Newsday - July 16, 2002
Laurie Garrett, Staff Correspondent

Ten years ago, it might have been possible to apply straightforward, relatively inexpensive approaches to controlling AIDS. Not anymore.

Today the scale of the epidemic is so immense that scientists find themselves scrambling to imagine what will come next. Political leaders are at pains to imagine where the money to treat and prevent HIV infection worldwide will come from.

The weeklong International Conference on AIDS here was an often bewildering, noisy scene in which all parties craned to hear words of encouragement. But the words they heard were largely grim, and speakers issued challenges rather than solutions. Regardless, the closing speaker called the future "simple."

Dr. Joep Lange of the Netherlands, new president of the International AIDS Societies that sponsors these biennial meetings, said the simple solution is treatment for all, no matter how remote or war-torn their home.

"Do not be fooled," he said. "People make simple things complex to condone inertia."

But the latest AIDS science presented here showed that making progress is far from simple. On the treatment front, numerous studies showed that the use of the combination drug cocktails is becoming more complicated. More American patients are developing resistance to the drugs, or the drugs' toxicity is overwhelming them. Twenty-one new drugs are coming on the market soon, and some appear to pose a lower threat of drug resistance. But increasingly, patients in rich nations are succumbing to heart attacks, researchers said, as the toxic effects of the medicines on their livers boost lipid and cholesterol levels.

The picture of the epidemic is undergoing change as well. In Africa, researchers said, it is becoming a women's disease, as study after study found that females 13 to 25 are as much as 10 times more likely to be infected as are their age-matched male counterparts. The teens and young women, seduced or raped by older men, are shifting the epidemic's demographics so sharply that some forecasters said 70 percent of African HIV cases will be female by the end of the decade.

In Botswana, one in four girls aged 15-19 at pregnancy clinics is HIV-infected.

In China, blood tests five years ago found no HIV prevalence with one exception: a 1 percent rate among drug users. But in 2001, HIV could be found in every province, with prevalences as high as 77 percent among drug addicts in some provinces and 11 percent in prostitutes.

In Russia, where an exploding AIDS problem is blamed on IV drug use, heterosexual transmission is an increasing problem. Dr. Vadim Pokrovsky, director of the Russian Federation AIDS Centre, said that in 2001 only 4 percent of new HIV cases were heterosexually acquired.

But in the first three months of this year, 8.4 percent were heterosexual, evidence that Russia's epidemic may be heading toward an African pattern.

In Ethiopia, an AIDS researcher counted the graves of Addis Ababa. Since 1984, the number of graves filled annually in the city has quintupled. In northern Tanzania, a researcher reported, AIDS "has become a grandmother's disease - they bear the burden," saddled with clusters of orphans, no income and fallow fields.

In India, researchers reported two grim findings. First, genital herpes infection increases the risk of becoming infected with HIV through sexual exposure by almost four times. And researchers discovered that the amount of virus in the blood of an infected person actually peaks only three weeks after infection - a time when most do not realize they have HIV.

During that time, each act of sexual intercourse poses a twenty-fold greater risk to the sex partner than at any other time in the course of the disease.

The most striking news from the laboratory front was a source of despair. Dr. Bruce Walker of Harvard Medical Center reported the case of a patient who received the drug treatment immediately after infection, and his immune system mounted a powerful response, 10 times greater than anything ever produced by any experimental AIDS vaccine. But the man then had unprotected sex and became "superinfected" with another strain of HIV. Even though the virus was almost 90 percent similar to the first one, it managed to overwhelm his immune system.

That was daunting news for anyone trying to make an AIDS vaccine, suggesting that even patients making strong immune responses cannot fight off similar viruses. There are now nine major classes of HIV, with thousands of subtypes in each.

Dr. Stephanie Jost of the University of Geneva offered another case of superinfection, this one involving an HIV-positive volunteer in an AIDS vaccine trial. He initially became infected in Thailand with an Asian strain of the virus in 1998, did well on antiretroviral therapy and then received a vaccination in 2000. He responded well. But then he had unsafe sex and acquired a superinfection involving a Brazilian strain of HIV. The virus level in his blood soared.

When Jost examined the man's cells, she could see that they were individually superinfected, with the Asian HIV and Brazilian HIV sitting side by side.

That finding offers stark challenges not only for vaccine makers but also for scientists who are studying the evolution of HIV. Andreas Meyerhans, a researcher at the University of the Saarland in Hamburg, Germany, found it was the norm that the spleens of infected patients were infected with multiple viruses, usually of different types. And, he said, there is "rampant recombination" going on, as the viruses swap genes.

When HIV replicates, it often mutates, Meyerhans said, making it nearly impossible to predict the pace and direction of HIV evolution.

Two vaccines received attention: One, the AIDSVax, was the topic of a news conference by its developer, VaxGen Inc. of Brisbane, Calif. But results of clinical trials under way won't be available for at least a year. A new trial involving 16,000 people is getting under way in Thailand. The vaccine was originally developed by the National Institutes of Health, which stopped research in 1995 when scientific consensus groups decided it was not likely to be 30 percent or more effective in protecting people from infection.

The other vaccine is Remune, invented during the 1980s by polio pioneer Dr. Jonas Salk. Remune never showed efficacy as a protective vaccine, and its manufacturer, Immune Response Corp., has not sought FDA approval for its use in the United States. Results of a 40-week trial in Thailand, using the vaccine as therapy to treat infection, were presented by proponents who said the drug had lowered virus levels in patients' blood. But a group of scientists from around the world signed a statement condemning the experiments as unethical, saying that it is not effective and that a researcher's partial ownership is unethical.

"Basically, these things are offering people false hope," Cornell University HIV vaccine researcher John Moore said.

So Barcelona ended up being a largely political meeting, filled with calls for the rich world to bail out the poor.

Former President Bill Clinton called for an alliance of past and present heads of state to mobilize against AIDS. "If we can see ourselves in those who suffer and find our freedom in their release," he said, "we will not only change the course of the epidemic, but change the course of history."

Clinton even conceded that he erred as president in not overruling Congress on the issue of needle exchanges to prevent transmission of HIV between IV drug users. Although it is the scientific consensus that such exchanges reduce the spread of HIV, Clinton had ignored the advice of his own surgeon general and blocked funding for such efforts.

Nelson Mandela, 83, the Nobel Peace Prize-winning hero of South Africa's struggle to end apartheid, leaned on Clinton for physical support as he made his way to the dais. He has emerged as the leading political voice on the world stage of AIDS.

"We are told that within the next twenty years nearly 70 million people will die of AIDS unless we take action," Mandela said. " ... This is a tragedy of enormous consequences. AIDS is killing more people than were killed by all the past wars of history and calamities, put together. AIDS is a war against humanity."

He issued three challenges: First, put every HIV-infected person, no matter how poor, on antiretroviral drugs. Second, end stigma and discrimination against people who are infected with the virus: "If we discard the people who are suffering from AIDS, then we can no longer call ourselves people," he insisted.

And third, test every person in the world for HIV infection and, if they're found positive, make treatment available.

The White House made an effort to have a strong presence, sending a delegation led by Health and Human Services Secretary Tommy Thompson, who said the administration's intention was to send a clear message that President Bush is committed to the global fight against AIDS. But the effort backfired, as Thompson became the lightning rod for anger over shortfalls in the wealthy world's donations to the Global Fund Against AIDS, Malaria and Tuberculosis. Thompson's speech was jeered by demonstrators.

The White House also had submitted a poster for presentation. Alongside hundreds of other scientific and analytical posters, it was displayed bearing the seal of the President of the Untied States and stating:

"It must be recognized ... America's health is Africa's health, and Africa's health is America's health. Unless domestic and international efforts are integrated into a global effort, progress against this disease will not be made at the urgent and strategic pace that is necessary."
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