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With tens of thousands of attendees viewing thousands of presentations, the 12th world AIDS conference was held June 27th through July 3 in Geneva, Switzerland. Despite advances in the treatment of HIV infection, presentations at this years conference indicate that there is still a long way to go before progress will be made against the virus on a planetary scale. A proven effective vaccine may be as far as a decade off and it will probably be longer before everyone HIV infected throughout the world has access to treatment.

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The Vaccine Search

There are now over thirty-three million people infected with HIV on the planet. Despite the best efforts of Public Health and Prevention Agencies, new infections of the virus continue to increase at a rate of 16,000 a day.

With so many becoming infected, a safe and effective vaccine remains the Holy Grail of HIV research. Seemingly countless vaccine candidates now exist, with several of them in clinical trials. Unfortunately there was no data to report from Geneva that verified the safety or effectiveness of any of them. Some researchers, such as David Baltimore, who leads U.S. vaccine research, claim that it may be as long as a decade before one of these candidate vaccines is proven to work. Margaret Johnson of the recently formed International AIDS Vaccine Initiative (IAVI) is critical of the slow progress being made in finding a vaccine: "The world is not on track to meet the goal of a safe and effective AIDS vaccine in the next decade."

In an attempt to speed the pace of vaccine development, IAVI announced in Geneva a new plan of action, or "Scientific Blueprint," to accelerate vaccine research outside of current worldwide efforts. "This program will not only put us back on track; it will put us on the fast track," said Johnson. With funding from various sources including Levi Strauss and Microsoft founder Bill Gates, IAVI will set up research teams to speed testing of promising vaccines. IAVI will then make them available to poorer nations where HIV infection rates are especially high.

HIV Treatment Abroad

At the last world AIDS conference in Vancouver, it was hoped that the new treatments for HIV could be made available to poorer countries. This year's conference theme, "closing the gap" was meant as a reminder that this challenge still exists. In fact, the gap between the small number of HIV treatment "haves" in the developed northern continents and tens of millions HIV treatment "have nots" in poorer southern countries is growing larger as treating HIV infection gets more expensive. The estimated cost for a year-long course of triple antiviral therapy is around $14,000. "With our living standard in our country, who can afford that?" asks Ugandan AIDS Educator Elly K. Sendi. Also, with some at the conference, such as David Ho, believing that four drug combos may be needed to stop the virus, the price of HIV treatment could continue to rise.

Lack of antivirals isn't the only problem facing those infected with HIV in the developing world. Clinical monitoring tools such as T-helper cell tests are not easily obtainable. The terms "viral load" was completely foreign to many delegates who attended the conference as these tests are not available for their use. It is almost impossible to get highly priced therapies to treat opportunistic infections such as CMV or MAI. "We don't have drugs such as Gancyclovir or Biaxin to treat O.I.'s," according to Sendi.

Few solutions on how to bridge this gap between the North and South have been found. After much political pressure, the pharmaceutical giant Glaxo-Wellcome lowered the price of AZT to the third world. However, this discount is only available for HIV-infected pregnant woman to prevent transmission of the virus to their children and not as treatment for HIV infection. Even with the discount, the cost for a full course of AZT to prevent mother to infant transmission is still hundreds of dollars . "The price is still far out of reach for millions of women," says advisor to the conference chair Chip Lindner. And with AZT sales declining in the face of growing competition, viral resistance and new questions surrounding its value as a first line therapy, Glaxo's gesture of a price cut is not one that could be called completely humanitarian.

In Geneva, the only program which seemed to offer hope in treating HIV in the developing world was the HIV Drug Access Initiative. The Initiative is a pilot program set up by UNAIDS to properly introduce HIV treatments to poor countries. However, the initiative will be limited, with only five countries receiving clinical support and medications. AIDS activists from all over the globe demonstrated in Geneva Wednesday to demand expanded treatment for developing nations. "World leaders such as Clinton should be playing a significant role in getting these drugs to all who are in need of them," said one U.S. activist, "yet we are lucky to just get Clinton to give us a minor increase in ADAP funding." Without this increased support from the developed world, the future looks grim for tens of millions who are now infected.

HIV Treatment At Home

For those who are fortunate to have access to HIV antivirals, other problems persist. Patients face complicated dosing regimens, increasing drug side effects, and viral resistance to the drugs. Data from Geneva suggests new developments may help alleviate some, but not all, of these problems.

One current trend in HIV drug development is to make antiviral dosing less frequent. Clinicians hope that this will mean better adherence to a drug combination regimen, while drug companies hope that this will make their drugs more attractive to take. Data presented in Geneva showed that once-a-day dosing of the drug DDI (Videx) appears as effective as twice a day dosing. Some protease inhibitors may also be dosed less frequently as long as they are combined with other protease inhibitors (Norvir with Crixivan, or Crixivan with Viracept). Unfortunately, not all the data on these new dosing regimens has been conclusive. Drug levels in the body can vary significantly from person to person, and less frequent dosing could put you at risk of developing resistance if these levels fall too low. On this issue the title of one conference presentation said it all: ''Low plasma levels of Indinavir (Crixivan) are highly predictive of virological treatment failure." Further studies will need to be done to determine if these less frequent dosing regimens can maintain effective drug levels in all people.

New complications

Another subject that has received considerable attention in Geneva has been a side effect caused by protease inhibitors known as "lipodystrophy." Lipodystrophy involves wasting of muscle tissue on the face, limbs and buttocks and an increase in fat on the abdomen, hips or breasts. This condition has been appearing in an increasing number of patients, especially women. Data presented showed some success treating it by the use of steroids or human growth hormone, along with exercise. In addition, there have been a few reports of heart attacks in patients, possibly as a result of increased cholesterol levels due to protease use. Blood lipid levels will have to be carefully monitored in patients on protease drugs, especially for those who have a history of heart disease.

What Goes Around

Perhaps the most frightening news of the conference were data presented on the transmission of drug-resistant strains of HIV from one person to another. One study on 67 newly-infected patients living in Geneva showed that a small number of them had been infected with HIV that was resistant to a variety of reverse transcriptase inhibitors, such as 3TC (Epivir) and Viramune (Neviripine). Several subjects were also infected with a strain of virus resistant to all of the current protease inhibitors. There was also a poster presented the next day on a San Francisco patient who had been exposed to a Crixivan resistant strain of virus by his treatment-experienced lover. The patient was treated with a combination of AZT/3TC and Crixivan, but the combo was ineffective against the resistant virus. This data suggests that unless additional antivirals are forthcoming which can stop these resistance strains of HIV, an entirely new epidemic may emerge in the future.

The latest World AIDS Conference illustrates that the problems that HIV presents the human race continue, like the virus itself, to grow and mutate. Without a vaccine, millions will continue to be infected by the virus, some possibly by drug-resistant virus. Tens of millions of others face death without sustained, effective treatment. The challenge as outlined in Geneva remains enormous.With tens of thousands of attendees viewing thousands of presentations, the 12th world AIDS conference was held June 27th through July 3 in Geneva, Switzerland. Despite advances in the treatment of HIV infection, presentations at this years conference indicate that there is still a long way to go before progress will be made against the virus on a planetary scale. A proven effective vaccine may be as far as a decade off and it will probably be longer before everyone HIV infected throughout the world has access to treatment.

The Vaccine Search

There are now over thirty-three million people infected with HIV on the planet. Despite the best efforts of Public Health and Prevention Agencies, new infections of the virus continue to increase at a rate of 16,000 a day.

With so many becoming infected, a safe and effective vaccine remains the Holy Grail of HIV research. Seemingly countless vaccine candidates now exist, with several of them in clinical trials. Unfortunately there was no data to report from Geneva that verified the safety or effectiveness of any of them. Some researchers, such as David Baltimore, who leads U.S. vaccine research, claim that it may be as long as a decade before one of these candidate vaccines is proven to work. Margaret Johnson of the recently formed International AIDS Vaccine Initiative (IAVI) is critical of the slow progress being made in finding a vaccine: "The world is not on track to meet the goal of a safe and effective AIDS vaccine in the next decade."

In an attempt to speed the pace of vaccine development, IAVI announced in Geneva a new plan of action, or "Scientific Blueprint," to accelerate vaccine research outside of current worldwide efforts. "This program will not only put us back on track; it will put us on the fast track," said Johnson. With funding from various sources including Levi Strauss and Microsoft founder Bill Gates, IAVI will set up research teams to speed testing of promising vaccines. IAVI will then make them available to poorer nations where HIV infection rates are especially high.

HIV Treatment Abroad

At the last world AIDS conference in Vancouver, it was hoped that the new treatments for HIV could be made available to poorer countries. This year's conference theme, "closing the gap" was meant as a reminder that this challenge still exists. In fact, the gap between the small number of HIV treatment "haves" in the developed northern continents and tens of millions HIV treatment "have nots" in poorer southern countries is growing larger as treating HIV infection gets more expensive. The estimated cost for a year-long course of triple antiviral therapy is around $14,000. "With our living standard in our country, who can afford that?" asks Ugandan AIDS Educator Elly K. Sendi. Also, with some at the conference, such as David Ho, believing that four drug combos may be needed to stop the virus, the price of HIV treatment could continue to rise.

Lack of antivirals isn't the only problem facing those infected with HIV in the developing world. Clinical monitoring tools such as T-helper cell tests are not easily obtainable. The terms "viral load" was completely foreign to many delegates who attended the conference as these tests are not available for their use. It is almost impossible to get highly priced therapies to treat opportunistic infections such as CMV or MAI. "We don't have drugs such as Gancyclovir or Biaxin to treat O.I.'s," according to Sendi.

Few solutions on how to bridge this gap between the North and South have been found. After much political pressure, the pharmaceutical giant Glaxo-Wellcome lowered the price of AZT to the third world. However, this discount is only available for HIV-infected pregnant woman to prevent transmission of the virus to their children and not as treatment for HIV infection. Even with the discount, the cost for a full course of AZT to prevent mother to infant transmission is still hundreds of dollars . "The price is still far out of reach for millions of women," says advisor to the conference chair Chip Lindner. And with AZT sales declining in the face of growing competition, viral resistance and new questions surrounding its value as a first line therapy, Glaxo's gesture of a price cut is not one that could be called completely humanitarian.

In Geneva, the only program which seemed to offer hope in treating HIV in the developing world was the HIV Drug Access Initiative. The Initiative is a pilot program set up by UNAIDS to properly introduce HIV treatments to poor countries. However, the initiative will be limited, with only five countries receiving clinical support and medications. AIDS activists from all over the globe demonstrated in Geneva Wednesday to demand expanded treatment for developing nations. "World leaders such as Clinton should be playing a significant role in getting these drugs to all who are in need of them," said one U.S. activist, "yet we are lucky to just get Clinton to give us a minor increase in ADAP funding." Without this increased support from the developed world, the future looks grim for tens of millions who are now infected.

HIV Treatment At Home

For those who are fortunate to have access to HIV antivirals, other problems persist. Patients face complicated dosing regimens, increasing drug side effects, and viral resistance to the drugs. Data from Geneva suggests new developments may help alleviate some, but not all, of these problems.

One current trend in HIV drug development is to make antiviral dosing less frequent. Clinicians hope that this will mean better adherence to a drug combination regimen, while drug companies hope that this will make their drugs more attractive to take. Data presented in Geneva showed that once-a-day dosing of the drug DDI (Videx) appears as effective as twice a day dosing. Some protease inhibitors may also be dosed less frequently as long as they are combined with other protease inhibitors (Norvir with Crixivan, or Crixivan with Viracept). Unfortunately, not all the data on these new dosing regimens has been conclusive. Drug levels in the body can vary significantly from person to person, and less frequent dosing could put you at risk of developing resistance if these levels fall too low. On this issue the title of one conference presentation said it all: ''Low plasma levels of Indinavir (Crixivan) are highly predictive of virological treatment failure." Further studies will need to be done to determine if these less frequent dosing regimens can maintain effective drug levels in all people.

New complications

Another subject that has received considerable attention in Geneva has been a side effect caused by protease inhibitors known as "lipodystrophy." Lipodystrophy involves wasting of muscle tissue on the face, limbs and buttocks and an increase in fat on the abdomen, hips or breasts. This condition has been appearing in an increasing number of patients, especially women. Data presented showed some success treating it by the use of steroids or human growth hormone, along with exercise. In addition, there have been a few reports of heart attacks in patients, possibly as a result of increased cholesterol levels due to protease use. Blood lipid levels will have to be carefully monitored in patients on protease drugs, especially for those who have a history of heart disease.

What Goes Around

Perhaps the most frightening news of the conference were data presented on the transmission of drug-resistant strains of HIV from one person to another. One study on 67 newly-infected patients living in Geneva showed that a small number of them had been infected with HIV that was resistant to a variety of reverse transcriptase inhibitors, such as 3TC (Epivir) and Viramune (Neviripine). Several subjects were also infected with a strain of virus resistant to all of the current protease inhibitors. There was also a poster presented the next day on a San Francisco patient who had been exposed to a Crixivan resistant strain of virus by his treatment-experienced lover. The patient was treated with a combination of AZT/3TC and Crixivan, but the combo was ineffective against the resistant virus. This data suggests that unless additional antivirals are forthcoming which can stop these resistance strains of HIV, an entirely new epidemic may emerge in the future.

The latest World AIDS Conference illustrates that the problems that HIV presents the human race continue, like the virus itself, to grow and mutate. Without a vaccine, millions will continue to be infected by the virus, some possibly by drug-resistant virus. Tens of millions of others face death without sustained, effective treatment. The challenge as outlined in Geneva remains enormous.

Author Profile:  Robert Folan-Johnson
Robert Folan-Johnson is a member of the AIDS Writers Group.
Email:	rofojo@sfac.org