Durban: Between the Lines
This year's XIIIth International AIDS Conference in Durban, South Africa was not the typical AIDS conference. Because of the pressing social needs faced by developing nations, the emphasis of the meeting was not primarily directed toward biomedical research and studies. Instead, the main topics of discussion included human rights, reducing the stigma faced by people living with HIV, prevention, vaccine research, access to care, reduced drug pricing and building medical and social infrastructure. Still, medical research was not ignored. This issue of PI Perspective represents a summary of some of the most significant findings presented at the conference. Topics include anti-HIV research, treatment interruption studies, women-specific issues, side effect warnings and the first ever report on the medical use of marijuana in people with HIV.
Some of the most important clinical care findings were discussions about strategies for combating HIV disease. New data were presented giving support to the notion that anti-HIV strategies need not always include a protease inhibitor, or even a non-nucleoside RT inhibitor like nevirapine (Viramune) or efavirenz (Sustiva). Instead, the new data suggest that the number of potent drugs in a combination (a minimum of three), rather than the mix of drug classes or the specific drugs, may be the critical factor in achieving success. See the article of Anti-HIV Drugs Update of this issue for a description of studies showing good, if preliminary, results from simple combinations of three nucleoside drugs. One such triple drug combination will soon be available in a single pill, two of which are taken twice daily as a person's complete anti-HIV regimen.
A critical wrinkle in treatment strategy is the growing debate about the proper time to start therapy. Though researchers at the Durban Conference only presented two new observational studies rather than rigid controlled studies, one seemed to support the notion that delaying treatment until relatively later stages of HIV disease can be done without harm. If so, this may shorten the time when a person is exposed to the risk of drug side effects or developing resistance to existing drugs while also reducing the overall cost of treatment.
Following shortly behind this discussion is a debate about the proper time to change therapy. Conventional wisdom for the last four years has argued that a person should change therapy as soon as viral load becomes detectable or begins to rise significantly. More recent studies have begun to question the necessity of this approach, which, if nothing else, accelerates the rate at which people cycle through the limited list of available drugs. More discussion of this topic will come in issue 32 of PI Perspective.
Several new approaches were reported to the subject of STI (Structured Treatment Interruption). One even has a new name, called "Structured Intermittent Therapy," though it is still just an extension of the existing STI concept. The National Institute of Allergy and Infectious Diseases latest studies are testing simple, short cycles of treatment in hopes of perhaps reducing the cumulative risk of side effects, increasing ease of adherence and lowering the cost of treatment. A European group offers a peek at early data from a study in which people repeat several cycles of "eight weeks on, two weeks off" treatment, followed by withdrawal of further treatment until viral load exceeds 5,000 copies of HIV RNA or a 25% drop in CD4+ cell count. These are described in the article on Structured Treatment Interruptions.
A long awaited, first-ever US study of medical marijuana in people with HIV was widely misreported in the media, which claimed that marijuana use had been proven safe for people with AIDS. See the article on Medical Marijuana for an accurate picture of what the study did and didn't show.
While concerns about the human rights, social needs and role of women in the epidemic dominated the conference's attention to women's issues, some groups reported new findings on treatment and opportunistic infections in women. Evidence was offered that hepatitis C virus (HCV) can be transmitted in childbirth and from a mother to child through breast-feeding, adding to the already widespread discussion of breast-feeding issues and HIV. During the conference, much of South Africa reverberated with a debate about how best to slow the currently out of control rate of mother-to-child HIV transmission.
An interesting study of the use of prednisone to try to prevent rashes associated with the drug nevirapine served as a reminder to all that things aren't always the way they seem. It has long seemed obvious to try to reduce the risk of nevirapine rash with prednisone, since prednisone is routinely used to treat the rash when it occurs. For the surprising finding of this study, see the related article.
CommentaryDespite its weaknesses and unsolved problems, AIDS research is continuing to make progress against the disease. The far bigger task before us today, perhaps, is to overcome the economic and social barriers that prevent progress from being available to all those living with HIV.
Despite the early perceptions that the Durban conference would disintegrate into a shouting match between AIDS specialists and a tiny worldwide group of so-called "AIDS denialists," once the conference opened the collective wisdom of all those who contributed to it prevailed. The spotlight of world attention was turned away from a few disturbing characters pursuing their own publicity and instead focused on the devastating need for care, treatment, prevention, increased human rights and public health infrastructure for millions of people in developing countries now living with HIV.
In light of past failures to cope with more manageable diseases such as malaria and TB, it is clear that to bring the problem of HIV under control the healthcare delivery systems in developing nations and the apathy of developed nations must be addressed. Either the world pulls together to help solve these problems or we will all continue to live with the consequences. Can we sit by and watch whole nations wiped out from disease? Can we afford to ignore a plague that will do more damage than centuries of warfare in but a few decades? Every person on the planet who is unwilling to accept such outcomes must find a way to contribute to the solution.
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