EU-Project: Prioritizing the Scope of HIV/Aids Action: Policy report


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DISSONANCE : INCREASED LIFE EXPECTANCY

A new medication, antiretroviral combination therapy, (HAART) popularly known as the ‘triple cocktail’ has been used since about 1996 to combat HIV/Aids and has achieved substantial success in delaying the development of the disease for many people. During the first meeting the experts were much more optimistic about the treatment than later on when it had become clear that some groups of patients could not benefit from this treatment. The treatment is very difficult to administer and carry out successfully. Medication has to be taken at precisely defined intervals during the 24-hour cycle and often has unpleasant side effects. Not everybody has the ability and motivation to sustain this regimen over long periods of time without substantial help and encouragement. The consequences of not carrying out the treatment exactly as prescribed are dire both for the patient who develops an immunity to the treatment, and for the patient’s sexual partner or partners who can also develop immunity to the ‘triple cocktail’. In this way immunity to the new drug treatment can easily spread far and wide to the detriment of everybody.

The ‘triple cocktail’ is very expensive, about $20,000 per patient year. Since the treatment developed out of medical research and has to be prescribed by a medical practitioner it seemed logical to keep the administration in medical hands although not all doctors are trained in handling the complex medication. Furthermore, medical practitioners operate under substantial pressure and often have to ration the time available to each patient and they do not receive additional financial compensation for handling the antiretroviral combination therapy with the need for follow up, monitoring and control. Additionally, according to our experts, not all doctors who administer this treatment have the necessary patience and social skills. What, if anything, can be offered to patients who, for a variety of reasons, cannot be treated with aniretroviral combination therapy effectively?

One way of dealing with this dilemma is to hand part of the drug administration back to non-medical people who regularly work with HIV/Aids patients and particularly to use qualified social workers available in hospitals and private surgeries to create the necessary motivational and supervisory condition to enable patients to persevere with the demanding and complex conditions to adhere successfully to HAART.

Increased Life Expectancy due to the new drug technology creates other problems. Patients who previously expected to die quite soon, left their employment and might have sold their home and other possessions. Now they are keen to re-establish themselves, obtain a job and a place to live. They need help to achieve their newly developed aims.

The Dissonance described by these conditions derives from what is called the technological imperative, that is to say an insistence that complex problems involving human beings can be satisfactorily solved by technology alone. There is extensive literature on the failure of technological imperative solutions.


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Dissonance Reduction

Since HAART treatment is very expensive and the resources of the Welfare State are limited, the technocentric solution at first appears sensible. However, it makes assumptions that are highly unrealistic and can be shown to produce seriously negative results for a large number of patients who cannot or will not continue with the drug treatment. The consequences of failure will affect the patient as well as a wider circle of people, as explained above. Thus, secondary prevention becomes a crucial issue with HAART. It is, of course, accepted that a reliance on psycho-social help alone cannot deal with this problem. In addition, there is the problem for patients who successfully take the HAART but who have to re-establish themselves and need non-medical help to achieve a reasonable quality of life.

In the circumstances it is possible to envisage a socio-technical solution, by urging the funding bodies to allocate a sum of money for a patient/year which includes the cost of the technical treatment as well as provision for regular qualified psycho-social help. For instance, if a certain small percentage of the overall costs for HAART could be earmarked for a professional social worker, this might secure a more effective overall solution to a complex problem.


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