AIDSWEEKLY Plus, Monday, 10 February 1997
Daniel J. DeNoon, Senior Editor

Only a vaccine can stop the AIDS pandemic, said the head of the United Nations AIDS effort.

Peter Piot, director of UNAIDS, the umbrella agency for United Nations AIDS programs, made his remarks in the plenary address to the Fourth Conference on Retroviruses and Opportunistic Infections, held January 22-26, 1997, in Washington, D.C.

"The epidemic is not over, despite what you may hear," Piot told delegates to the conference, which featured reports on the efficacy of new anti-HIV drugs. "I strongly believe that without a vaccine we will not be able to stop this epidemic."

Piot said that his speech was intended "to provide a reality check on our research agenda." This reality is that the epidemic is accelerating, not slowing down.

Last year's AIDS death toll - 1.5 million people - represents one-fourth of all the people who have died of AIDS since the epidemic began. The reality, Piot said, is that it would cost $300 billion to provide the three-drug therapy currently recommended for treatment of HIV infection to everyone living with the virus.

"Universal access to triple therapy is just not possible today," he said. "The reality of health budgets in most of the world is that current combination therapy costs 1000 to 2000 times the annual health expenditure per person in many African countries."

Piot therefore concluded that the end of AIDS will come only with universal access to an effective vaccine.

He spelled out his agenda for HIV vaccine research:

* Emphasize research. "The number one priority is move the science forward," Piot said.

* Seek a balanced approach. Move forward by testing different approaches in parallel rather than by trying one concept and then another.

* Plan now for human trials. "UNAIDS is very aware of ethical issues," Piot said. "This means making sure that the vaccines tested in an individual country correspond most strongly to what is needed there."

* Meet the economic challenge. "Investments must increase, support of industry efforts must go up," Piot said.

The UNAIDS chief acknowledged the "enormous" scientific challenges posed by an HIV vaccine. He listed what he considered to be the most essential questions:

* What is the significance of HIV-1 genetic subtypes for immunity to the virus? "We must make sure that we are not working on subtypes that occur only in one part of the world, particularly when we are talking about vaccines needed in parts of the world where other viral subtypes are circulating," he said.

* What are the immunologic correlates of protection and non- protection against HIV?

* What can we learn from animal experiments? "How far can we extrapolate and how far should we go and how long should we wait for their results and interpretation?" Piot asked.

* Is mucosal protection needed, and if so, how can it be elicited?

* What are the criteria for moving to human efficacy trials?

"Above all I would say the question is: 'Is it possible at all to induce better protective immunity if it is not naturally present?'" Piot said. "This will require a joint effort among the greatest minds of our time - and also some real entrepreneurship."

Piot worried that political, scientific, and community leaders are losing their sense of urgency about the AIDS epidemic. He warned that a successful response to the epidemic requires leadership with the courage to seek technically and ethically sound approaches.

"Too much money is wasted on what I would call the myths of HIV, on unproductive responses," he said. "We need to reduce not only the risk but also the vulnerability of people infected because of social factors in their lives."

While providing state-of-the-art treatment to everyone with HIV is currently impossible, Piot said that much can be done to improve access to existing technologies. He recommended a three-pronged approach:

1) Work with communities within countries to improve access to drugs, especially generic drugs for preventing opportunistic infections and for palliative care. Pilot projects should explore improving access to antiretroviral treatments.

2) Political and financial leaders should work together with the pharmaceutical industry to explore novel mechanisms for expanding the drug-purchase potential in developing nations.

3) A global strategy should be developed for making desperately needed drugs available.

Piot suggested that these approaches could best be used to find a way to make antiretroviral drugs available to pregnant women with HIV.

"The epidemic will not be under control in any single country if it is not under control everywhere," he concluded. - by Daniel J. DeNoon, Senior Editor

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