Important note: Information in this article was accurate in July 2000. The state of the art may have changed since the publication date.| Dissenters Meet Mainstream Opposing Strategies Broad context of AIDS Disturbing Figures Sad and Surreal Drug Firms, UN Agencies Partner to Boost ARV Access |
Take a step back in time. The day is July 7, 1996. In a darkened lecture room of the Ford Centre for the Performing Arts in Vancouver, British Columbia, Canada, hundreds of scientists, physicians and media are gathered to hear David Ho unravel the mysteries of HIV infection.
Ho, of the Aaron Diamond AIDS Research Center in New York City, gives an elegant presentation outlining HIV's staggering replication rate in the early days and weeks of infection. During the next four days of the 11th International Conference on AIDS, attendance will be standing room only at presentations by Ho and his colleagues. Their methodical research, published prior to the meeting in the journal Nature, has turned conventional wisdom on its ear: rather than a lengthy quiescent period, they demonstrate that HIV attacks with a vengeance early on, generating billions of virus particles every day. These are the most detailed descriptions of HIV pathogenesis to date.
Take another step back in time. The day is May 6, 2000. Thirty-four researchers, physicians, public health specialists, and others with special interests in the AIDS pandemic have been summoned to Pretoria by South African President Thabo Mbeki. Their stated goal: come together as an expert panel to develop consensus on strategies to combat HIV/AIDS in South Africa.
But as stated, the goal is unattainable. Not because the virus has cut such a wide swath, but because this group never will be able to reach a consensus on how South Africa can effectively combat HIV. Eight members of the expert panel hold the staunch belief that HIV is a fallacy and AIDS a syndrome that befalls recreational drug users and those who have taken AZT, which they assert is highly toxic.
Among the dissenters are biochemists Peter Duesberg and David Rasnick, both of the University of California at Berkeley. The dissenting side also includes Harvey Bialy of Mexico and Christian Fiala of Austria. For more than a decade Duesberg has espoused the theory that HIV is not infectious and therefore is incapable of causing the magnitude of suffering and death associated with AIDS. It is as if the work of Ho, his colleagues, and the vast array of pioneering virologists and immunologists who have come before and after him is suspended in time and imagination. The dissenters dismiss out-of-hand years of painstaking research by the world's leading experts.
In industrialized nations, views expressed by the dissenters were dismissed years ago. But Mbeki--who by all accounts is committed to fighting AIDS, has strengthened his government's anti-HIV program, and has fought to expand access to HIV/AIDS care--apparently came across the dissenters' hypotheses while searching the Internet for AIDS information. He invoked his country's history of white, minority rule when the rest of the world suggested that South Africa, too, should dismiss the dissenters.
"We are now being asked to do precisely the same thing that the racist apartheid tyranny we opposed did, because, it is said, there exists a scientific view that is supported by the majority, against which dissent is prohibited," Mbeki said in an April 3, 2000, letter sent by diplomatic pouch to world leaders, including US President Bill Clinton.
But when Mbeki's Presidental AIDS Advisory Panel assembled in Pretoria, Duesberg, Rasnick and the other dissenters came face-to-face with the likes of HIV co-discoverer Luc Montagnier and Helene Gayle of the US Centers for Disease Control and Prevention (CDC). With an extensive hand in treatment access and medical education efforts in Africa, the International Association of Physicians in AIDS Care (IAPAC) also was invited to join the panel.
"Our position is that HIV causes AIDS," IAPAC President José M. Zuniga emphasized during his May 6 opening statement. "Thus, IAPAC's recommendations will be based on this fundamental scientific assumption and influenced by the urgent need to develop and implement HIV prevention, treatment, and healthcare access strategies that are relevant to and appropriate for the South African experience."
During the first day of the two-day meeting, panel members split into groups to discuss issues surrounding disease etiology, prevention, and treatment. Even though South African government leaders wanted to continue those discussions on the second day, panelist (and IAPAC member) Stefano Bertozzi of Mexico's National Institutes of Public Health suggested that the dissenters and those in the mainstream form two main groups, and that each propose strategies and recommendations based on their assumptions of AIDS' causal agent.
The mainstream group raised practical concerns, aiming strategies at attempts to get more accurate surveillance data, explore alternative options for the prevention of mother-to-child transmission (in light of the South African government's ban on the use of AZT as prophylaxis), and promote the need for microbicides. International AIDS Society (IAS) President-elect Stefano Vella and IAPAC's Zuniga urged the development of clinical guidelines that are economically feasible and relevant for developing countries.
"In this document we recognized that we cannot apply a cookie cutter approach to South Africa or to any other nation," says Zuniga, echoing Mbeki's sentiments in his statement to world leaders. "Thus, our strategy document contained fundamental questions about the AIDS epidemic in South Africa that should drive decision-making processes."
The dissenters, maintaining that HIV does not cause AIDS, that anti-HIV drugs are lethal, and that AIDS is neither contagious nor sexually transmitted, also offered recommendations for South Africa. They advised the South African government to take the bulk of resources now used for AIDS care and devote them instead to the prevention of tuberculosis, malaria, and enteric diseases. They supported improvements in nutrition and sanitation and the promotion of sex education to avoid STD transmission and unintended pregnancies. But they also favored the suspension of HIV testing, of anti-HIV drug use, and of disseminating the "psychologically damaging" message that HIV infection is fatal.
"We were appalled," Zuniga says of the collective mainstream group's reaction.
Pending approval from the South African government, IAPAC Trustee William Cameron of the University of Ottawa in Ottawa, Ontario, Canada, is likely to take up IAPAC's work on the panel due to Zuniga's involvement in ongoing IAPAC-specific and -related initiatives, including the establishment of a global HIV medicine certification process for HIV/AIDS-treating physicians in developing countries.
Cameron says strategies to combat HIV/AIDS in South Africa must be viewed in a broad social, demographic context. "AIDS in Africa and other parts of the world is related not just to HIV and sex, but to the influence of poverty, warfare, and migration."
While Mbeki has questioned why the AIDS epidemic is largely heterosexual in Africa but homosexual in the West, Cameron says that distinction is less important than "the degree to which infection and disease have occurred in the population." For example, he explains, in large cities populations are migrant, with disrupted families and sexual mixing in the population that is less stable than in traditional social settings. "Because of that increase in sexual mixing of people, particularly in large cities where prostitution is common, sexually transmitted diseases have very fertile soil," Cameron says. He adds that warfare migration is an important factor in the increase of sexually transmitted diseases. "We've seen these increases after major wars; it's related to the movement of soldiers." Warfare is nearly constant on the African continent.
Recommendations from the dissenters, which in effect advise the South African government to dismantle all current efforts to combat the epidemic, have come at a time when the AIDS Foundation of South Africa reports disturbing statistics:
As this issue of JIAPAC went to press, six weeks of Internet discussion were expected to yield enough consensus to warrant another (possibly final) face-to-face meeting of the panel in late June or early July 2000, in advance of the 13th International Conference on AIDS on South African soil in Durban. Because the process is ongoing, Gayle of the CDC preferred not to discuss the panel's work. However, CDC issued a statement. It read, in part:
"Conclusions of more than two decades of epidemiologic, virologic, and medical research are that HIV infection is transmissible through sexual contact, injecting drug use, perinatally, and from receiving blood or blood products. Virtually all individuals infected with HIV will eventually develop AIDS in the absence of effective treatment."
Some news accounts of the panel's meeting indicated that the CDC would join with South Africa's Medical Research Council (MRC) and individuals from the dissident group to further investigate the relationship between HIV and AIDS. But the CDC's statement said no established study design exists, and that in keeping with its binational agreement and longtime relationship with the MRC, "CDC has agreed to supply technical support to the Council as needed."
In the meantime, Cameron and Zuniga call the spread of HIV in eastern and southern Africa a catastrophe, an emergency, with growth in a way like nowhere else in the world. As a result, they say, Mbeki should not be criticized for wanting to examine the big picture. "Does HIV cause AIDS?" Cameron asks rhetorically. "That's a separate issue."
But as the mainstream group left Pretoria, Zuniga says, it was with "sadness and the feeling that we had gone through something surreal." Some in the group related to the dissenters how the frequent funerals they attended early in the epidemic have been replaced with "Lazarus-like" stories of friends reclaiming their health and productivity through combination antiretroviral therapy. "To see all of that dismissed, to hear Peter Duesberg question whether there is an AIDS catastrophe on the African continent is very sad," Zuniga adds.
Sad indeed. Take a step forward in time.
Recognizing that HIV/AIDS is decimating the African continent and threatens the future of other nonindustrialized nations, five major research-based pharmaceutical companies agreed in May 2000 to team with several United Nations agencies to accelerate and enhance access to medical care in the developing world.
Headlines have emphasized a provision in the program to offer price reductions on antiretroviral drugs to developing nations. For example, Glaxo Wellcome stated publicly that it would offer "preferential pricing" of zidovudine, lamivudine, and a fixed-dose combination of those two drugs sold under the brand name Combivir. Through the program, the price of Combivir would drop from about US$16 per day to US$2 a day. Few other specifics on price reductions for other drugs, countries that will be included in the program, or additional access measures were available as this issue of JIAPAC went to press.
But even though reduced drug prices are a critical factor in improving access to medical care in poor countries, representatives from the pharmaceutical companies and the United Nations agencies involved have emphasized that pricing alone will not ensure access to care.
"The target, in our view, is to use access to antiretrovirals as an entree to the wider availability of medical care," said Badara Samb, a care adviser with the Joint United Nations Programme on HIV/AIDS (UNAIDS). That would mean providing greater clinician education and voluntary HIV testing in addition to lower drug prices, he explained.
IAPAC President José M. Zuniga, while supporting the proposed price discounts, echoed Samb's call for targeted medical education, adding that capacity building and strengthening infrastructure also are essential to make optimal use of complex treatment regimens containing antiretroviral drugs. Zuniga cited the positive experience he has witnessed in his independent observation of the UNAIDS HIV Drug Access pilot program in Côte d'Ivoire, Chile, Uganda, and Vietnam, in which pharmaceutical makers offered discounts from 10 percent to 46 percent. Today, in Uganda alone, more than 1300 people living with HIV/AIDS are obtaining and deriving clinical benefit from once prohibitively expensive antiretroviral therapy--up from 400 patients two years ago.
"Lower prices coupled with medical education and a strengthening of social support and healthcare delivery infrastructures proved a successful combination; reinforcing the notion that a comprehensive, step-wise approach to healthcare provision allows for the successful introduction of antiretroviral therapy in resource-limited settings," said Zuniga.
In the new program, some drugs will be discounted as much as 85 percent. Samb said that strategies from the UNAIDS pilot "will fuel everything" for the new program. According to UNAIDS and the five participating pharmaceutical companies, the preferential pricing program will attempt to enhance access to care based on six fundamental principles:
In addition to Glaxo Wellcome, drug companies involved in the new access coalition effort are Boehringer Ingelheim, Bristol-Myers Squibb, Merck & Co., and F. Hoffmann-La Roche. Joining UNAIDS and WHO are the World Bank, United Nations Children's Fund (UNICEF), and the United Nations Population Fund (UNPF).
Rebecca Voelker is a Chicago-based freelance medical writer.
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