AIDS: Report From the Front

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AIDS activists march in Barcelona demanding treatments for developing countries

After 21 years as the world's most elusive and mysterious killer, the AIDS virus has ended 24 million lives. It's likely to get worse: the United Nations predicts that as many as 70 million could die from AIDS over the next 20 years, leaving 25 million orphans behind by 2010.

These are the grim headlines from the14th Annual International AIDS Conference in Barcelona, where world leaders in research and advocacy gathered this week to celebrate the small victories in the battle against AIDS — and to pool artillery for the coming onslaught. The highlights:

The current climate

The most vocal and angry group of activists anyone's seen in the last five years appeared at the conference. "This meeting was tinged with fear, anger and a great deal of concern over what's happening in Africa and what could happen in other parts of the world," says Dr. Robert Gallo, director of the Institute of Human Virology at the University of Maryland's Biotechnology Institute. Gallo is credited, along with French scientist Luc Montagnier, with pinpointing the link between HIV and AIDS. "I don't want to say there was pessimism, but there was a realization that a lot of the critical issues — like providing follow-up studies and continuing care to the neediest countries — are about policy, and are out of the realm of AIDS scientists."

The conference also marked a shift away from looking for cure and toward finding new ways of prevention "We're going back to the original goal in this fight, which was the preventative vaccine," says Dr. Ronald Kennedy, chair of the department of microbiology and immunology at Texas Tech University Health Sciences Center, and an expert on the spread of AIDS and the search for a vaccine. The fight against AIDS is no longer about wiping out all traces of the virus in the bloodstream, says Dr. Kennedy. Now scientists are focusing on the development of an HIV/AIDS vaccine that behaves like most other vaccines: the virus is purposefully introduced into the body in order to boost immune response, which doctors hope will lower the viral load and prevent AIDS from taking hold in the first place.

While new drug cocktails make living with HIV more of a reality than ever before, millions continue to die, either because they cannot afford that life-extending cocktail, or because they've developed a new form of AIDS that's resistant or non-responsive to existing drugs. Many others will die because they don't believe AIDS is still a deadly disease: recent breakthroughs in treatment means the gut-wrenching fear of the late 1980s has evaporated — and with it, obsessive (and lifesaving) condom use. Today, young people in many developed countries, including the U.S. have seen people live symptom-free for years with an HIV-positive diagnosis. As a result, many are not particularly worried about HIV and AIDS. Rates of youth infection are skyrocketing; the UN estimates as many as half of all new infections occur in young people aged 15 to 24.

Following the money

The big question is money for research and prevention programs, and who should provide the funds. Many activists believe the richest nations should fill up the collection plate. And they made their point loud and clear Tuesday when U.S. Health and Human Services Secretary Tommy Thompson was booed off the stage mid-speech by protesters angry over what they perceive as the U.S.'s lack of commitment to fighting the spread of HIV and AIDS.

In April of 2001, Secretary General Kofi Annan established the U.N. Global Fund to Fight AIDS, Tuberculosis and Malaria. The initial goal was set at $10 billion a year, with contributions pledged by countries around the world. As activists and economists have noted, those contributions are not coming in as fast as might have been hoped — the 2002 figure stands at $3 billion — and some protestors are targeting the European Union and the U.S. for not giving enough. (The U.S. has pledged $500 million to the fund.)

The geopolitics of treatment

The prognosis is worst for residents of Caribbean nations and of sub-Saharan Africa, including Botswana, which has the world's highest caseload. But rates of infection are also on the rise in Russia and China, both of which are predicted to become the next hot spots of the disease. Earlier this month, 15 Caribbean nations agreed to purchase desperately needed AIDS drugs from major pharmaceutical companies — at discounts of up to 90 percent. The companies, including Abbot Laboratories, Bristol-Myers Squibb and Merck decided it was more expedient to strike a deal with the Caribbean as a region, rather than wrangle with the individual countries. Local leaders called the agreement a "major victory" in the fight against AIDS.

This is one happy example of what can happen when drug companies move to assist countries in need. Sadly, there are many countries left without this kind of aid. And until a reasonable compromise can be reached between the financial responsibilities of pharmaceutical companies and the economic realities of AIDS-stricken nations, the best hope appears to lie in the manufacture and distribution of cut-price "copycat" drugs, like those created in India and sold to Uganda's government at drastically reduced prices. Since the introduction of these drugs in Uganda, a country devastated by AIDS, prices for treatments have fallen by 97 percent, according to Oxfam, an international aid organization.

In Brazil, the government has sidestepped drug companies' patent claims by actively promoting generic drugs. Today, Brazilians comprise more than half the 230,000 citizens of poor countries currently taking retroviral drugs. Dr. Kennedy believes this trend will spill over into other countries, including China, creating a surging generic market. It's also quite possible, he adds, that scientists in those countries will simply use samples of the drugs to create their own, far less expensive versions.

There was good news for patients struggling with drug-resistant AIDS; Roche's Enfuvirtide, or T-20, has had great success in two large late-stage trials. The drug is a so-called "fusion inhibitor," which, when added to a patient's larger drug cocktail, reduces the HIV levels found in the blood. T-20's trial performance was better than what researchers had hoped for. But even amidst this positive development, some AIDS experts expressed concern that the drug might have unknown long-term side effects. (The trials lasted just 24 weeks).

T-20 is more effective when used in combination with an existing regimen. Does this rule out T-20 for anyone who cannot afford a very expensive cocktail? "Not necessarily," says Dr. Kennedy. "They will start testing the drug on its own." But for now, T-20 serves little purpose for those in countries without access to costly AIDS drugs.

Meanwhile, American pharmaceutical company VaxGen created quite a controversy by announcing early in the conference that its AIDS vaccine, currently in trials, could come to market as early as 2005. While many activists leapt at the news, scientists and journalists were more skeptical. "Until the trial results are available in 2003," wrote Mark Henderson of the London Times, "we have only the company's word to go on, which is not enough to convince that this is the breakthrough it claims to be." Dr. Kennedy agrees: "I think we've seen a lot of exaggerated claims surrounding this vaccine," he says.

That's not to say there won't be a vaccine some day, says Dr. Gallo. "We'll solve this problem. I will never again make specific predictions, but I believe that despite what some scientists think, we will find a vaccine. And I'll take on anyone with that bet."