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AIDS 2012: Another major step in war against HIV epidemic
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Anyone who has never attended the semi-annual International AIDS Conference (IAC), can’t possibly imagine what those of us who are repeat attendees have come to expect. It’s always “different” than other medical conferences, but this year was truly special and by far the most upbeat since the first of these meetings held in Atlanta in 1985.
Advantages of open door policy
The International AIDS Society (IAS) — a global professional organization governed by elected regional representatives — convenes the global HIV conference. Just before the 1990 IAC in San Francisco, we learned that the United States Government had passed legislation barring foreign visitors here unless they disclosed their HIV infection status. This was rightly seen as discriminatory and the IAS voted to boycott the United States as a conference site until the legislation was overturned. This was accomplished by the Obama administration in 2009 and Washington, D.C. was chosen promptly as the site for this year’s meeting, AIDS 2012, making the first time in 22 years that we were able to demonstrate our leadership in combating the epidemic here in the country that has contributed so much to this effort.
Paul A. Volberding
The IAC is a scientific conference with the usual oral and poster presentations, but it is much more. It has grown in size over the years — 20,000 attended this year — but it provides a unique stage for political leaders, patients and community organizations all covered by an extremely large international media. The IAC often highlights the regional impact of the epidemic, but also provides a very visible opportunity for individuals and organizations to advocate for correcting perceived gaps in research and care funding or to counter inequities or injustices adversely affecting HIV-affected communities. In years past, the fear and anger expressed in demonstrations and protests nearly drowned out the scientific content of IAC.
AIDS 2012 was very different. The conference organizers worked hard to include the community in planning the conference, and also tried to organize an agenda that presented new research results and ample time for a dialog that addressed the policy and clinical application of new data. Recent political decisions also aided the success of the conference in more effective debate. Repeal of the US military is “don’t ask, don’t tell” policy and the administration’s endorsement of same-sex marriage were undoubtedly popular with attendees, as was the decision to infuse additional funds in the AIDS Drug Assistance Program to eliminate state wait lists for HIV medications. Finally, the prospect of moving many uninsured HIV-infected persons to Medicaid as part of the health insurance reform legislation is also widely favored in HIV circles.
Data takes center stage
The political developments, though, were overshadowed by the science reviewed or newly presented at the conference. Well covered in previous issues of Infectious Disease News, many new clinical trials are creating a consensus much discussed at the conference that every HIV-infected person should be treated regardless of CD4 cell count. This conclusion is based on clinical research and experience that ever-earlier treatment is of value to the infected person, but that it simultaneously is a potent public health measure. Suppression of the HIV viral load in the plasma is almost completely effective in blocking transmission to sexual partners. And for those unable to otherwise protect themselves against HIV exposure — often women sex workers whose clients refuse to use condoms — antiretroviral therapy, as pre-exposure prophylaxis is also effective if used regularly.
New data at IAC extended confidence in previous reports by showing even more personal health benefit to very early treatment with reduced rates of tuberculosis and other infections. Also, we are beginning to see data that document the benefits of community-wide efforts to treat all infected persons, both in reduced new infections and in an impact on education, employment and other social and economic indicators.
Even prior to IAC, the US DHHS antiretroviral guidelines panel recommended HIV treatment regardless of CD4 cell count. At IAC, the International Antiviral Society-USA updated their guidelines in a special issue of JAMA and also endorsed treatment for all infected persons. Still, the debates at IAC were sober and well informed. Most appreciated that resources to treat all infected persons don’t exist. But the conclusion was that we finally have the tools needed to actually not just slow but actually begin to reverse the epidemic. We can, with will and resources effectively deployed, prevent transmission to newborns of infected women. We know that sexual transmission is essentially eliminated in those with HIV viral loads suppressed below assay detection limits and that infection risk can be substantially reduced by male circumcision and, where necessary, oral pre-exposure prophylaxis or vaginal antiretroviral microbicides.
The future
No one should think the next battle in the war against HIV/AIDS will be easy. The global economy remains weak and political support for foreign health assistance is always subject to challenge, particularly in an election season.
Still, some signs are good. The major US program PEPFAR is committing to substantial expansion in treatment coverage, and other donor countries are still engaged and supporting the Global Fund. The next phase in our campaign will require much more research with data, if positive, used to support policies and funding for universal HIV treatment. A true end to the epidemic remains far off, but we are entering a crucial new phase all on display at AIDS 2012.