Over the next few days, I will be deeply involved in the details of new drugs, new combinations, resistance testing, long term complications and strategy issues. For most Americans living with HIV and for those of us who work with them in their medical care, these are the issues we spend our time thinking about. But on the opening night to the 12th International Conference, I was reminded of the bigger picture. It is a truly international conference and I was surrounded by dozens of languages, by people from roughly 100 countries. Some 30 million people around the world are thought to be infected with HIV; 90% of them live in developing countries and have limited access to antibiotics, let alone triple and quadruple antiretroviral therapy. Prevention remains the best tool for most of the world, and there are wonderful exhibits and presentations from programs around the world. I am always struck by how much we could learn about sex education, condom promotion and needle exchange from other countries.

Peter Piot, head of UNAIDS gave an impassioned talk in which he reviewed the progress and the disasters of the last two years. It may be posted on the Conference Web site (AIDS98.ch) and if so, is worth listening too.

The good news: Mortality rates in most developed countries are plummeting with modern therapy. Perinatal transmission rates are dropping, and now with short course AZT and agreements from Glaxo Wellcome and Bristol Myers to make their drugs available at a deep discount in developing countries, transmission to children should be preventable in many other parts of the world. Countries such as Thailand and Switzerland have had successful education programs that have decreased the number of new infections.

The bad news: The epidemic continues to be completely out of control. UNAIDS now estimates that 30 million people are infected worldwide – more than 90% live in developing countries. People there would be delighted to have lipodystrophy ("protease paunch") as an issue to worry about. India, Southeast Asia, and the former Soviet States are experiencing explosive outbreaks.

Some of the issues that will be debated at this conference will include whether we are doing the right things to move vaccines forward as fast as possible, how to use antiretrovirals in the developing world, and what that will do to the already scary problem of transmission of resistant viruses.