WITH all the optimism about new treatment developments in the fight against AIDS, a cure or a preventative vaccine still appear to be a long way off. But as more people with the disease survive, as a result of being treated with the new combination therapies, a number of issues will have to be dealt with.
The cost of treating AIDS patients on combination therapy, estimated at around £12,090 a year, is bound to become an issue in the future. The therapy is available to all suitable patients in Ireland.
Dr Gerard Sheehan, consultant in infectious diseases, believes that the cost is in many ways justified. "There are indirect savings in that people are no longer being admitted to hospital. The amount of pounds per year of life saved compares very favourably with other medical conditions. The cost will depend on whether the theory of eradication is true. If it is true it will be a bargain. If not it will be one of many therapies that are costly but should be offered since it is of benefit."
Previously, according to Dr Fiona Mulcahy, genito-urinary physician, the cost of treating an AIDS patient would have been based on a life expectancy of 10 years. "But a lot of patients who would have given up their jobs and been drawing social security are now talking about getting back to work."
The treatment advances also mean that it will be harder to track the disease and there are dangers that a resistant strain of the virus could be passed to another for whom treatment would then fail because of the resistance to the drugs.
Experts in the area emphasise the continued need to take precautions. They are slow to address publicly the issue of whether or not a person whose viral load has dropped to undetectable levels would have reduced infectivity. It is not possible to say at this stage, they say, and the message of safer sex must keep being pressed home, they emphasise.
Sharyn Oye, executive director of the Dublin AIDS Alliance, believes that the number of HIV positive people in Ireland could be much higher than the official figures. "It could be three times as high. There are the number of Irish people who tested in England and people who are positive but do not consider themselves at risk."
In Ireland intravenous drug users account for 46 per cent of AIDS cases. Most people at risk of HIV in Ireland are "on the margins", mainly drug addicts, according to Dr Joe Barry, specialist in public health with the Eastern Health Board.
One of the problems with drug users and the new drug therapies is compliance with the strict treatment regime. Those working in this area say that sometimes addicts may stop treatment simply when they begin to feel better.
There is a parallel with antibiotics. If a patient does not complete a course of antibiotics, enough resistant bacteria survive and multiply, and a second course of the same antibiotic is far less effective. "The issue of compliance is a big one," says Dr Barry.
There is also a danger of over-dosing for those who are active drug users and on combination therapy. However, according to Dr Fiona Mulcahy, the "word is out" among this community of patients about the benefits of the treatment and an increasing number are willing to try to stabilise their habit and go on the new therapy.
Dr Joe Barry says thee female partners of drug users make up a largely "hidden" population. Drug abusers will change needle practice on advice but it is much more difficult to get them to practise safer sex. They, in particular, must be targeted for testing and treatment. "If the male partner is a drug user and the female is not they tend not to come near our services. They are a hidden population. We have to push the man to allow us access to the women to get them tested."
The advances in treatment mean it is even more important that there is an active campaign to encourage people to be tested, he says. "We are trying to identify people at an early stage. Before, when someone tested positive, you assumed they would die quickly. I know of a lot of people who gave up work assuming they were going to die.
"But now they live longer and there will be bigger numbers of HIV positive people so the message about safer sex is even more important. Obviously we are talking about people having as normal a life as possible, including a sex life. It is a natural follow on that if people are feeling better they are more likely to want to have sex. Of course we do not want people to be lulled into a false sense of security about AIDS. It was easier before when you said prevention was the only thing on offer. This does complicate matters."
Despite the huge medical advances, the same psycho-social issues surround the virus as a decade ago, according to Ms Oye. "In terms of attitude or conditions in which people with AIDS live, there have not been huge advances. AIDS in Ireland is a cultural thing not simply a medical condition. The communities that are disproportionately affected by AIDS are gay men and, marginalised inner-city communities where there is poverty and deprivation.
"For these people infection, is not the focus of their lives, getting money or drugs is. HIV is just another piece of crap they have to deal with. They do not deal with it well in terms of managing their illness. The regime is difficult so they do not adhere to it. These people tend to be ignored really. People will dispute that but all of the money is being invested because the drug problem causes a crime problem not because of HIV.
PREVENTION, she stresses, is the way forward. But she is concerned that the stigma attached to the disease, mainly in middle-class sections of Irish society, has not lessened. "Even if there is a cure tomorrow, the problems continue. The stigma is huge. Psycho-social issues need to be addressed for people who are HIV positive - equality, equal opportunity, health, education. We haven't seen problems for HIV positive children in schools. But I suspect that is often because the children themselves do not know in case they let it slip.
"Often when it is discovered at work, the employer pays off the person suspected of being HIV and they accept it because they do not want to be exposed. But the new legislation which is being introduced should improve things hugely in this area. This is very important because the new treatments mean that more and more people will be able and ready to work," adds Ms Oye.
According to Dr Sheehan, those most isolated are usually those who became infected through heterosexual contact. "They often forgo treatment because of fears around confidentiality."
Further afield, the epidemic in North America and Europe has stabilised with the number of people dying with AIDS in the US falling for the first time since the start of the epidemic. Despite the encouraging overall figures, there was a rise in AIDS deaths and incidence in the US in 1996 in people infected through heterosexual contact and in women. Twenty per cent of newly reported AIDS cases were women, an all-time high.
The proportion in the industrialised world will further decline - over time, however the United, Nations estimates that up to 90 per cent of the world's AIDS cases live in the developing world.
The epidemic in Latin America substantially exceeds that in North America. The epidemic in Asia began in the late 1980s but has been growing at least as rapidly as the African epidemic did 10 years ago. New Asian cases may exceed one million a year by the turn of the century.
The African epidemic is of an almost "unimaginable magnitude", according to the WHO figures. The projected decline in HIV cases in the late 1990s is a consequence of a saturation with HIV infection of those at risk, because the number of new HIV infections will be limited by a decreasing pool of susceptible people, rather than any prevention successes.
"It is great to see the success here," says Ms Oye. "But we must not forget the situation in these countries where there is no, hope of anyone getting the treatment and the main concern is simply getting enough food."
