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—We agree with Dr Lyman that it may not be possible for many of her patients to succeed with combination antiretroviral regimens. We also agree that having limited goals is important and that modifying the delivery system to provide usable services like twice-a-week preventative therapy for tuberculosis is the first priority in this population. Blanket recommendations to prescribe protease inhibitors do not always serve either our patients or the public health. With some severely mentally ill and substance-using patients, successful delivery of prophylaxis for Pneumocystis carinii or isoniazid prophylaxis for tuberculosis is a substantial achievement.However, system barriers account for some of the difficulty in managing severely mentally ill, substance-using patients. These patients are often underinsured and require more time than the typical clinic schedule allows. Some clinicians are not eager to share the responsibility in managing their multidisciplinary problems through referral and consultation. We find that patient-resistant clinicians are
Bangsberg D, Tulsky JP, Hecht FM, Moss AR. Prescribing Protease Inhibitors for the Homeless-Reply. JAMA. 1997;278(15):1236. doi:10.1001/jama.1997.03550150040031
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