San Francisco Examiner - July 16, 2000
Ulysses Torassa, EXAMINER MEDICAL WRITER

"The process that started here - nobody will be able to stop," said Stefano Vella, incoming president of the International AIDS Society, which organized the conference, which ended Friday. "Nobody will have the courage to step down from the table without losing their image" in the world community, he said. Pulling off the first such conference in a developing country was a success in itself, as doubts had been raised about Africa's ability to host an event of such scope, which drew more than 12,000 people.

While the event opened with a disappointing speech from South African President Thabo Mbeki and fresh statistics showing the alarming numbers of people already infected, by week's end there were glimmers of hope, capped by a rousing speech by former President Nelson Mandela that sent delegates home energized. But no one left thinking major breakthroughs were just over the horizon.

"We see that there are different approaches that can work," said Charles Chidothi, who trains people to do HIV counseling in Malawi, a small country in central Africa. Specifically, he pointed to programs described at the conference that are teaching people to care for AIDS patients at home, as the hospitals are too full already.

Malawi does not provide drugs that prevent pregnant women from passing HIV onto their newborns, a hot topic during the week. But Chidothi said results of studies presented at the conference - combined with a new offer from drug maker Boehringer Ingelheim to provide the medicine nevirapine for free - could pave the way.

"There is room for us to go into that area," he said. "I think we can push further. We have learned that it is possible to do initial treatments for mother-to-child transmission."

Treatment too expensive

While activists demonstrated outside the conference demanding that pharmaceutical companies drastically lower prices for AIDS drugs, many African delegates said Western-style anti-retroviral therapy was not their first priority.

"Treatment is not a major thing in our country - it's too expensive," Chidothi said.

He was referring not only to the drugs themselves, but to the additional doctors and health workers needed to monitor the complex regimes, and the high cost of tests needed to make sure the drugs were working properly.

Reports from some small trials of anti-retroviral therapy among mostly well-off people in the Ivory Coast and Uganda found that the drugs did help keep many alive. But they found the same problems that were already major issues in the West: creating drug-resistant strains and keeping people on the expensive and sometimes nauseating drugs.

Many African leaders - even those who aren't eager to embark on widespread anti-retroviral treatment - said they at least needed better access to drugs to fight the opportunistic infections that ultimately kill people with AIDS.

Drug companies pressured

The pharmaceutical companies clearly are feeling the pressure. Gone were the gigantic exhibit displays, free pens, tote bags and logo umbrellas from past conferences. Instead, the companies staffed more discreet booths. Even so, they were each taken over, one by one, by ACT UP activists denouncing what they said were obscene profits by drug makers in the face of the crippling epidemic.

Following the free nevirapine offer, Merck and the Bill and Melinda Gates Foundation announced a joint effort to provide $100 million in drugs and health infrastructure support for Botswana, where a staggering 36 percent of young adults are believed to be infected with HIV.

But for every bit of good news about free drugs or the success of certain ways to promote condom use, there was also disappointing news about some of the most hoped-for strategies to defeat the virus.

Studies showing that anti-retroviral therapy significantly cut the rate of transmission of HIV from pregnant women to their newborns was overshadowed by further evidence that those gains could be wiped out if the mother breast fed. Attempts to get around the problem by using formula only led to even more infant deaths, as many women don't have access to clean water and other tools needed to deliver nutrition to their babies.

Gel fails to protect

Even more upsetting was the report from studies among prostitutes in Africa and Thailand who were testing a spermicidal gel as a potential way to kill HIV. It turned out those using the gel were more likely to be infected with HIV than those using a placebo.

It was a major blow to scientists seeking to develop a microbicide that could be used by women to protect themselves against men who refuse to wear condoms. Another theme at the conference was how powerless many women in Third World nations were and how that had led to a horrifying rate of HIV among young girls in southern Africa.

Still, microbicide research marches on, with a handful of other substances further down the pipeline as potential candidates. The same holds for vaccine research, which most scientists believe is the best hope for conquering the virus.

Surprisingly, only in the past few years has a significant amount of money been marshaled for such research, and the vaccines now being tested on humans are not expected to be very powerful.

Tests of a vaccine based on the notable ability of some Kenyan prostitutes to remain uninfected, despite repeated contact with HIV, is about to undergo its first human tests in England and Kenya later this year, it was announced at the conference. And an Italian study of monkeys found nine of 11 were able to ward off the virus after being inoculated with a vaccine that seeks to block a key protein HIV needs in order to proliferate.

Third World focus

With more than a third of delegates coming from African nations and a heavy emphasis on studies of Third World issues, it was not surprising that American scientists found little information of practical use.

"Nothing will change the way I practice medicine," Josh Bamberger, director of special projects for the San Francisco Health Department, said of the scientific and clinical presentations. He runs a pilot project on Sixth Street aimed at keeping HIV-positive homeless people on medication.

What he did walk away with, he said, was a greater appreciation for what Africans were facing, and the chasm between rich and poor that made it all worse.

His patients back home "are living in the Taj Mahal compared to South Africa," Bamberger said. "It was worth it just getting the sense of the world as bigger than the block of Sixth between Mission and Howard."

Tom Coates, director of UC-San Francisco's AIDS Research Institute, said he felt an obligation to attend and support the efforts of Africans to come to grips with what was threatening to become a holocaust. "The principled thing to do is be here and understand what is going on," he said.

The United States, which spends $2.2 billion on AIDS research, will ultimately provide many of the answers the developing world needs, he said. Reaction to speeches Like many attendees, Coates was severely disappointed by Mbeki's opening speech Sunday, in which he sought to downplay the role of HIV in the epidemic and instead focused on poverty as the root of his country's health problems. The president also defended his controversial decision to invite dissidents who do not believe HIV causes AIDS onto an advisory panel.

"What's frustrating is that everything I've heard here and seen here is that HIV is going to eat this country alive, and the government is throwing up committees and throwing up every possible objection to every possible solution," Coates said.

Coates did not stay long enough to hear Mandela's speech on Friday, a no-holds-barred call to arms in which he talked in stark terms about what HIV is doing to his country and the region. Many delegates said the speech had moved them to tears.

"The opening speech, it kind of left you wondering, 'Are we taking this as seriously as we should?' It seems like we're not on the same page," said Ingrid Andrews, a community worker for Charles Drew University in Los Angeles. "But (Mandela) was just the opposite. He said all the right things. It's just what we needed to hear."

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