Managing HIV in a Complex World

This issue of OUTReach provides an overview of our current efforts to end the AIDS epidemic. It is not a simple picture to portray, because as the epidemic has evolved, our work has grown more complex--like solving a puzzle with ever changing shapes.

In the early 1980's the work of the Foundation was easier to explain--to provide accurate and timely information to communities confronting an emerging epidemic. Rumors were rampant and scientific facts were scarce. We helped to sort out the difference amidst profound fear and suffering.

The suffering led to new dimensions of our work as we, together with others, patched together a network of services that became known as the San Francisco model of care. It was born of our communities' response to its collective grief--and grew as the government and private sectors finally came to realize their obligations to respond.

Ten years ago a titanic shift occurred when the first protease inhibitor, saquinavir, emerged from clinical trials and in a series of historically rapid steps was approved by the US Food and Drug Administration (FDA). This long sought development seems nearly miraculous as we reflect on the changes since.

By the turn of the century, AIDS had been transformed from a near death sentence to an often-manageable chronic disease. Newspapers previously filled with obituaries became filled with drug advertisements. And communities in despair reemerged with a newfound hope and sense of future.

The AIDS Foundation's response to these changes has been no less dramatic, but rather than simplifying our work, it has brought new complexities.

The decline in mortality, the slowing of disease progression and the relaxation of community fears and behaviors resulted in an ever-growing population of people living with HIV with different needs.

Protease inhibitors are not a cure and sustaining complex lifelong regimens takes a toll physically and mentally that demands highly skilled medical and social service providers. And drug-resistant strains, such as that recently reported in New York City, highlight the additional challenge of a constantly mutating virus.

Sadly, access to treatment remains far from universal. Inequities in access to health care translate to treatment disparities linked to ethnicity, sexuality, gender, and economic status. Through our programs we seek to address these inequities as well as the intersections of HIV, homelessness, substance use and mental health-- complexities that cannot be ignored if we are to succeed in treating those most in need.

Prevention, too, has become more complex as the consequences of unsafe behaviors are no longer perceived as fatal and as community norms discount HIV prevention as a priority. Our focus on community-level interventions reflects this new reality as we seek innovative ways to help communities change their own norms and perceptions.

Treatment progress we have made here at home creates a moral imperative that these treatments be made available throughout the world. Through our affiliate, the Pangaea Global AIDS Foundation, we are sharing what we have learned with treatment initiatives in Africa and Asia -- and addressing a host of familiar complexities tied to health care infrastructure, drug pricing, local culture and political will.

Simply put, the constellation of services needed to assure widespread access to treatment and prevention is much more complex than a decade ago. That is why our work occurs on so many fronts and why your ongoing support for our efforts remains more important than ever.