Got Their Back

Four afternoons every week Michael swings by the Action Point program in San Francisco's gritty Tenderloin neighborhood to see nurse-practitioner Deirdre McDermott-Santos. As they sit in her small office, McDermott-Santos pours Michael a glass of orange juice. She then places eight pills, including four anti-HIV medications, into his hand. A quick swallow, a gulp of juice, and the pills are gone. In many ways Michael, who requested that his last name not be used, is a poster child for a medication adherence strategy called directly observed therapy. HIV-positive since at least 1990, without income, and all-too-familiar with life on the streets, 38-year-old Michael could easily be missing med doses. But thanks to Action Point, he is taking them and is doing well. To some, it might seem obvious that supportive programs like directly observed therapy that infuse structure into the chaotic lives of HIVers who are drug users, homeless, or mentally ill, could work. But anecdotal information is not enough. Researchers as well as funders treat the introduction of a new HIV program the same way they do the development of a new medicine'that is, they want to see statistics and studies that prove that it works. [Click on link above for 'More Meds on the Way' for news of drugs in the developmental pipeline.] Consequently, over the past six years researchers have been studying an array of short-term pilot programs for directly observed therapy. Some have evaluated DOT's effectiveness in prisons, methadone clinics, and community heath centers. Others have explored what happens when outreach workers meet people in their homes, on the street, or in shelters. (Action Point, launched in March 1999, is believed to be the only long-term city-run and city-funded adherence project.) As the findings from these pilot projects come in, researchers say a consensus is building that DOT can be an important intervention'for the right people. As one study conducted in Los Angeles found, people who go to a general health clinic tend to have good adherence and do not need DOT. And it doesn't appear to work for substance users or people using methadone clinics who aren't ready to try and stay on treatment. But for a certain 'targeted population,' it does work, says David Bangsberg, MD, MPH, an associate professor at the University of California, San Francisco. 'In my view this is the patient who has tried and not succeeded on therapy, is in late-stage disease, and is at high risk for dying in absence of sustained treatment.' But identifying the right population is merely the very first step toward implementing DOT programs. The next set of studies, Bangsberg says, will need to answer whether DOT can'or indeed even should'include an exit strategy. Using DOT for tuberculosis treatment, the setting in which it was first introduced, 'didn't require behavior change,' says Jennifer Mitty, MD, an assistant professor of medicine at Brown Medical School. It's a time-limited treatment. 'But with HIV, you are talking about lifelong medication, so any DOT program has to incorporate learning skills.' And if those skills can't be developed, says Elinore McCance-Katz, MD, Ph.D., an assistant professor of psychiatry at Virginia Commonwealth University, it could be a problem. 'I don't think it's realistic,' she says, 'to think we could provide ongoing perpetual DOT.' But Joshua Bamberger, MD, MPH, medical director of San Francisco's Housing and Urban Health program, which oversees Action Point, says it depends on how you see DOT'as a program someone must come to every day or one that provides ongoing support for people in a way that works for them. Which is why no one at Action Point is looking for Michael, who has been a client for seven years, to 'graduate.' Action Point is where he is accustomed to taking his medication four days a week. It's where he expects to get the small manila envelopes that contain the medications he needs for the three days he takes his pills on his own. 'I need this program,' Michael says. 'If I didn't see the people here, I'd probably forget about taking my meds.'