San Francisco Chronicle - Friday, July 12, 2002
Sabin Russell, Chronicle Medical Writer

On Thursday, the penultimate day of the 14th International AIDS Conference, a veteran of the worst years of the epidemic in the United States decried the world's current failure to muster some of the earliest weapons found to work against the disease: condoms.

"Condoms are neither under patent nor expensive and should not be in short supply in the world," said Dr. James Curran, who headed the federal Centers for Disease Control's anti-AIDS effort in the 1980s.

A U.N. report found a shortage of 2 billion condoms this month in Africa alone. "While we are considering making pharmaceuticals available, why not provide a mechanism to provide free condoms worldwide?" Curran asked in a speech delivered Thursday.

Meanwhile, millions of dollars are being spent on high-tech remedies that may or may not prove effective. Research on an AIDS vaccine continues, but immunologists had little encouraging to report, and there was some potentially bad news at this meeting.

On Wednesday, Harvard researchers described how a closely watched patient who had developed a strong immune response to one strain of HIV had apparently been reinfected and sickened by a slightly different strain.

Because this patient had developed precisely the kind of immune protection sought from several potential new vaccines, the discovery that a mutant strain of HIV sidestepped his defenses is a discouraging hint that such vaccines might not work as hoped.

In response to the widespread pessimism his report provoked, Harvard research Dr. Bruce Walker said that he still had faith in the vaccine strategy, which is being developed by Merck.

The only major human trial of an AIDS vaccine, developed by VaxGen of South San Francisco, will be completed in November, and results of it won't be known until early next year. VaxGen uses a classic vaccine design that uses a piece of the AIDS virus' outer coat to rally antibodies against it.

The fear is that the virus will quickly mutate the appearance of its coat to fool any antibodies mustered against it. Many at the conference say they doubt the VaxGen product -- which has protected chimps from infection -- will work as hoped in humans because of the mutation problem.

Millions of dollars have been raised to search for an AIDS vaccine, which is universally regarded as the best long-term hope for halting the disease.

Yet Canadian researchers have found a startlingly protective effect against HIV using a practice developed thousands of years ago. Their studies in Africa suggest that men who are circumcised have, on average, a 50 percent lower risk of contracting HIV. Serious clinical trial began this spring to prove or disprove their case.

Circumcision, the surgical removal of the foreskin, is practiced in at least one-third of human cultures around the world. It is a single, low-cost, permanent medical intervention -- often criticized in the United States as antiquated, medically unnecessary and barbaric.

Yet 35 different studies in Africa have found that uncircumcised men had between two and eight times the risk of HIV infection as their circumcised counterparts. Scientists argue whether the effect is biologically based or the result of unrelated behaviors.

"If we had something that would really reduce infections by 50 percent, we should do something about it," said Dr. Helene Gayle, a former chief of AIDS prevention at the CDC, who now directs HIV programs for the Bill and Melinda Gates Foundation.

Meanwhile, researchers are trying to find a vaginal microbicide, an HIV- killing gel that women could apply with or without their partner's knowledge.

No microbicide has proved safe and effective, although serious trials of several promising products are under way.

San Francisco AIDS researcher Nancy Padian has launched a trial in Zimbabwe of a radically new idea: using a diaphragm to reduce, not eliminate, risk of sexual HIV transmission.

Each of these interventions cost a fraction of even the cheapest generic antiviral drugs.

James Love of the Consumer Project on Technology in Washington, D.C., said it should eventually be possible for generic drugmakers in India to drive down the cost of antiviral drugs to $100 a year -- one-third the current price and hugely discounted from the Western prices of $10,000 to $15,000.

Efforts to fine-tune antiviral drug dosages could further reduce overall cost -- experiments are under way to see whether taking the drugs for seven days, then stopping for seven, is medically effective.

On Thursday, National Institutes of Health researcher Mark Dybul reported that a group of seven closely followed patients on the on-off regime had shown no increase in virus in their bloodstream for up to two years, although it is too early to recommend the therapy to anyone.

E-mail Sabin Russell at srussell@sfchronicle.com.

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