First IAS Conference on HIV pathogenesis and treatment draws 3000 scientists

Buenos Aires, Argentina – The focus was on science, but not far behind the curtain, the reality about the worldwide AIDS epidemic still pervaded the first International AIDS Society Conference on HIV Pathogenesis and Treatment. More than 3000 scientists from every corner of the globe made the meeting in Buenos Aires so successful that the second conference is being readied in Paris for 2003. The importance of the meeting was underscored by an overflow crowd of international health and science reporters. Journalists from Norway to New Zealand, Canada to Argentina covered the more than 700 scientific papers and presentations. Included were writers for industry publications, health publications, community press representatives, Internet reporters and worldwide wire service reporters for organizations such as United Press International, the Los Angeles Times Syndicate and MSNBC.com. In the background of the meeting, however, was the dire warning from Dr. Stefano Vella, president of the IAS, that the reason for the meeting was to find answers to the disease that continues unabated. Just beginning? In fact, Dr. Vella said, the epidemic may only be in its infancy. ‘‘This epidemic is just a baby,’’ he said. ‘‘In 20 years we could have 200 million people with this disease, and if we don't act 100 million of them will die by 2020.’’ About 60 million people have been infected by human immunodeficiency virus and 22 million of these people worldwide have died of AIDS since the disease was first recognized in 1981. `‘My hope is that we can turn this disease around,’’ said Helene Gayle, MD, former director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention, Atlanta. ‘‘But Dr. Vella's estimate is not unreasonable if you consider that the epidemic is really just starting in nation's such as India, China, the former Soviet republics, and in the populous Africa nations of Nigeria and Ethiopia.’' Dr. Vella implored the wealthy nations of the world to contribute to the $10 billion yearly fund required to put the brakes on the epidemic. Only about $1 billion has been contributed so far. Dr. Pedro Cahn, MD, chairman of the conference which is intended to meet in alternate years to the World AIDS Conference, said that new work gives researchers insights as ‘‘when to start therapy, whether it is safe to delay therapy and what role new drugs will make in treating people with HIV.’' Vaccine needs Though the conference reported numerous examples of pre-clinical work in the development of a preventative or therapeutic vaccine, Dr. Peggy Johnston, assistant director for HIV Vaccines at the US National Institute of Allergy and Infectious Diseases, admitted that she was not confident that current vaccine candidates, some of which are in human trials, will prove to be greatly effective against HIV. ‘‘What we really need is a Van Gogh,’’ she said during one of the press conferences. ‘‘We need someone with uncommon talent to design a vaccine against this disease. Perhaps that person isn't born yet. But the current designs do not appear to be successful.’’ And once that design is found, the road to getting the vaccine into the bodies of at-risk individuals is a long process, said Dr. Anthony Fauci, director of the NIAID. He predicted that if a vaccine can be developed and it can be successfully tested, it would still take an additional 5 to 7 years before effective vaccination programs would be possible. That means the chance of a useful vaccine being available by the end of this decade is in doubt, he indicated. Treatment delays In the area of treatment, Dr. Julio Montaner, co-chairman of the conference's scientific program and professor of infectious diseases at the University of British Columbia, Vancouver, Canada, argued that delayed treatment of patients with HIV infection was a more prudent course of action now that the scientific community understands that eradication of the disease remains a dream. ‘‘Total eradication of HIV is a not a realistic goal today,’’ Dr. Montaner said in the opening session of the 4-day conference, ‘‘with the treatments we have available.’' Montaner said studies show that delaying treatment with highly active antiretroviral therapy (HAART) until CD4-positive cell counts are lower, permits patients to extend the useful life of treatments that are available; it reduces the cost of treatments and will reduce the appearance of metabolic and fat distribution side-effects. Another way of reducing the impact of therapy on patients, Dr. Fauci said, is through structured treatment interruptions. His study of 10 patients who received 1 week of HAART and then went off HAART in the second week has shown success after more than a year of experimentation. ‘‘We have seen no viral rebound nor have we seen evidence of development of resistant virus,’’ he said. The next step is a larger clinical trial to see if the treatment plan – designed to reduce the pill burden, the medication bill and side effects – can be extended beyond the carefully selected patients in his pilot study. The conference also looked at new treatments for AIDS on the horizon, even though these drugs are still relevant only in countries which have the economic strength and political will to provide them. Researchers said investigational drugs – tipranavir, atazanavir, mozenavir and others – appear to be moving forward and will soon be added to the armamentarium of treatment options. HIV and diamonds The impact of the epidemic has moved some individual companies to supply HAART to its employees. The Debswana Diamond Company, possibly one of the wealthiest companies in southern Africa – equally owned by the international diamond producer DeBeers and the government of Botswana – has begun a program in which 90 percent of the cost of HAART is paid by the company for infected workers and their spouses. Voluntary testing among company employees found that 28.8 percent have HIV infection and that the infection is rampant at all levels of company workers. In 1999 and 2000, there were 25 deaths each year from AIDS – representing 61 percent of deaths among the workforce. About 6000 people work for Debswana, the single largest contributor to Botswana's gross domestic product. Overall, nearly 40 percent of Botswana's adult population is infected with HIV. ‘‘When we did the actuarial studies,’’ said Tsetsele Fantan, a human resources manager at Debswana, ‘‘we found that the cost of antiretroviral therapy exceeded the cost of doing nothing for the workers.’’ But Fantan said company officials recognized that when they considered the intangible of loss of morale, loss of motivation, the cost of accidents that would occur due to untreated illness and the loss of organization memory due to the deaths of workers, that offering effective treatment of the disease was the proper course of action. ‘‘We are recognizing that it makes more economic sense to pay for treatment than to replace workers,’’ said the CDC's Dr. Gayle. In another program discussed, the government of Botswana, Merck & Co., and the Bill and Melinda Gates Foundation are working on a pilot program to provide treatment to residents of the main cities in this country of 1.7 million people. Websites of interest: IAS Conference Secretariat http://www.iasconferences.org Bill and Melinda Gates Foundation http://www.gatesfoundation.org Debswana Diamond Company (Pty) Limited http://www.debeersgroup.com Merck & Co. http://www.merck.com Government of Botswana http://www.gov.bw/home

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