AIDS Treatment News, Issue No. 177 - June 18, 1993
John S. James

For the last nine years, the International Conference on AIDS has been the major scientific meeting of the year. The 1993 conference, June 6-11 in Berlin, was like the others in several ways:

* About 12,000 persons attended, about as many as in recent years.

* No one expected a major breakthrough, and none was announced. (This is not surprising, since it would be wrong to delay announcing an important advance in order to wait for a conference.)

* A number of potentially important advances in understanding AIDS came to light; significant progress was reported. But most of them were not immediately relevant to better patient care.

* Overall, people left the meeting with the usual annual disappointment at how little has been accomplished in finding better treatments for AIDS -- and with worse reports each year about the rapid spread of HIV in populations around the world, and the inadequacy of the efforts to stop it.

But the Berlin conference also differed from previous meetings in several ways:

* Better quality research is now being reported. This improvement reflects better design of clinical trials during the last two to three years (compared to those designed earlier), as well as the availability of better virological tests. The results of the new trials are now coming in.

But many of these results were negative or inconclusive. The basic reason is that while the technique of trials has improved, the vision of what is needed, and the selection of drugs to study, has not. Major clinical trials, even when publicly funded, are still driven by commercial pressures in a game of influence that only large companies can play, generally assuring copycat products attempting to imitate the big commercial success (AZT) of the past.

* The situation for physicians and patients making treatment decisions is more confusing after this conference than before. Most people seem to be responding by continuing what they would have been doing anyway, until enough clarity and consensus develop to support new decisions. This differs from most previous conferences, where there was less potential impact on treatment because less accomplishment was reported.

* Another improvement this year is that the top leadership of AIDS research is more open to new ideas than before -- both the same ideas dismissed in the past, and new observations which might or might not turn out to be critically important.

* While figures are not available, reports suggest that there was less media coverage of this conference than in previous years. But working journalists were as busy as ever in the media facilities provided. The fewer column inches this year could indicate more seriousness rather than less interest, since during the last two years, much of the coverage resulted from media feeding frenzies: two years ago, an unfortunate remark about a "deep kiss" possibly spreading AIDS; and last year, ICL (idiopathic CD4+ T lympho- cytopenia, meaning AIDS-like immune deficiency with no finding of HIV or any other known cause), which got media attention because of the possibility that it could affect people who considered themselves removed from AIDS. The talk in the press room last year was that the reporters already knew that ICL was a non- story (probably reflecting only the fact that more immunological testing was being done), but were running with it anyway because everyone else was. This year produced no comparable false headlines.

What Wasn't in Berlin

Our deepest impression from the conference is that the most important and productive approach possible to saving the lives of those already infected was simply not on the table there -- not among the scientists, not among the physicians, and not among the activists. The greatest need, everyone did seem to agree, is for better drugs -- including drugs which control HIV activity in chronically as well as acutely infected cells. Existing drugs are largely useless in chronically infected cells, which maintain reservoirs of virus to provide a source of endless mutations to escape control by the drugs we have and also by the immune system itself.

But there are many potential treatments which do control HIV in chronically infected cells in laboratory tests, and are probably safe to use, and could be inexpensive and readily available. If they can greatly suppress HIV activity in humans (which is fairly easy to test), then they will probably be major advances in AIDS/HIV treatment. The last issue of AIDS TREATMENT NEWS included a background report on one such possibility, curcumin, which is already in the human diet because it is contained in curry. Our conference coverage will include at least two others -- a protease inhibitor which received much attention at the conference (although it is limited by major supply problems), and an LTR inhibitor, topotecan, which is now in human trials for cancer.

Probably dozens of such candidate treatments, many already in human use so that basic safety information is available, could be identified from the published literature alone. It would take a few weeks and probably less than $50,000 each to test them for antiviral activity in humans. While the odds are against each possibility individually, cumulatively it is very likely that such a program would produce at least one major treatment advance, entirely changing the current picture of HIV care. If the treatment was already known to be safe, it could be in widespread use within months.

The reason this hasn't been done already is because nobody is pushing for it. Not pharmaceutical companies, which are only interested in drugs when they have the patent rights, the marketing prospects, the executive commitment, and the personnel, capitol, facilities (manufacturing, laboratory, etc.) and all other resources available. Not government programs, where good ideas must wait in line along with bad ones, and where funding reductions are likely to affect both equally. Not private charity, which usually won't touch AIDS -- and when it will, usually won't touch research. Not community-based research, which was intended to address this gap, but in practice seldom has the funding to be independent, and must limit itself to funded projects, almost always drugs which pharmaceutical companies are already developing anyway. And not established researchers, unlikely to be attracted to something simple that would highlight a decade's failure to produce practical HIV treatment advances. The "alternative" and "underground" treatment movements come closest to addressing this opportunity (curcumin is already being tested this way), but they have not had the resources to do formal trials. The clear impression at Berlin was that the whole world is accepting the lack of progress in AIDS treatments as inevitable, and overlooking the fact that the entire situation could be turned around in a rapid, straightforward and relatively inexpensive way, if there were the institutional will to do so.

We will continue to develop this possibility below, and in future issues.

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