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By Nancy Touchette
Like its predecessors, the XVth International AIDS conference, held last month in Bangkok, Thailand featured a mix of science, policy and politics.
The theme of this year's conference was "Access for All," and presentations highlighted key scientific advances in preventing and treating HIV infection, and ways to deliver the most effective treatment and prevention strategies to people around the globe, particularly those in developing nations who have been the hardest hit by the AIDS pandemic.
For example, data from Thailand show that giving a single dose of nevirapine during labor to HIV-infected women who had been taking AZT from 28 weeks of gestation resulted in very low rates of mother-to-child transmission of HIV. Such advances are especially important to regions where HIV infection rates are skyrocketing, notably Asian countries such as China and India, and nations of the former Soviet Union.
But according to NIAID director Dr. Anthony Fauci, this year's mix was skewed by politics and a decisive anti-American sentiment that frequently overshadowed the science.
"There was a complete misunderstanding of what the President's program was and in many respects it seemed to be deliberately misconstrued," Fauci said.
Perhaps most distressing, he observed, were comments from world leaders who suggested that the United States is showing no leadership in combating the global HIV/AIDS epidemic. This was based on the opinion that all of the U.S. resources for global HIV/AIDS should be channeled through the multi-lateral Global Fund to Fight AIDS, Tuberculosis and Malaria rather than the bilateral PEPFAR.
"This is a point upon which people can in good faith disagree," Fauci said. "However, to translate that into a 'lack of USA leadership' or statements that the USA is not doing nearly enough for global HIV/AIDS is not consistent with the facts."
The Global Fund is an international effort initiated by the United Nations to provide funds to developing countries with approved programs for treating and preventing disease. As of July 19, the USA had contributed approximately $1 billion to the fund.
"The USA is by far the major contributor to the fight against AIDS, having spent more than $150 billion since AIDS was recognized 23 years ago," said Fauci. "Also lost in the discussion is the fact that the USA is by far the largest contributor to the Global Fund."
Another controversial point was the type of antiretroviral drugs used by the program. PEPFAR allows the use of low-cost generic or copy drugs, but requires that such drugs pass FDA review for safety and efficacy. The FDA has agreed to streamline the application process for use in developing countries in which the epidemic is rampant.The USA was also criticized for backing programs that promote abstinence and fidelity as a way of preventing HIV transmission. However, Randall Tobias, U.S. Global AIDS coordinator, pointed out that abstinence and fidelity are only part of a total program that also includes use of condoms.
"When Ambassador Tobias was giving his talk about PEPFAR and its goals and vision, he was shouted down by people who were uninformed about the flexibility of the program," said Fauci. "It was one of the most misinformed activist displays I have ever seen."
In many respects, the bi-annual international AIDS conference has become less important in terms of the science presented, Fauci observed. This is due, in part, to the heated political climate at the meetings, and also because the science has reached a level where progress is steady but incremental, and breakthroughs are fewer and far between.
"Breakthroughs do not coincide conveniently with the timing of an international meeting," he said. "And the low-hanging fruit of HIV research was picked a long time ago."
There has also been a major scientific stumbling block the development of an effective HIV vaccine. It is an issue that will persist as scientists resolve some of the remaining scientific questions, such as determining the precise correlates of immunity that might protect a person against HIV.
Nonetheless, Fauci said that good, solid science was presented in Bangkok. For example, data on several new drugs that block the entry of HIV into target cells were presented, as were data on the development of a drug that blocks the maturation of HIV particles and hence their infectivity.
Fauci also discussed his own laboratory's recent findings on the pathogenesis of HIV infection, which underscore the contribution of aberrant and persistent immune activation in propagating viral replication and depletion of immune cells. A videocast of his lecture in Bangkok is available at http://www.niaid.nih.gov/director/lectures.htm.
"Ultimately, I came away with a sense of optimism of what can be done," Fauci said. "Despite the staggering toll of the epidemic and the scientific challenges that remain, important progress is being made. With the dramatic increase in funding and political will in hard-hit countries I am hopeful that HIV prevention and treatment services will begin to reach many more of the people who desperately need them."
The next International AIDS Conference is scheduled for August 2006 in Toronto, Canada. The conference web site is http://www.aids2006.org/.
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