combination with reverse transcriptase inhibitors, protease inhibitors give unprecedented improvements in CD4+ cell count, viral load, morbidity, and mortality.1 One press report used the term "Lazarus effect"2 to describe the return to functional status of some patients with end-stage acquired immunodeficiency syndrome (AIDS). Driven by both science and enthusiasm, the standard of care for HIV-infected patients has quickly become combination antiretroviral therapy with a protease inhibitor.1,3 The price

REFERENCES

1 +
Deeks SG, Smith M, Holodniy M, Kahn JO.  HIV-1 protease inhibitors: a review for clinicians . JAMA . 1997;;277:145-153.
2 +
Leland J.  The end of AIDS . Newsweek . (December 2) ,1996;:65-73.
3 +
BHIVA Guidelines Coordinating Committee.  British HIV Association guidelines for antiretroviral treatment of HIV seropositive individuals . Lancet . 1997;;349:1086-1092.
4 +
Sontag D. Richardson L.  Doctors withhold HIV pill regimen from some . New York Times . (March 2) ,1997;:A1.
5 +
Waldman A.  When you want to live but can't afford it . Washington Post . (April 27) , 1997;:C01.
6 +
Zolopa AR, Hahn JA, Gorter RG, et al.  HIV and tuberculosis infection in San Francisco's homeless adults: prevalence and risk factors in a representative sample . JAMA . 1994;;272:455-461.
7 +
Fournier AM, Tyler R, Iwasko N, LaLota M, Schultz J, Greer PJ.  Human immunodeficiency virus among the homeless in Miami: a new direction for the HIV epidemic . Arch Intern Med . 1996;;100:582-584.
8 +
Thomas SB, Quinn SC.  The Tuskegee Syphilis Study, 1932-1972: implication for HIV education and AIDS risk education programs in the black community . Am J Public Health . 1991;;81:1498-1504.
9 +
Moore RD, Stanton D, Goplan R, Chaisson RE.  Racial differences in the use of drug therapy for HIV disease in an urban community . N Engl J Med . 1994;;330:763-768.
10 +
Johnson PA, Lee TH, Cook EF, Rounan GW, Goldman L.  Effect of race on the presentation and management of patients with acute chest pain . Ann Intern Med . 1993;;118:593-601.
11 +
Maynard C, Fischer LD, Passamani ER, Pullum T.  Blacks in the Coronary Artery Surgery Study (CASS): race and clinical decision making . Am J Public Health . 1986;;76:1446-1448.
12 +
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia . JAMA . 1993;;269:1537-1539.
13 +
Moore RD, Bone LR, Gellor G, Mamon JA, Stokes EJ, Levine DM.  Prevalence detection and treatment of alcoholism in hospitalized patients . JAMA . 1989;;261:403-407.
14 +
Powe NR, Griffiths RI, de Lissovoy G, et al.  Access to recombinant erythropoietin by Medicare-entitled dialysis patients in the first year after FDA approval . JAMA . 1992;;268:1434-1440.
15 +
Diehr P, Yergan J, Chu J, et al.  Treatment modality and quality differences for black and white breast cancer patients treated in community hospitals . Med Care . 1989;;27:942-958.
16 +
Brudney K, Dobkin J.  Resurgent tuberculosis in New York City: human immunodeficiency virus, homelessness and the decline of tuberculosis control programs . Am Rev Resp Dis . 1991;;144:745-749.
17 +
Frieden TR, Fujiwara PI, Washko RM, Hamburg MA.  Tuberculosis in New York City: turning the tide . N Engl J Med . 1995;;333:329-333.
18 +
El-Sadr W, Medard F, Barthaud V.  Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993 . Am J Public Health . 1996;;86:1146-1149.
19 +
Gerberding JL.  Prophylaxis for occupational exposure to HIV . Ann Intern Med . 1996;;125:497-501.
20 +
Wilfert CM.  Prevention of perinatal transmission of human immunodeficiency virus: a progress report 2 years after completion of AIDS Clinical Trials Group trial 076 . Clin Infect Dis . 1996;;23:438-441.
21 +
Katz MH, Gerberding JLG.  Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use . N Engl J Med . 1997;;36:1097-1100.
22 +
Susser E, Valencia E, Conover S, Felix A, Tsai W-Y, Wyatt RJ.  Preventing recurrent homelessness among mentally ill men: a 'critical time' intervention after discharge from a shelter . Am J Public Health . 1997;;87:256-262.
23 +
Bush CT, Langford MW, Rosen P, Gott W.  Operation Outreach: intensive case management for severely psychiatrically disabled adults . Hosp Community Psychiatry . 1990;;41:647-649.
24 +
Stein LI, Test MA.  Alternative to mental hospital treatment . Arch Gen Psychiatry . 1980;;37:392-397.
25 +
Molla A, Korneyeva M, Gao Q, et al.  Ordered accumulation of mutations in HIV-1 protease confers resistance to ritonavir . Nat Med . 1996;;2:760-766.
26 +
Condra JH, Schielf WA, Blahy OM, et al.  In vivo emergence of resistance of HIV-1 variants resistant to multiple protease inhibitors . Lancet . 1995;;374:569-571.
27 +
Conlon CP, Klenerman P, Edwards BA, Larder BA, Phillips RE.  Heterosexual transmission of human immunodeficiency virus type 1 variants associated with zidovudine resistance . J Infect Dis . 1994;;169:411-415.
28 +
Centers for Disease Control and Prevention. Continued sexual risk behavior among HIV-seropositive, drug-using men—Atlanta , Washington, DC, and San Juan, Puerto Rico, 1993;.
29 +
MMWR Morb Mortal Wkly Rep . 1996;;45:151-161.
30 +
Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW.  The emergence of drug-resistant tuberculosis in New York City . N Engl J Med . 1993;;328:521-526.
31 +
Saravolatz LD, Markowitz N, Arking L, Pohlod D, Fisher E.  Methicillin-resistant. Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak . Ann Intern Med . 1982;;96:11-16.
32 +
Perelson AS, Neumann AU, Markowitz M, Leonard JM, Ho DD.  HIV-1 dynamics in vivo: virion clearance rate, infected cell life-span, and viral generation time . Science . 1996;;271:1582-1586.
33 +
Havlir D, Richman DD.  Viral dynamics of HIV: implications for drug development and therapeutic strategies . Ann Intern Med . 1996;;124:984-994.
34 +
Stansell JD, Osmond DH, Charlebois E, et al, for the Pulmonary Complications of HIV Infection Study Group.  Predictors of Pneumocystis carinii pneumonia in HIVinfected persons . Am J Respir Crit Care Med . 1997;;155:60-66.
35 +
Selwyn PA, Hartel D, Lewis VA, et al.  A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection . N Engl J Med . 1989;;320:545-550.
36 +
Hibbs JR, Benner L, Klugman L, et al.  Mortality in a cohort of homeless adults in Philadelphia . N Engl J Med . 1994;;331:304-309.
37 +
Ashe J, Brandon J, Contogouris M, Swanson M. The San Francisco Death Review Preliminary Report . City and County of San Francisco, Calif: Dept of Public Health Homeless Programs; 1996;.
38 +
Hanzlick R, Parrish RG.  Deaths among the homeless in Fulton County, Ga, 1988-90 . Public Health Rep . 1993;;108:488-491.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Deeks SG, Smith M, Holodniy M, Kahn JO.  HIV-1 protease inhibitors: a review for clinicians . JAMA . 1997;;277:145-153.
2 +
Leland J.  The end of AIDS . Newsweek . (December 2) ,1996;:65-73.
3 +
BHIVA Guidelines Coordinating Committee.  British HIV Association guidelines for antiretroviral treatment of HIV seropositive individuals . Lancet . 1997;;349:1086-1092.
4 +
Sontag D. Richardson L.  Doctors withhold HIV pill regimen from some . New York Times . (March 2) ,1997;:A1.
5 +
Waldman A.  When you want to live but can't afford it . Washington Post . (April 27) , 1997;:C01.
6 +
Zolopa AR, Hahn JA, Gorter RG, et al.  HIV and tuberculosis infection in San Francisco's homeless adults: prevalence and risk factors in a representative sample . JAMA . 1994;;272:455-461.
7 +
Fournier AM, Tyler R, Iwasko N, LaLota M, Schultz J, Greer PJ.  Human immunodeficiency virus among the homeless in Miami: a new direction for the HIV epidemic . Arch Intern Med . 1996;;100:582-584.
8 +
Thomas SB, Quinn SC.  The Tuskegee Syphilis Study, 1932-1972: implication for HIV education and AIDS risk education programs in the black community . Am J Public Health . 1991;;81:1498-1504.
9 +
Moore RD, Stanton D, Goplan R, Chaisson RE.  Racial differences in the use of drug therapy for HIV disease in an urban community . N Engl J Med . 1994;;330:763-768.
10 +
Johnson PA, Lee TH, Cook EF, Rounan GW, Goldman L.  Effect of race on the presentation and management of patients with acute chest pain . Ann Intern Med . 1993;;118:593-601.
11 +
Maynard C, Fischer LD, Passamani ER, Pullum T.  Blacks in the Coronary Artery Surgery Study (CASS): race and clinical decision making . Am J Public Health . 1986;;76:1446-1448.
12 +
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia . JAMA . 1993;;269:1537-1539.
13 +
Moore RD, Bone LR, Gellor G, Mamon JA, Stokes EJ, Levine DM.  Prevalence detection and treatment of alcoholism in hospitalized patients . JAMA . 1989;;261:403-407.
14 +
Powe NR, Griffiths RI, de Lissovoy G, et al.  Access to recombinant erythropoietin by Medicare-entitled dialysis patients in the first year after FDA approval . JAMA . 1992;;268:1434-1440.
15 +
Diehr P, Yergan J, Chu J, et al.  Treatment modality and quality differences for black and white breast cancer patients treated in community hospitals . Med Care . 1989;;27:942-958.
16 +
Brudney K, Dobkin J.  Resurgent tuberculosis in New York City: human immunodeficiency virus, homelessness and the decline of tuberculosis control programs . Am Rev Resp Dis . 1991;;144:745-749.
17 +
Frieden TR, Fujiwara PI, Washko RM, Hamburg MA.  Tuberculosis in New York City: turning the tide . N Engl J Med . 1995;;333:329-333.
18 +
El-Sadr W, Medard F, Barthaud V.  Directly observed therapy for tuberculosis: the Harlem Hospital experience, 1993 . Am J Public Health . 1996;;86:1146-1149.
19 +
Gerberding JL.  Prophylaxis for occupational exposure to HIV . Ann Intern Med . 1996;;125:497-501.
20 +
Wilfert CM.  Prevention of perinatal transmission of human immunodeficiency virus: a progress report 2 years after completion of AIDS Clinical Trials Group trial 076 . Clin Infect Dis . 1996;;23:438-441.
21 +
Katz MH, Gerberding JLG.  Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use . N Engl J Med . 1997;;36:1097-1100.
22 +
Susser E, Valencia E, Conover S, Felix A, Tsai W-Y, Wyatt RJ.  Preventing recurrent homelessness among mentally ill men: a 'critical time' intervention after discharge from a shelter . Am J Public Health . 1997;;87:256-262.
23 +
Bush CT, Langford MW, Rosen P, Gott W.  Operation Outreach: intensive case management for severely psychiatrically disabled adults . Hosp Community Psychiatry . 1990;;41:647-649.
24 +
Stein LI, Test MA.  Alternative to mental hospital treatment . Arch Gen Psychiatry . 1980;;37:392-397.
25 +
Molla A, Korneyeva M, Gao Q, et al.  Ordered accumulation of mutations in HIV-1 protease confers resistance to ritonavir . Nat Med . 1996;;2:760-766.
26 +
Condra JH, Schielf WA, Blahy OM, et al.  In vivo emergence of resistance of HIV-1 variants resistant to multiple protease inhibitors . Lancet . 1995;;374:569-571.
27 +
Conlon CP, Klenerman P, Edwards BA, Larder BA, Phillips RE.  Heterosexual transmission of human immunodeficiency virus type 1 variants associated with zidovudine resistance . J Infect Dis . 1994;;169:411-415.
28 +
Centers for Disease Control and Prevention. Continued sexual risk behavior among HIV-seropositive, drug-using men—Atlanta , Washington, DC, and San Juan, Puerto Rico, 1993;.
29 +
MMWR Morb Mortal Wkly Rep . 1996;;45:151-161.
30 +
Frieden TR, Sterling T, Pablos-Mendez A, Kilburn JO, Cauthen GM, Dooley SW.  The emergence of drug-resistant tuberculosis in New York City . N Engl J Med . 1993;;328:521-526.
31 +
Saravolatz LD, Markowitz N, Arking L, Pohlod D, Fisher E.  Methicillin-resistant. Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak . Ann Intern Med . 1982;;96:11-16.
32 +
Perelson AS, Neumann AU, Markowitz M, Leonard JM, Ho DD.  HIV-1 dynamics in vivo: virion clearance rate, infected cell life-span, and viral generation time . Science . 1996;;271:1582-1586.
33 +
Havlir D, Richman DD.  Viral dynamics of HIV: implications for drug development and therapeutic strategies . Ann Intern Med . 1996;;124:984-994.
34 +
Stansell JD, Osmond DH, Charlebois E, et al, for the Pulmonary Complications of HIV Infection Study Group.  Predictors of Pneumocystis carinii pneumonia in HIVinfected persons . Am J Respir Crit Care Med . 1997;;155:60-66.
35 +
Selwyn PA, Hartel D, Lewis VA, et al.  A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection . N Engl J Med . 1989;;320:545-550.
36 +
Hibbs JR, Benner L, Klugman L, et al.  Mortality in a cohort of homeless adults in Philadelphia . N Engl J Med . 1994;;331:304-309.
37 +
Ashe J, Brandon J, Contogouris M, Swanson M. The San Francisco Death Review Preliminary Report . City and County of San Francisco, Calif: Dept of Public Health Homeless Programs; 1996;.
38 +
Hanzlick R, Parrish RG.  Deaths among the homeless in Fulton County, Ga, 1988-90 . Public Health Rep . 1993;;108:488-491.

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