• Keynote: Evolution of treatment and treatment strategies (MoOr8)
  Speaker: S. Vella (Italy)

• Keynote: Evolution in prevention interventions and strategies (MoOr9)
  Speaker: R. Parker (Brazil)

• Keynote: What does the future hold? (MoOr10)
  Speaker: S. Bertozzi (Mexico)

Keynote: Evolution of treatment and treatment strategies (MoOr8)

Stefano Vella discussed the evolution of HIV treatment and treatment strategies. Since the introduction of antiretroviral therapy, there has been a dramatic decrease in AIDS mortality. This change has been possible due to the research concerning the basic biology of HIV, which made possible the development of antiretroviral drugs. These drugs, when used in combination, can completely block viral replication.

Vella discussed the different paradigms we've gone through to treat HIV infection over the past 15 years. He reminded us how, with each step forward, we have also encountered problems. AZT monotherapy, as we all know now, turned out to be no better than having no treatment at all in the long run. Vella also mentioned how double nucleosides improved patients' outcome and was at one time recommended, but how -- to our disappointment -- we discovered this was also misleading. After that we discovered how triple-drug therapy was able to completely block viral replication, which prevents viral evolution and the development of resistance. By this point we had become so hopeful that we even thought we would be able to soon eradicate the virus. It did not happen, as we all know. In spite of this, treatment progress has been remarkable and patients are doing much better. But this success has been plagued with a multitude of problems, including difficulties with adherence, virologic failure, and drug-associated toxicity.

Vella reminded us that we need to focus on long-term strategies and work on answering such questions as when it is best to start therapy and which drugs should be used. We clearly need new drugs better than current ones, drugs directed at multiple targets. We need strategies to purge the reservoirs and to develop immune interventions to restore immunity against HIV. Vella mentioned the idea of pulsed therapy as a possible strategy to move forward and to close the gap between the north and the south.

Keynote: Evolution in prevention interventions and strategies (MoOr9)

In this keynote address, Parker discussed the evolution of prevention strategies. Initially, he reminded us, prevention energies were focused on strategies to change behaviors of what we considered "high-risk populations." But we learned quickly that changing behaviors is complicated and that the efficacy of interventions with this target in mind was quite limited. Information and education are insufficient to change behaviors. In the late 1980s, we began to realize that social and cultural factors were as critical as individual factors. Since then, interventions have become more social and collective in nature, culturally appropriate and community-based. Structural factors related to the spread of the epidemic like poverty, exploitation, gender inequity, sexual discrimination, and racism and other forms of social exclusion have become the targets of those interventions.

The implications of this knowledge has led to the development of more global interventions such as plans for increasing employment and access to drugs -- knowing that those interventions could have a much more significant impact on the HIV epidemic than interventions at the individual level. HIV prevention will have to focus in the future on decreasing vulnerability of societies to AIDS and correcting the inequities in our world between the rich and the poor.

Keynote: What does the future hold? (MoOr10)

In this keynote address, Bertozzi was asked to look in a crystal ball and discuss the future, particularly in South Africa (he served in President Mbeki's committee on AIDS). He stated that the silence about AIDS will be broken (the theme of the conference) -- no matter what anybody thinks about it. The short future can be predicted from what we know from the virus: in South Africa the mortality rate among young individuals has gone up four or five times. In 2002 there will be 250,000 deaths because of AIDS, doubling in the following years. The figures are overwhelming and really too big to comprehend. In the long run, the future unquestionably will bring massive political and social mobilization. The big question is when it is going to happen. The midterm requires adequate political leadership or half of the population of South Africa will surely die because of AIDS. Massive responses are necessary. The current disjunction between the perception and the reality of the infection has to change. What can be done? He suggested massive community-level testing and enhanced support of HIV-positive individuals would lead to demands of prevention. He also recommended large programs aimed at preventing mother-to-child transmission and also a focus on education programs at the high school level.