The Bay Area Reporter - October 30, 1995
William Snow, ACT UP/Golden Gate Writers Pool

At an optimistic press conference in 1984, then-Health and Human Services Secretary Margaret Heckler announced discovery of the HIV virus and forecast that we would have an AIDS vaccine within five years. No Jean Dixon, Heckler will probably only be remembered for this incredibly wrong-headed prediction. Through the intervening 11 years - the average length of an HIV-infected person's life - and into the foreseeable future, it's been a slow and haphazard struggle for science, industry, and government toward a vaccine to prevent HIV infection or disease, which is turning out to be extremely difficult. The same decade has seen a rapid spread of HIV throughout the world, with young men in our community becoming infected again at an alarming rate.

As we learn more about how quickly and how thoroughly this virus establishes itself, and how actively the virus reproduces in spite of consistently strong immune responses, the less likely eradication of HIV from an infected individual becomes. Although we may be able to tip the balance toward the immune system by controlling the virus better with antiviral drugs or manipulating the immune system, we are far from a cure or having a manageable chronic disease yet.

Some have argued that behavior modification alone can be used to conquer AIDS. The recognition of how difficult it is to control transmission through educational programs has led to major investment in behavior research. A great deal of resources have gone into slowing the spread of the virus by modifying risky behavior. Despite these efforts, costing $1.5 billion per year globally, the World Health Organization estimates that millions more will become infected by the year 2000. Here in the gay community we are groping not very successfully for techniques that work better than what we've got, while infection rates are not going down. Scientists conducting the Multi-Center AIDS Cohort Study recently concluded that a 20-year-old gay man has a less than 50% probability of remaining HIV-negative during his lifetime.

Preventive vaccines are the most effective medical intervention there is. This is dramatically demonstrated by the total eradication of smallpox. There has not been a single naturally acquired case of smallpox since 1977 anywhere in the world. Vaccines have been developed for many diseases that were once major afflictions of mankind, though none of these vaccines were easy or fast to develop. And vaccination is generally many times cheaper than treating an illness, better for the individual and the society, and can be made available to the poorest parts of the world.

The report from an international meeting on the development of preventive HIV vaccines for the world, sponsored by the Rockefeller Foundation in 1994, states that "development and distribution of a safe, effective, and inexpensive vaccine to prevent HIV infection probably represents the best hope of controlling the global HIV/AIDS pandemic."

"Protective immunization, the strategy that has been the principal one for the control of all other viral diseases, is virtually the only modality that is likely to offer the possibility of control and elimination of HIV infection and AIDS," says Dr. William Paul, Director of the NIH Office of AIDS Research.

The real difficulties

AIDS vaccine development faces difficulties far greater than those encountered with other infectious viruses against which successful vaccines have been developed. Since we have no hard proof of anyone being protected from HIV exposure, or recovering from HIV infection, there are some who even question the possibility of making a vaccine, but the Division of AIDS of NIH believes very strongly that a safe and effective vaccine can be developed.

In spite of the many scientific challenges to developing an effective vaccine, and the incredibly valuable outcome, in 1993 less than $160 million was spent worldwide on HIV vaccine research and development, which is less than ten percent of the total amount spent on HIV/AIDS related research and development, a fraction of the amount spent on HIV prevention and HIV-related health care, and a very small fraction of the amount spent overall on health research. Government is the main source of funding for HIV vaccine research and development, with about 75% of that ($120 million) by the U.S. National Institutes of Health. We need more investment at the scientific level to understand how a vaccine could work.

The resources that have been invested by industry in the development of preventive HIV vaccines have been targeted predominantly at those approaches perceived as being safest and have been based on the sub-type of HIV found in the U.S. and Europe. The safest, most marketable approaches may not work; we need to pursue all approaches full steam ahead. Many vaccines were developed through trial and error, without knowing exactly if or how they would work. We need more investment and incentives at the industry level to develop alternative vaccine strategies that can be tested.

At an individual and community level, no vaccine is 100% effective, so even an excellent vaccine down the line would not eliminate the need for safe sex. Nevertheless, even a small reduction in transmission can have a large impact on the epidemic as a whole. There is even a point (known as herd immunity) where transmission becomes so unlikely that the virus would die out even if everyone is not protected. This is a goal well worth working toward.

Vaccine vs. treatment research?

A charge has been raised in the press that AIDS activists have ignored, or sabotaged, vaccine research in the interest of treatment research. It is true that the vaccine program is the smallest element of the NIH HIV-related research budget, but in fact, the problem is that vaccines have had no natural constituency to advocate for them. The at-risk communities need to become involved, including the community-based organizations involved in other prevention efforts, and AIDS treatment activists. Nothing will be lost by trying to prevent and cure this horrible illness.

Larry Kramer, never one to mince words, calls the AIDS plague genocide, and says that we've been allowed to get infected and die because of who we are. Is the lack of emphasis on preventive vaccines an indication of that?

Scientists now believe that it will take a series of candidate vaccines being tested, going well into the 21st century, to develop a truly effective vaccine. Widespread support for this effort would focus attention on the process and could shorten it. We need to be prepared to support this long-haul effort, while looking out for the interests of ourselves and our community.

Following articles in the months to come will look at lessons to be learned from other vaccines, scientific challenges, risks, and legal/ethical challenges of an AIDS vaccine.

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