Barcelona comments.

The XIV International AIDS Conference, July 712 in Barcelona, Spain, was the biggest AIDS conference ever, with more than 15,000 people and more than 10,000 research, program, and other reports presented. Some have wrongly concluded that little important medical or scientific information was included. But it can be hard to find what you need, so we will continue to point to the best and most accessible reviews as new ones become available.

But first, here are some (not all) of the important take-home messages, as we see them:

* Clinical care. Lots of information will affect treatment of patients over the next several years--including new drugs, better ways to use existing drugs, and better understanding of why HIV treatment is difficult. For example, the approved drugs efavirenz and tenofovir, and T-20, which should be approved within a year, continue to look good. For a link to in-depth clinical information, see "Barcelona Conference: New Online Report" in this issue.

Incidentally, T-20 is expensive to manufacture--and there are likely to be serious equity issues in who gets access within the U.S. But we doubt that there will be major access issues in developing countries. This is because T-20 is injected twice a day, and therefore is likely to be used only by those who need it because they have developed extensive viral resistance to other HIV drugs. So few people in developing countries have received any antiretroviral treatment that there is not likely to be much need for T-20 for several years. By that time there should be other new antiretrovirals that can be provided more easily.

* Vaccines--What's Missing on Faster Testing? The discussion we have seen from the Barcelona conference has missed what may be the most important practical fact about vaccine development--that by far the fastest way today to develop a preventive vaccine is to test candidates as therapeutic vaccines first. This is because therapeutic vaccines can be tested in weeks in a handful of HIV-positive volunteers during structured treatment interruptions, to see if they show any anti-HIV effect by delaying the return of the virus humans. But getting any idea of whether a preventive vaccine works takes thousands of people in trials that run for years. (There were a handful of presentations on therapeutic vaccines in Barcelona--including DermaVir, a vaccine designed to be applied to the skin, that could begin human trials this fall.)

Eventually the development paths for preventive and therapeutic vaccines may diverge. But this has not happened yet, because so much is still unknown about immune protection from HIV.

Scientists now can measure a seemingly endless number of potential immune responses--and often can stimulate these responses in human volunteers with vaccine-like treatments. The problem is that we don't know which immune responses actually help to protect against HIV (and we may know less after the Barcelona conference than we thought we knew before). If we had a vaccine that would greatly reduce the return of viral load after antiretroviral therapy was stopped, that would not prove it would protect against initial infection; additional tests would still be required. But such a vaccine would be a much better candidate for a preventive trial than any we now have. Therapeutic vaccine testing can quickly screen many ideas, allowing for successive improvements in basic science and in products alike, greatly advancing the search for a preventive vaccine.

And although it is clearly a setback for vaccine development, we are not too worried by the news that a person's immune response to HIV infection may not protect against another HIV infection. We know that the immune system does largely contain the virus in early infection, so immune control of HIV is possible. And vaccines can be engineered to produce many immune responses that natural infection usually does not produce.

* Global epidemic. The biggest need now is to prevent India, China, Indonesia, Eastern Europe, and other large population centers from developing major epidemics like the one in Africa, which could ultimately kill a quarter of the population or more--especially parents, and workers in their most productive years. These epidemics are already in their early stages. They could be mostly stopped if the proper steps are taken now--but while proven prevention programs exist, they are not being scaled up in most countries, due to lack of leadership and the resulting lack of resources. If current trends continue, the number of people killed or otherwise affected will be far larger than in Africa, because the population is greater.

For an in-depth look at a world epidemic much worse than many people thought even recently see the UNAIDS Report on the Global HIV/AIDS Epidemic, July 2002. Epidemics that were thought to be leveling off because they were running out of new people to infect have instead increased to levels that were not thought possible. (Links to this report and other UNAIDS information are at: http://www.unaids.org/whatsnew/newadds/index.html. The links are in chronological order; this report is one of several published July 2, 2002.)

Also from the United Nations, an expert panel recently convened by UNAIDS and WHO estimated that just expanding the prevention successes already achieved in some countries could prevent two thirds of new infections save 29 million lives by 2010. But a three-year delay in acting would reduce the effectiveness by 50%. (The report, "Can We Reverse the HIV/AIDS Pandemic with an Expanded Response," was published in The Lancet, July 6, 2002. A July 3 press release and link to a downloadable copy are at: http://www.unaids.org/whatsnew/press/eng/pressarc02/Lancet_040702.htm l. These can also be reached through the "whatsnew" link above.)

* Treatment access. Only 30,000 people in Africa are now receiving antiretroviral treatment (less than 1% of those who clearly need it). On the positive side, many new programs are expected to start in the coming year, so this number should be considerably higher next year. Also good news is the strong consensus that treatment needs to be part of prevention, which gives people a reason to be tested and to fight against the stigma that stops so much of what needs to be done. Most experts now agree that condemning almost everyone with HIV in developing countries to death on the grounds that prevention is more cost-effective than treatment will not work as prevention in the real world. (A less obvious factor is that the great majority of those who need treatment will not get it anyway, no matter what we do; for example, most of those who are infected do not know it, and do not want to be tested. Policies can give or deny hope without suddenly requiring enormous resources for treatment.)

* Leadership and Resources. By different groups' estimates, the public money needed to control AIDS, tuberculosis, and malaria around the world would be about ten billion dollars ($10,000,000,000) per year. This is less than Africa alone pays on debt service every year (which is over $14,000,000,000). The share of this money needed from the U.S. and other rich countries to control these three epidemics worldwide would be about the cost of a movie and a bag of popcorn for each person once a year. People are willing to pay this but world leaders are not ready to move. So opportunities to control HIV epidemics in their early stages are being lost forever.

Also, despite much progress, intellectual-property rules and trade restrictions do remain a problem on the ground, and are still keeping treatment away from many people in Africa and elsewhere who would otherwise have a possibility of getting it--a human sacrifice which in this case does not add one dollar to the funding of research for new treatments in the future, the reason cited for justifying the pharmaceutical patents in the first place. Other major access problems include unworkable distribution systems, uncoordinated regulatory requirements throughout much of the world, and of course lack of medical infrastructure.

The greatest disappointment from Barcelona is that most of the governments of the world, led by the U.S. government, are still not serious about dealing with the epidemic. President Bush set the tone for the U.S. (and therefore other rich countries) shortly before the Barcelona meeting, by killing a serious effort in Congress to move forward on global health--replacing it with a speech about saving babies by preventing mother-to-child transmission, which everyone already supports. It is generally believed that most European and other countries use the U.S. government's seriousness (or lack of it) as a benchmark for their own commitment on the worldwide epidemics of HIV and other diseases. There is widespread concern that once again, top leaders will downplay the problem until the bodies pile up, and as much as a third of the population in some of the worlds' largest population centers already has an incurable infection.

Could we do better at asking for resources? At organizing grassroots support everywhere for AIDS control around the world? Of course.

Former presidents Nelson Mandela and William Clinton addressed political issues in their talks during the closing ceremony. Both focused most (and in different ways) on the problem of AIDS stigma. But here we selected short quotes focusing mainly on leadership.

Mandela

"There is no doubt that strong leadership is the key to an effective response in the war against AIDS. Leadership starts at the top. When the top person is committed, the response is much more effective.

"This means not only political leaders, but also business leaders, union leaders, religious leaders, traditional leaders, and the leaders of NGOs. One has to make special mention of the role played by NGOs and the leadership in those organizations. These are often small organizations with meager resources that have made an impact far beyond what would have been expected from their size. One is often moved to reflect that, if only the big institutions of government and business had made a similar effort proportionately, we might very well already have turned the tide of the AIDS pandemic." (Former president Nelson Mandela, Barcelona, July 12, 2002.)

Clinton

"The first responsibility of leaders in the AIDS epidemic, in my view, before they seek new funding, or launch new initiatives, or expand treatment and prevention--their first obligation is to make the case loudly and repeatedly that AIDS is not a threat against people of a particular group or country or continent; AIDS is a threat against all of us. The AIDS epidemic has been so devastating so quickly because it has exploited our worst human instinct--the instinct that demonizes, or at best is indifferent to, people we see as different. We were slow to act on AIDS because the wealthier, more powerful people in the world saw people with AIDS as different. They're sex workers; they're drug addicts; they're poor; they're gay; they're from another country, another continent, another race. We're not from another race; we're from the same race--the human race. We need to get this right today. Tomorrow may be too late."

(Former president William J. Clinton, Barcelona, July 12, 2002.)

Recordings and transcripts of both talks are at: http://kaisernetwork.org/aids20O2/webcast_12_a.cfm