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David Cooper, MD, DSc

September, 1996

Advances in the understanding of pathogenesis and treatment of HIV infection in the past year, which culminated in the plethora of good news at the XI International Conference on AIDS in Vancouver, have indicated the potential of viral eradication from the blood for up to one year with aggressive combination therapy. The concept of a low or negligible viral load contains many exciting possibilities which were canvassed in Vancouver, as were areas of research necessary to delineate future combination therapy treatment protocols. We need answers about durability of response, viral eradication from other compartments, resistance, and compliance with treatment regimens.

Unfortunately, this phenomenal advance also brings a clear range of possible negative outcomes. Among the issues of concern: If infectivity is shown to be lower in the presence of a low viral load, will this lead to an abandonment of safer personal behaviors and a surge of recidivism in unsafe sexual and injecting practices? Will people everywhere be less careful if they believe that the elusive "cure" is just around the corner?

Will governments seize on a mistaken presumption of an imminent end to the epidemic to reduce or withdraw funding? How will this advance of combination therapy and its accompanying hoopla affect vaccine research, so desperately needed in resource-poor countries? How will each community address the need for education, in order to explain the need for compliance with a difficult, long-term, and complex regimen of drug therapy?

Will the prospect of viral suppression encourage the supporters of compulsory testing to return to this repugnant assault on human rights? A concerted effort was needed a decade ago to dissuade most--but, notably, not all--jurisdictions from implementing compulsory testing of designated high-risk groups, and one basis for that dissuasion was the lack of available treatment. Will the dramatic results of combination therapy be used to bludgeon legislators into reconsidering this Draconian move?

This is a new horizon in HIV treatment, and these issues, both positive and negative, require a revolution in the thinking of both science and community.

The second policy area which requires urgent attention is one concerning developing countries. At Vancouver and elsewhere, the question is continually heard: How can this treatment advance be transferred? Few viable answers have been offered up to now, but consider this possibility, first suggested by my colleague Bernard Hirschel, MD, of the University of Geneva: Companies that have developed effective analog antiretroviral drugs (shelved only because they arrived second in the patent race) could be encouraged to make these drugs available to international agencies for study in developing countries. This move would allow the standard of care to be transferred for the cost of manufacture only. There are at least four major pharmaceutical companies with analog drugs simply gathering dust. There are precedents in other developing-world epidemics, such as schistosomiasis and onchocerciasis. Such an analog program is not a pipe dream when the cost of a single tablet may be less than one US cent. In his role as chair of the 12th World AIDS Conference in Geneva in 1998, Hirschel plans to develop novel aspects of drug availability such as this one as a theme of the conference.

Our goals must be drug accessibility for all infected people: in the short term, vaccine development; in the long term, viral eradication; and above all, effective universal prevention.

©1996, Medical Publications Corporation

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