June / July 1994
Essay: World AIDS Conference
by Mike Barr
Pessimism reigns as Japan's World AIDS Conference nears
On August 7, the World AIDS Conference in Japan will mark the 10th such international scientific meeting. Its watershed quality is rendered even more telling by the fact that the Xth is also the last of the international scientific meetings. From here on out they'll be biannual, a sobering symbol of earlier optimism now faded as well as a public submission to a slower, more protracted scientific agenda.
At the recent pan-European conference held in Milan, the buzz among friends from London, Berlin and Paris was that no, they were not going to Yokohama for the conference. Distance, expense and most of all a weariness of this annual reminder of the stymied international research effort have all conspired this year to set the stage for what could well turn out to be the most underattended international AIDS conference to date.
Of course much of what will be presented in Japan will have already been presented to smaller, less public audiences. Even though researchers like to embargo new results for a big splash before the throngs of international press, there are simply too many conferences and too few breakthroughs to allow for riveting presentations time after time. Robert Gallo has hinted at a cheery announcement concerning Kaposi's Sarcoma (KS), while Harvard's Max Essex may have new data about genetic resistance and susceptibility to HIV's havoc. Each conference seems to have a slick sideshow or two. Last year it was Anthony Fauci's disingenuous presentation heralding the benefits of interleukin-2 (IL-2) therapy and his "multi-factorial" model of disease and Gallo's twin announcements implicating human herpes virus 7 (HHV-7) as a possible cofactor in AIDS and basic fibroblast growth factor (bFGF) as a target for treating KS. Then, too, there was Mario Clerici's stunning TH-1/TH-2 hypothesis. Somehow it seems that these momentary bombshells never get followed up.
Among predictions of the rise in AIDS orphans and reports of the continued ascent of heterosexual transmission in this country, we will learn how one in three heterosexual men (and almost inevitably their wives) in the northern regions of Thailand have become infected with an especially virulent HIV strain transmitted through their weekly unsheathed visits to Thai prostitutes. We'll learn, too, how in India male truck drivers are bringing HIV home to their wives and families at an alarming rate. And, most relevant to urban gay men like myself, how education and prevention efforts have floundered, belying their earlier successes. By the end of the decade, we'll learn, fully half of the twentysomething (and younger) gay men in the San Francisco Bay Area (for whom HIV infection has been mostly an abstraction) will have seroconverted. Equally distressing will be the reports of new, more virulent strains of HIV -- that persons infected recently appear to succumb to illness and die faster than those infected a decade ago -- and the discovery of a type of HIV-3 which closely resembles the virus that infects monkeys.
As for therapeutics, we're likely to overdose on reports of viral mutations which confer resistance to every protease inhibitor yet to make it into human studies. From the Americans we'll hear Pollyanna promises about combination therapies; you know, AZT+ddC+protease and the like. The new buzzword of the year (to replace "SI/NSI," "apoptosis" and "TH-1/TH-2 shift" of conferences past) is likely to be "individualized therapy", a fancy algorithm for determining when to initiate or switch antiviral treatment based on what's going on with a person's own individual viral activity.
There will be a new antifungl here, a better acyclovir there and a study suggesting oral Gancyclovir is nearly as effective as the intravenous type of maintenance therapy for CMV retinitis. The obligatory nod to better the treatment of opportunistic infections will have been made; but, overall, the state-of-the-art for OI prevention and treatment will go relatively unchanged. Liposome Technology will sing the praises of its stealth chemotherapy, Doxil, but this will be overshadowed by longitudinal studies reporting that the prognosis for persons diagnosed with KS has changed little since 1982.
There will be more reports of fungal infections which do not respond to standard treatment, more reports of people getting PCP despite conscientious prophylaxis and as always more lymphoma. Reports from the U.S. that its multimillion dollar campaign against TB seems to have begun paying off will list spirits for a moment or two.
What does it all mean? We'll have to wait two years for the next significant gathering to answer some pressing questions. And that's just too long to wait.
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