The Bay Are Reporter - December 16, 1999
Jeff Gustavson/ACT UP Golden Gate Writer's Pool

David Ho, TIME magazine's man of the year in 1996, wrote an essay in that magazine last month that even if an effective vaccine were found, it would take an enormous amount of political will to get it to where it is most needed in the developing world. Some have argued that the lack of infrastructure precludes getting medications to the people in the poorest nations on earth. At a World AIDS Day Event at City Hall, in a moving speech, former East Bay Congressman Ron Dellums spoke about the need to commence the task, rather than fretting about how large it looms. "How do you eat a rhinoceros? One bite at a time." In other words, create the infrastructure at the same time as you are delivering the medicine - don't wait. San Francisco Board of Supervisors' President Tom Ammiano introduced a resolution this Monday that called on the World Trade Organization to "safeguard access to essential drugs, especially HIV drugs, and reaffirm the primacy of public health interests over commercial considerations".

Think ACT UP is irrelevant in the late 90's? Think again. Getting medicine to Africa and elsewhere has been brought to the forefront largely through the efforts of ACT UP\New York and Act Up\Philadelphia. They charged the greed of the pharmaceutical manufacturers was preventing poorer countries from manufacturing the drugs themselves, since they could not afford the exorbitant prices ($15,000 US) of what has become the US and Western Europe's standard of care. They dogged Al Gore on his campaign trail, and got the White House to declare on World AIDS day that "...we will ensure the application of U.S. trade law related to intellectual property, such as Special 301, remains sufficiently flexible to respond to legitimate public health crises...The WTO [World Trade Organization] Agreement on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) allows the flexibility for all WTO Members to respond to public health crises. As a related policy objective, we continue to assist developing countries create the public health infrastructure that will allow treatments to be utilized effectively." ACT UP will monitor the situation to ensure this isn't just more empty rhetoric.

There are ethical issues of international trials which the pharmaceutical industry as well as government-sponsored trials have yet to fully address. The $43 million dollar grant announced recently by the National Institutes of Health to study IL-2 internationally (interleukin 2, a cytokine centrally involved in many pathways in the immune system) has not adequately dealt with the issue of substandard antiretroviral care in countries where it will be enrolling. Notoriously, prevention of mother to child transmission trials have focused on preventing infection of the child while failing to treat the mother's HIV infection. Who do they think will care for all those orphans? Clearly, more oversight is needed.

Think access to medication is just a third world issue? Think again. Across the United States, there are no federally mandated requirements for the implementation of nationally funded but state administered ADAP (AIDS Drug Assistance to Patients) program. This program for uninsured and underinsured persons, delivered in "block grants" to the states, varies widely in its implementation between states. In California, the state has generally made up the difference between monies received from the federal government and the actual demand for the program. Other states, notably in the southeast, have failed to make up the difference where demand far exceeds supply and have instituted a lottery system.

Think we know how to treat HIV in America? Think again. It is still not definitively known when to begin treatment. There are followers of the "hit hard, hit early school", but the pendulum seems to have swung back in the other direction. This is not surprising considering the seriousness of combination therapy's side effects, and the questionable sustainability of years long maximal suppression. Nevertheless, much meaningful data could be mined from existing databases of long-term observational studies.

There are many for whom treatment has failed. The refusal of some pharmaceutical companies to test new antiretroviral medications in this population and still apply for accelerated approval is subverting the intent of that particular reform, fought hard for by ACT UP. Accelerated approval was designed to allow new agents be approved for a life threatening illness where no other treatment existed. Towards that end, the FDA recently sent correspondence to the pharmaceutical stating that "...it is expected that most new drug applications for antiretrovirals submitted under the accelerated approval mechanism will include some clinical data in patients with limited treatment options." This implies that the bar for accelerated approval will be raised higher, as it should.

Think it's easy being positive? Think again. AIDS discrimination still exists. This is perhaps the strongest argument against implementing names reporting in California, one of the last holdouts in the United States. Despite Assemblywoman Carole Migden's twice passing of a bill to require feasibility of a unique identifier system, Governor Wilson as well as Governor Davis have vetoed it. The Centers for Disease Control (CDC) issued new guidelines last week asking states and local public health departments to report all HIV cases. Thirty-five states already have such a system, the majority name-based. UCSF's AIDS Research Institute's Director Tom Coates called this move "a huge mistake" in the Chronicle "because it cannot detect when or where the HIV infections have occurred and surely would discourage many people from being tested or treated". With the CDC system, it would be virtually impossible to approach accuracy due to anonymous HIV testing sites and home testing kits whose use can only be expected to climb in the face of reportability.

Nevertheless, it is estimated that forty thousand new infections occur annually in the U.S., where condoms are relatively available, as is information on safer sex. People for whatever reason seem reluctant to internalize that information. Despite rhetoric about preventing a second HIV epidemic, the first one hasn't ended yet. The rising incidence of multi-drug resistant virus in newly acquired infections points to the necessity of targeting HIV positive people in prevention campaigns without being accusatory.

As the millennium draws to a close, one can only be awed by the enormity of the pandemic. This should not, however, preclude one from getting involved. The AIDS crisis will unfortunately continue to wreak an incredible toll in human suffering, however insulated we may be here in America. ACT UP. Fight back. Fight AIDS.
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