1995 was a watershed year in the AIDS pandemic. Researchers were able to demonstrate the survival advantages of combination antiretroviral therapy over monotherapy. Stavudine gained greater acceptance by AIDS specialists as the nucleoside analog of choice. And the FDA's fast track approval of lamivudine and saquinavir added two new ingredients to the antiviral cocktail for the New Year's toast for a long and happy life.
There are 8 to 5 odds in Las Vegas that ritonavir will be approved by the FDA by June 1996. And while there are no predictions from Merck about when their NDA filing for indinavir is expected, the Wall Street Journal reports that Agouron is getting nervous about its possible fourth-place showing in the protease inhibitor sweepstakes. Apparently there is some concern that the majority of AIDS patients will be on other protease inhibitor combination regimens and there may not be enough eligible patients (ie, those whose health plans will pay for multiple protease inhibitors) to justify drug development costs. The new marketing reality for antiretroviral drugs is that each new effective drug will play an important and often critical role in the new combination therapy model, but that it will now take longer to recover drug development costs.
Getting the new FDA-approved drugs cleared for the hundreds of national, state, and managed-care formularies will be as critical to the survival of people with AIDS as is new drug development. Stavudine, lamivudine, and saquinavir are already black-market commodities for PWAs in many countries. Survival with HIV disease may become a privilege for the highest bidder. We may soon be able to establish the indirect dollar value of a human life by determining the amount of money that countries, states, institutions, and health plans will or will not pay to significantly extend lives.
HIV/AIDS is finally being recognized as a disease primarily affecting the poor and disenfranchised. An increasing number of people may now be able to survive their disease with the growing armamentarium of more effective drugs. Most of these people will be white men. Unfortunately there is less hope for the tens of millions of others affected by the pandemic.
We may rail over the lack of leadership by government officials in developing policies that support the sanctity and dignity of human life, but the situation could be worse. One news story that didn't make our Caput Mortuum page in 1995 was that of the Kenyan politician who suggested that hospitals without mortuaries simply leave their dead outside the grounds for hyenas to devour. The way things are going in Washington, DC, this Kenyan cost-saving proposition could be the cornerstone of the new healthcare reform proposal for the US Congress. We can just leave the bodies of the poor out for Newt Gingrich and his minions.
This may be a dark New Year's message. But we are haunted by the myth of Tantalus, a king of Phrygia, whose punishment in the lower world for betraying the gods' secrets was to stand in the river Tartarus up to his chin, under branches of fruit. Whenever he tried to drink or eat, the water or fruit withdrew from his reach. That's where ninety-five percent of the millions of people with HIV are: seeing the fruit of effective combination antiretroviral therapies--but always out of reach. These millions of people have also been damned, not because they have revealed the secrets of the gods, but for being poor.