Reports From the 14th International AIDS Conference, Barcelona
July 7-12, 2002
At the opening night ceremony, speakers urged the crowd to end 20 years of bickering and unite in a call for a worldwide response to HIV/AIDS. "We did not come to Barcelona to renegotiate promises. We are here to ignite leadership, to keep the promise," said UNAIDS Director Dr. Peter Piot. (Newsday (New York City), 07.07.02, Laurie Garrett)
Unlike the traditional AIDS drug cocktail that inhibits the division of already infected cells, T-20 keeps the HIV cell from fusing with healthy cells. When added to combinations of standard drugs, injections of T-20 significantly reduced high levels of HIV in the blood of patients deemed infected with drug-resistant virus, compared with those who took standard drugs.
In one study, the amount of HIV in the blood fell to recommended levels in 121 of 326 patients (37 percent) among the T-20 recipients compared with 27 of 165 (16 percent) among those who did not receive T-20. In the second study, the comparable figures were 95 of 335 T-20 recipients (28 percent) and 23 of 169 patients who did not receive T-20 (14 percent). The T-20 combination also led to an increase in the number of CD4 white blood cells. The studies involved 1,000 patients at 112 hospitals in the United States, Europe, Australia and South America.
AIDS experts welcomed the news about T-20. They have long pleaded for pharmaceutical companies to develop a new class of drugs to help extend the lives of the thousands of patients who are infected with drug-resistant HIV. Dr. Anthony S. Fauci, the director of the National Institute of Allergy and Infectious Diseases in Bethesda, Md., said the trial findings "are important because they are proof of the concept" that fusion inhibitor drugs can work. The trials, Fauci said, "were meticulously done by meticulous researchers."
The Food and Drug Administration has given T-20, manufactured by Roche, fast-track designation, meaning that the FDA will expedite review of applications for drugs that have the potential to fill gaps in treatment of life-threatening diseases. If licensed, T-20 would become the fifth class of HIV drugs approved for standard use. "That would greatly broaden therapeutic options," for fighting AIDS, Fauci said.
T-20 is a synthesized version of a protein known as a peptide, made up of amino acids. It was developed by Trimeris and Roche from a discovery that Dr. Thomas Matthews and Dr. Dani Bolognesi made at Duke University in 1992.
Once started, lifetime treatment of HIV is needed. But because T-20 trials lasted 24 weeks, the long-term benefits and dangers of the drug are not known. In addition, T-20 has a drawback in that it has to be injected under the skin twice daily. The most frequent adverse effect of T-20 was a skin reaction at the site of injection. A number of T-20 recipients also experience diarrhea, nausea, dizziness, fatigue, insomnia and headaches.
Roche officials plan to file for approval of T-20 this year and are expected to manufacture enough of the drug to allow expanded use on a compassionate basis later this year. (New York Times, 07.09.02, Lawrence K. Altman)
A sobering assessment of current drug therapy was delivered by Dr. Robert Siliciano, an AIDS researcher from the Johns Hopkins University School of Medicine, who said that even in patients in whom the virus has been suppressed by drugs to below-detectable levels, the body still has a "latent reservoir" for HIV that "guarantees lifetime persistence of the virus and makes the disease intrinsically incurable with antiretroviral therapy alone. I realize this conclusion is a hard one to hear. But I think it's a disservice to persons living with HIV to ignore what the science is telling us." Still, Siliciano offered hope, saying the same science is revealing that antiretroviral drug cocktails are able, under optimum circumstances, to "completely stop virus evolution, making permanent suppression possible." (Miami Herald, 07.09.02, Fred Tasker)
When to start treatment is one of the most difficult medical decisions HIV-infected people face. The pills can be life-sustaining, but they have to be taken regularly, can change one's physical appearance, are expensive and are occasionally dangerous. When triple-drug therapy began in 1996, doctors recommended early, aggressive treatment. Early treatment was later abandoned as it became clear that the drugs often work well in relatively advanced cases but can never cure the infection, even when used early. The federal government's current recommendation is to start treatment when the CD4 count falls below 350.
In one study, Alvaro Munoz of Johns Hopkins University's Bloomberg School of Public Health compared the experience of people who started triple therapy when their CD4 counts were below 200 to those who began triple therapy with counts between 201 and 350, and between 351 and 500. Normal CD4 count is about 600 to 800.
Munoz and colleagues measured the time people stayed healthy and free of AIDS after starting therapy, compensating for the fact that people who started with high CD4 counts were likelier to have longer AIDS-free survival than those who started with lower counts because it takes time for a count to fall. Their results showed that it was detrimental to defer treatment until the CD4 count was below 200. But there was almost no difference in outcome between people starting treatment when the CD4 count was 201-350 and those starting it at a count of 351-500. A study presented by Genevieve Chene of Bordeaux, France, found a similar outcome. She and her colleagues examined the experience of about 12,600 people taking antiretrovirals, comparing when they started treatment, how they acquired the infection, and other variables. (Washington Post, 07.10.02, David Brown)
Over two years, Walker treated 14 patients with HIV drugs immediately after infection for a few weeks, then took them off the medicine to allow their immune systems a chance to detect the viruses as they surged out of hiding. One of those patients, a gay Boston man, went through two rounds of on/off medication and seemed to be doing extraordinarily well.
But in one month's time the virus's replication surged, and when genetically analyzed proved to be 12 percent different from the type of HIV in the patient just 30 days earlier. The patient's immune system was suddenly helpless in the face of this apparently new HIV.
The patient said he had recently had unprotected sex with a male partner. The patient was superinfected with another virus, 88 percent identical to the first, Walker said. "He never got a new response against the second virus, and he declined clinically," Walker said. "The public health implication of this is that it is possible to become infected with a second strain of HIV, even a very closely related one."
Vaccine researchers assumed that an effective vaccine would have to be made up of samples of each of the major seven or eight classes of HIV now circulating around the world. But Walker's patient was infected with two viruses from the same class, genetically very similar. "The strength of the [patient's] cellular immune response at the time of exposure was substantially greater than you get from vaccination, but it could not prevent infection," said John Moore, a Cornell University AIDS vaccine researcher. "This case, albeit anecdotal, has shattering implications for the development of a prophylactic vaccine."
A protective vaccine potentially containing hundreds or thousands of viral samples would be impossible to test and manufacture and may not be tolerated by human beings. Dr. Margaret Johnson, head of the National Institutes of Health's AIDS vaccine program, noted that nobody really knows how common superinfection may be. (Newsday (New York City), 07.11.02, Laurie Garrett)
Structured treatment interruptions are a subject of debate among AIDS researchers. With results of several studies mixed, however, most researchers think the approach cannot currently be recommended except under closely monitored conditions.
The French team studied a group of 68 patients who had exhausted all currently available HIV drug therapies. Eligible patients had to have more than 50,000 copies of the virus per milliliter of blood and CD4 counts below 200 cells per microliter. Half the study group were immediately given a "salvage" therapy including as many as nine antiretroviral drugs, while the other half were given an eight-week break before starting the rescue treatment.
More than half of the patients in the deferred treatment group became responsive to at least one class of drugs they had previously been resistant to, Katlama reported. Interrupting the treatment seemed to have no adverse effects, she added, but the patients were already very sick.
The amount of virus in the blood of patients who did not have treatment interruption remained constant for 24 weeks after the study began. In contrast, viral levels in those who had a break in treatment dropped by a factor of ten after 24 weeks of resumed drug therapy. (Reuters Health, 07.10.02)
The study reports that one-third of all children in sub-Saharan Africa who have lost a parent have lost him or her to AIDS. In 2010, about half of all parent losses will be attributable to AIDS. The third such report since 1997 enumerates both children who have lost one parent ("orphan") and children who have lost both parents ("double orphan"). It is the first report to reflect more detailed demographic data and to determine the fraction of parental loss worldwide due to the disease. "This is one of the most shocking reports released at this conference," said Peter Piot, director of UNAIDS.
There are 108 million orphans from all causes in Africa, Asia, Latin America and the Caribbean. That makes up about 7.4 percent of all children in those regions. The proportion orphaned by AIDS is 12 percent. The long lag between HIV infection and death from AIDS virtually guarantees an increase in orphan numbers. "Even if by some miracle the spread of the AIDS virus stopped today, the number of orphans would still rise for a decade," said Anne Peterson, a USAID official. (Washington Post, 07.11.02, David Brown)
More than 90 percent of the world's HIV-infected people live in developing countries; 70 percent live in sub-Saharan Africa. A study released at the conference predicts that in less than a decade, many southern African countries will have average life expectancies of about 30 years; in Botswana, the figure will be 26.7 years. "How can you create a future for a country when the life span is 27 years of age?" said Paul De Lay of the HIV/AIDS office of the US Agency for International Development.
Protesters -- some of whom disrupted a speech Tuesday by US Health and Human Services Secretary Tommy Thompson -- claimed that European countries contribute up to 25 times more per capita than the United States to the Global Fund to Fight AIDS, TB and Malaria. Responding to Thompson's suggestion that the United States was doing its share, Columbia University economist Jeffrey Sachs said, "For everybody to be doing their share is not enough."
An Oxfam study said that many of the hardest hit countries are spending more on foreign debt repayments than on health care. Study author Kevin Watkins said $1.6 billion in debt relief would free up significant revenues that could be spent on AIDS programs.
Some pharmaceutical companies have slashed prices on AIDS drugs but refuse to give up patents to allow manufacturers in poor countries to make generic versions. Martin Sutton of GlaxoSmithKline said scrapping patents would eliminate the incentive to do further research. (Associated Press, 07.11.02, Jerome Socolovsky)
Clinton called on governments of rich countries to "figure out what our share is" of the yearly $10 billion the UN says is needed to finance the global AIDS fight. He called on America to increase its spending by nearly $2 billion, which would amount to "less than two months of the Afghan war, less than 3 percent of the requested increase of defense and homeland security budgets."
Mandela, who had tuberculosis while imprisoned during his nation's apartheid era, noted that AIDS is claiming more victims "than all wars and natural disasters. AIDS is a war against humanity ... this is a war that requires the mobilization of entire populations." He called for access to HIV drugs "for all those that need it, wherever they may be in the world, regardless of whether they can afford it."
As the largest-ever HIV/AIDS conference drew to a close, experts said more determination and more money must be devoted to the worldwide war against the epidemic if HIV is to be thwarted. Issues that dominated the weeklong gathering, which drew 15,000 people, included the need to get drugs to more people, the plight of women in HIV-ravaged nations, and determining how much the efforts will cost during the next decade. Seth Berkley, president of the International AIDS Vaccine Initiative, called the conference "a splash of cold water" on how the world is doing in the fight against AIDS. (Associated Press, 07.12.02, Emma Ross)
Programs that once seemed inconceivable will commence within the coming months. They will include efforts to massively increase AIDS prevention; to bring AIDS drugs to hundreds of thousands of people in the world's poorest countries; to create a global arbiter of AIDS spending; and to extract billions of dollars annually from the world's wealthy nations.
There is a dawning realization that what has been done to fight the epidemic in wealthier nations can probably be done anywhere. "If we can get Coca-Cola and cold beer to every remote corner of Africa, it should not be impossible to do the same with drugs," said Joep Lange, president of the International AIDS Society.
In the two years since the conference was held in South Africa, much more has been learned about successful strategies for prevention in high-prevalence areas. Guidelines for three-drug antiretroviral therapy have been simplified to the point at which there is essentially no setting too poor to use them if they are available.
The price cut agreed to by five pharmaceutical companies (later joined by a sixth) is generally considered the event that began to move rhetoric toward action. Despite reducing the price of drugs in poor countries to one-tenth their cost in rich ones, health economists believe the price must fall further to about $30-40 a year before their cost ceases to be an impediment.
Also generating world resolve is the Global Fund to Fight AIDS, TB and Malaria, which currently has $2.1 billion in pledges. The fund will be forced to arbitrate on many levels, and much of the success or failure of global AIDS efforts will rest with it. Still, its power to unify is immense. Mexican Health Minister Julio Frenk called on middle-income countries to contribute as well. "It has to become truly a global effort where everyone participates," he said. (Washington Post, 07.14.02, David Brown)
This article was provided by Body Positive. It is a part of the publication Body Positive.