In brief

Today inequities have dented the concept of a common front against HIV disease, and this was one of the underlying themes for the 15 000 delegates who attended the XI International AIDS Conference in Vancouver last summer. Delegates could take pride that in some parts of the world behavioural change had led to lower infection rates, and in optimism that pharmacologic breakthroughs may eventually turn a fatal disease into a chronic but manageable illness. For others more acutely aware of the greater impact of the HIV epidemic in the developing world, however, there was also frustration and despair.

The Vancouver conference emphasized four guiding principles -- excellence, practicality, sustainability and solidarity -- that must be supported in the global battle against AIDS. In their opening message the Vancouver physicians and/or researchers who cochaired the conference -- Julio Montaner, Michael O'Shaughnessy, Michael Rekart and Martin Schechter -- voiced confidence about the implications of progress so far: "As a global community, we know we can lower HIV incidence through STD [sexually transmitted disease] control programs and other interventions. The global AIDS pandemic no longer feels out of our control -- we have begun to feel that we have the necessary tools within our grasp. It is not a hopeless situation."

However, they also expressed concern. "It is alarming at this juncture that we find political leadership drifting toward indifference. . .. Let us shun indifference and choose the path of renewal and hope."

In the developing world, the logistics of poverty and diminished resources mean that the sophisticated and expensive drug therapies that were described in great detail in Vancouver will be unavailable to millions of patients. Because of that, developing strategies to prevent the transmission of HIV is the most realistic approach. One example is educational interventions to reduce the number of sexual partners, promote condom use and control STDs. Such moves have helped lower seroprevalence rates in young people in Uganda.

Catherine Peckham, an epidemiologist at the Institute of Child Health in London, suggested that because more than 1.5 million children are estimated to have become infected perinatally, the first priority in preventing such infections has to be stopping HIV infection in women. "The development of safe and effective topical antiviral preparations to prevent sexual transmission of HIV and other STDs remains a priority," she said.

Although prenatal screening for HIV has obvious merits, Peckham cautioned that any benefit for women participating must be weighed against the potential for harm. In a study in Nairobi, most women who consented to testing did not want to know test results and did not inform sexual partners if results were positive. Knowledge of a woman's HIV status sometimes leads to violence or blame for bringing AIDS into a family; it also becomes meaningless, at least to the patient, when no treatment is available.

"In this situation, identification of infected women is not feasible and we need to consider other less costly practical alternatives that can be given to all women regardless of whether or not they are infected with HIV. It is time to integrate the management of HIV-infected children and mothers with existing mother­child health services. We can't cure those who are already infected, but we can reduce the risk of infection and offer longer and better quality of life to those who are infected."

A retrospective look at the early days of AIDS was provided by Dr. Paul Volberding, who cofounded the AIDS program at the San Francisco General Hospital in 1981. Volberding, who examined the therapeutic changes he has witnessed over 15 years, noted that the addition of 79 approved drugs to an arsenal that 6 years ago contained only 1 drug (zidovudine) has created significant patient-compliance quandaries.

"How easy is it for patients today to go home armed with prescriptions for trimethoprim sulfate, prednisone, clarithromycin, zidovudine, 3TC, indinavir and other supportive medications, each of which requires a different schedule, or fasting for 2 hours prior to using the drug?"

To enable patients to follow complex regimens, he suggested that researchers have to make convenience a priority. Drugs should not interfere with other necessary treatments and should not need to be taken more than twice daily or require fasting in order to be absorbed. "Drugs that patients cannot comply with are of no value and will exclude an increasing portion of the population, or inadequate compliance will lead to an expanding population of patients with multiply-resistant HIV."

Volberding called for the addition of behavioural science colleagues, nurses and social workers to HIV care teams, and suggested they also have a role to play in designing drug trials. "The real bottom line of AIDS care is commitment," he said, "with expert patient-oriented care that combines high technology and compassion."