IF THE CONDOM BREAKS

By Christine Gorman

The 30-year-old Bostonian knew he was taking a chance when he visited a bathhouse for a homosexual tryst. It wasn't until the condom broke and he saw the blood that he blanched. Had he picked up HIV, the virus that causes AIDS? The next morning, he called his physician, Dr. Stephen Boswell of the Fenway Community Health Center, in a panic. Could the doctor please do something to help?

As it happened, Dr. Boswell thought maybe he could. It wouldn't be easy, he explained, and there was no guarantee of success. The treatment he offered--an intense chemical barrage with the same combination of powerful anti-HIV drugs that has given so many patients with advanced AIDS a new lease on life--would last six weeks and make the man very sick. But if it worked, the potent cocktail could destroy any viral particles that might have been transmitted and prevent a potentially fatal infection from taking hold.

The chastened patient leapt at the chance for a reprieve. In his case, it appears to have paid off. One year later, a thorough examination of his blood and tissue shows that he is completely virus-free.

The so-called morning-after AIDS treatment the Boston man received is being offered in only a handful of clinics across the U.S., but it has already sparked a fierce debate among physicians and health-care policymakers. Just last week, the Food and Drug Administration warned doctors that protease inhibitors, a key ingredient in the new therapies, can cause diabetes--in addition to known side effects that include liver complications and debilitating nausea. Are the benefits worth the risks? Could overuse of antivirals unleash a new strain of drug-resistant superviruses? Will the availability of a morning-after treatment make people relax their guard? Will there be a widespread return to the risky sexual practices that preceded the AIDS epidemic? These and a host of other questions will be addressed next month at a special meeting of AIDS experts at the Centers for Disease Control and Prevention in Atlanta.

The fact that morning-after treatments are being discussed at all shows just how far HIV drug therapy has come in the past two years. There is still no cure for AIDS, but doctors have watched with growing excitement as the new therapies forced the level of HIV in the blood of some of their most advanced AIDS patients below their ability to detect it. HIV still lurks in these patients' lymph nodes, nervous system and other parts of the body. But some scientists believe that if the virus is caught early enough in the cycle of infection, it may some day be eradicated from the body. Why not hit the virus immediately after the first suspected exposure, thus wiping it out before it manages to get a foothold?

Physicians have already scored some successes in hospitals where health-care workers have been accidentally jabbed by needles containing HIV-contaminated blood. By starting combination therapy immediately after exposure, and continuing treatment for a month and a half, they have been able to cut the risk of infection due to needle-stick injuries from as much as 1 in 200 to 1 in 1,000.

The trouble begins when doctors start offering these complex and grueling treatments to otherwise healthy people who think--but aren't certain--that they have been exposed to HIV. In the past year, eight of the 20 patients treated at the Fenway Center couldn't finish the full six-week regimen because the side effects were so painful. It's also very easy to foul up the carefully coordinated sequence of as many as 20 pills per day--some of which must be taken on an empty stomach to have their full effect. Any HIV particle hardy enough to exploit a gap in the treatment could eventually lead to the development of a drug-resistant strain. "You don't want to give the virus a chance to mutate," says Dr. Kenneth Mayer of Brown University in Providence, R.I. "That's a potential nightmare."

An even worse nightmare would be if millions of people started relying on pills rather than safe-sex practices to guard against infection. Mayer was shocked to hear one of his patients suggest that the new drug treatments had made AIDS seem more benign, like herpes, rather than the life-threatening illness it is. "People are letting down their guard because they don't see the consequences as [being as] tragic as they are," Mayer says.

For some, however, the morning-after treatment for HIV could offer just the kind of wake-up call they need. At Fenway, patients undergo intense counseling as part of their treatment regimen. Boswell also makes it clear that he won't prescribe combination therapy over and over again. When it comes to treating HIV, a second chance should never be taken for granted.

--Reported by Alice Park/New York and Dick Thompson/Washington

With reporting by Alice Park/New York and Dick Thompson/Washington