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Select Highlights from IAC 2006: Gates & Clinton, TB, integrase, HIV testing...
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"At International AIDS Conference, Big Names Emphasize Big Gaps"
Jon Cohen
Science 25 August 2006:
Vol. 313. no. 5790, pp. 1030 - 1031
Double Bill. Former U.S. President Bill Clinton and the world's richest man, Bill Gates, packed the hall at the 2006 international AIDS conference.
TORONTO, CANADA--When Bill and Melinda Gates gave the keynote speech here at the XVI International AIDS Conference, it signaled that this mega, biannual meeting had evolved far from its roots as the premier gathering for researchers to swap their latest scientific findings. "It's a marker that AIDS has made it as one of the landmark issues of our times like global warming and security issues," said Peter Piot, who heads the Joint United Nations Programme on HIV/AIDS.
The Gateses--whose foundation has committed $1.9 billion to battling the epidemic--helped set the tone for the gathering, during which scientists, clinicians, activists, and celebrities repeatedly emphasized that more needs to be done to prevent and treat HIV infection. "We know more, and we have more, and there's a greater will to do more," said Helene Gayle, co-chair of the meeting, which attracted 26,000 attendees and ran from 13 to 18 August. But, she added, "there are still too many areas where we're not doing enough."
According to new figures from the World Health Organization (WHO), at the end of June 2006, 6.8 million infected people in low- and middle-income countries needed anti-HIV drugs, but only 1.65 million were receiving them. "We're still behind the eight ball," said former U.S. President Bill Clinton, whose foundation helps countries negotiate lower prices for antiretroviral drugs. Scaling up access to drugs won't solve all problems, either. "We can't treat ourselves out of this epidemic," said epidemiologist Kevin De Cock, the new head of WHO's HIV/AIDS program. In his keynote speech, Bill Gates did a crude mathematical exercise and concluded that, with 38.6 million infected people in the world, it would soon cost a minimum of $13 billion a year just for the drugs required to treat everyone in need. "Treatment without prevention is simply unsustainable," he said.
A key limitation to both treatment and prevention efforts is that 90% of infected people do not know their status. De Cock and many others stressed the need to move beyond voluntary counseling and testing to "provider-initiated testing," in which health-care workers recommend, without insisting, that people get screened for HIV. Botswana for the past 2 years has increased testing with this "opt-out" policy, and nearby Lesotho recently launched a "know your status" campaign.
With trials ongoing in several countries, one of the most promising prevention strategies is pre-exposure prophylaxis (PrEP)--providing anti-HIV drugs to the uninfected. Leigh Peterson of Family Health International in Research Triangle Park, North Carolina, described the combined results of studies in Nigeria, Ghana, and Cameroon that involved 936 women at high risk of becoming infected. The women took either the anti-HIV drug tenofovir or a placebo each day. Although too few infections occurred to determine whether PrEP worked, the researchers mainly aimed to assess safety, and no one appeared harmed by the drug. Nor was there any indication that PrEP encouraged people to take more risks, as some feared: Women in both arms of the study reported using condoms more frequently than at the trial's start and also reduced their number of sexual partners. "They're very intriguing results," said Kenneth Mayer, who directs the Brown University AIDS Program in Providence, Rhode Island.
Uganda has been widely praised for reducing HIV prevalence in the 1990s, in part through campaigns that led people to limit their number of partners. But results from a large, multiyear study suggest that such gains are hard to sustain. In the Masaka district--chosen as a representative rural area--prevalence increased in both men (5.6% to 6.7%) and women (6.7% to 8.9%) between 2000 and 2005. New infection rates also were strikingly high in men between the ages of 40 and 49. Leigh Anne Shafer, an epidemiologist with the U.K.'s Medical Research Council who conducted the study with the Uganda Ministry of Health, said she does not know what accounts for the rising prevalence but thinks that people may have "prevention fatigue," leading to increased risky sexual behavior.
More disturbing news came from a report suggesting that "extensively" drug-resistant (XDR) tuberculosis--in which people fail all TB drugs--may be a much more widespread problem than appreciated. Worldwide, only 347 cases of XDR were identified between 2000 and 2004. But Neel Ghandi of Albert Einstein College of Medicine in New York City reported here that of 544 tuberculosis patients in KwaZulu-Natal, South Africa, 53 were dually infected with HIV and XDR TB; 52 died quickly. "It's ominous," says Gerald Friedland of Yale University, who headed the study. "XDR TB may be present in other locations, but it has not been looked for because it requires culturing TB, and that's minimally available in Africa. It needs to be looked for more aggressively now."
On a more hopeful note, researchers reported encouraging new data about an anti-HIV drug from Merck that won much attention this winter (Science, 17 February, p. 943) for rescuing people who had developed resistance to every other antiretroviral drug. A 24-week study showed that this so-called integrase inhibitor, when given in combination with other antiretroviral drugs to previously untreated people, quickly reduced the virus to undetectable levels. "This is a tremendous drug," said Joseph Eron, a clinician at the University of North Carolina, Chapel Hill, who has patients in the study.
The usual roar of AIDS activists assailing governments and researchers was muted this year, as attendees from many quarters blasted South Africa's leaders for still flirting with the idea that HIV doesn't cause AIDS. Canadian Prime Minister Stephen Harper also attracted scathing reprimands from activists, researchers, and even a U.N. official for not attending the meeting. "Your action sends a message that you do not regard HIV/AIDS as a critical priority," charged conference co-chair Mark Wainberg, who heads the McGill University AIDS Centre in Montreal, Canada. "Clearly all of us here tonight disagree with you." Wainberg received a standing ovation.
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