Dave Gilden on the return of the HIV dissidents: Don’t let it divert us from our destination— immune-based drug research.
With the realization that current anti-HIV drugs can never cure AIDS but require lifelong use, the HIV dissidents are suddenly back in style. Journalist Celia Farber, a longtime critic of HIV as the cause of AIDS, appears in the pages of Gear, The New York Post and, of all places, POZ (see “The Most Dangerous AIDS Reporter,” April 2000), posing as the defender of the masses against the AIDS drug barons. Elsewhere in the same issue of POZ, we read that HIVers are turning to herbs, vitamins, “healthy diets” and alternative therapies to achieve well-being. And long-discounted but largely treatable microbes are touted as necessary “cofactors” in causing AIDS. You’d think we’d turned the clock back to the early 1990s, when science had little to offer for opportunistic infections (OIs) and even less for HIV.
That is precisely the situation in South Africa, where the high price of antiretrovirals puts them out of reach for all but a few. There, the dissidents have the ear of President Thabo Mbeki, creating an uproar in the international AIDS establishment. Mbeki included the question of whether HIV causes AIDS in his charge to a new national commission that formed in April to devise an anti-AIDS strategy specific to African conditions.
In reality, the introduction of viral load testing and potent anti-HIV cocktails over the past five years has made the link between HIV levels and sickness undeniable.
Suppressing HIV is now the treatment of choice for many OIs. Once the virus is brought under control, the immune system usually recovers enough to take care of any coinfections on its own. A simple before-and-after picture comes from the Swiss HIV Cohort Study, which described what happened to 2,410 HIVers after they started protease combos: Over the next 15 months, their OIs plummeted 86 percent. Whatever benefits the anti-HIV drugs confer result from blocking HIV and the resulting boost in CD4 cells. Otherwise, their consequences are entirely negative; the disruptions of liver, kidney and nerve functions and fat processing are notorious.
These toxicities can be life-threatening, but so far, people have not been dying from drug side effects in discernable numbers—Celia Farber to the contrary. The death rate in U.S. HIVers has declined 60 percent to 75 percent since HAART’s advent in late 1995. When people do die, the main causes are traditional OIs, which have diminished drastically, plus a number of “non-AIDS” conditions, including bronchial pneumonia, blood-borne infections, hepatitis C and malignancies. Heart disease, a concern because of the HAART-related cholesterol increases, is not yet noticeable in significant numbers.
When an anti-HIV drug works, it knocks out about 99.9 percent of the virus—impressive, but not enough to end the danger of viral rebound. The immune system, which in most diseases cleans up the residual infection left by the drugs, remains absent from the struggle. Without the immune system, HIV therapy will always be a cumbersome, costly lifetime burden unsupportable in most of the world.
To help the immune system provide the final blow, we should look at the few cases in which the body naturally controls the virus. About 1 percent of people with HIV keep their viral loads minimal and never progress to AIDS. A new National Institutes of Health study found that such people have a particular, partly genetic ability to flag and destroy HIV-infected cells. If every person could combat HIV with this kind of immunity, no drugs would be necessary. Helping the body create effective defenses against HIV is only possible now that drugs can give the immune system a break from the destructive effects of the virus. Immune-based drug development is the next big step to supplementing antiviral therapy.
Finding a cure for AIDS does require a truly wholistic approach—a more complete strategy based on the interaction among HIV, drug therapy, the immune system and other bodily processes, as well as environmental and lifestyle factors. Without this, we cannot move beyond the 20th-century antagonism between modern science and a folk-medicine holism that relies largely on untested claims. Nor can we break the rich countries’ monopoly on medical advances. Rather than fostering popular pressure for a cure accessible worldwide, the HIV dissidents divert our political will with populist clichés. They disparage medical knowledge and attack researchers, creating a parody of both science and activism.