What 'DBC' got wrong about the AIDS crisis (Washington Post)

'Tis the season for Oscar bait, and this year, "Dallas Buyers Club" looks set to get at least a few nominations. The movie stars Matthew McConaughey as Ron Woodroof, a Dallas man who contracts HIV in 1985, when the diagnosis was a death sentence.

After responding poorly to AZT, the first drug approved to treat HIV/AIDS, Woodroof began acquiring unapproved medications from Mexico, Japan and other places around the world, and formed the titular "buyers club" to distribute them to other people in his area, whether the Food and Drug Administration liked it or not.

It's a very-well-made movie, and McConaughey and Jared Leto (who plays a transgender woman named Rayon who partners with Woodroof) give great performances. And the script, which had been written over the course of 20 years and was based in large part on interviews with Woodroof and on his personal journals, is by all accounts an accurate depiction of Woodroof's life. But it risks leaving a false impression of that period in the history of HIV/AIDS, and in particular of the role of AZT.

Let us now praise AZT


A bottle of AZT, also known by the brand name Retrovir. (Sam Morris / Associated Press)
In 1987, the FDA made azidothymidine — also known as zidovudine and usually shortened to "AZT" — the first government-approved treatment against HIV and AIDS. AZT is an antiretroviral which slows the replication of HIV, although it cannot stop it all together.

In the film, Dallas Mercy Hospital is having a randomized controlled trial to test AZT's effectiveness. Unable to be sure he's getting the drug rather than a placebo in the trial, Woodroof bribes a hospital employee to supply him with AZT, to which he reacts very badly. Throughout the rest of the movie, he and other characters denounce the drug as "toxic," and Woodroof recommends that customers of the buyers club dispose of what AZT they have and never take it again. At one point, a news broadcast is heard which emphasizes that AZT was the most expensive drug ever produced at that point. One could be forgiven for coming away with the sense that the medical community was poisoning HIV/AIDS patients with the drug, and keeping them from other, safer, therapies.


The trouble is that AZT is actually a very effective therapy against HIV/AIDS. "People who were consistently using AZT prolonged life for one year," says Jonathan Engel, a medical historian at Baruch College and author of "The Epidemic: A History of AIDS." That may not sound like a lot, but at a time when the disease had a mortality rate of 100 percent, anything that delayed death was valuable.

This is not to say that Woodruff and others were imagining things. The dosages at which the drug was prescribed really were too high, but that was because of worries that a lower dose wouldn't be enough to meaningfully slow the virus.

Peter Staley, a longtime HIV/AIDS activist and co-founder of the Treatment Action Group who informally consulted on "Dallas Buyers Club," notes that though later studies showed that half the original dose worked just as well, researchers didn’t know this in the early days of the epidemic, and they only figured it out by comparing a lower dose to the original dose and finding the two had same rate of deaths. "They basically had to guess at a dose to use and decided to 'hit hard.'" Staley says. "It was not some government conspiracy that picked a high dose of AZT; it was a fear that hitting the virus too lightly wouldn't do the trick."

That did have negative consequences, notably bone marrow toxicity which manifested as anemia, but those side-effects were easy to diagnose and could be reversed by lowering the dosage or stopping the drug altogether. The bigger problem was that AZT was being used alone. With a virus that mutates as quickly as HIV, using only one antiviral drug often causes the virus to develop a resistance to that therapy. "Even if one half of one percent of cells were resistant, that within 20 generations (or about two months) that could become a broad strain," Engel explains.

The solution, as David Ho and other researchers at the Aaron Diamond AIDS Research Center discovered in the mid-1990s, was to knock the virus back using a "triple whammy" of three different antivirals. Though the odds of a strain developing that was resistant to one of the three antivirals was fairly high, the odds of one developing that was resistant to all three was much lower. This approach — now known as highly active antiretroviral therapy (HAART) — effectively turned HIV/AIDS into a chronic, manageable disease rather than a death sentence.

And AZT, often in the form of a pill marketed as "Combivir" that also included the antiviral lamivudine, was a key component of HAART for almost a decade. "In 2005, the number one selling antiviral in the world was Combivir," Staley says. "This is nine years after the triple drug regimens came out, and well after the AIDS death rate in the developed world dropped by 80 percent between 1996 and 1998. In two years, the death rate collapsed, and combivir was playing a huge role in that."