More than three years after HIV/AIDS physicians began reporting an alarming trend of patients with high triglyceride levels, insulin resistance, accumulations of fatty tissue, and/or other alterations in body shape, the jury is still out on exactly what causes the phenomenon known as lipodystrophy or HIV-related adipose redistribution syndrome. In fact, after major studies in the United States, Australia and Europe, as well as three international workshops specifically addressing the problem, researchers have yet to arrive at even a common definition for the problem generally referred to as lipodystrophy
Perhaps the biggest headline to emerge during ICAAC came not from the Toronto convention center but from Rockville, Md., where the US Food and Drug Administration (FDA) gave its seal of approval to Abbott Laboratories' second PI, lopinavir.
With the success of HAART in industrialized nations, the AIDS epidemic turned two corners. The obvious one is that effective combination therapy has allowed thousands of HIV-infected patients to live longer, more productive lives. The other is far more subtle.
When William Lewis (Emory University, Atlanta) started studying cardiomyopathy in mice exposed to zidovudine (AZT), his was a lonely pursuit. It was 1989, the tender morn of this antiretroviral age. And while many AIDS clinicians rejoiced to see how quickly anti-HIV therapy had come from bench to bedside, Lewis recalls he chose a road less taken--from bench to cageside.
The ongoing devastation wrought by HIV/AIDS is requiring governments to take bold actions to stem the tide of HIV and its resulting impact on citizens and society as a whole. Yet recent announcements in Botswana and Swaziland demonstrate a dangerous temptation for governments that are under extreme pressure. Officials in both countries are on the verge of crossing the line from aggressively proactive to dangerously rash.
Scientists and doctors are confident that they now know how to prevent most cases of mother-to-child transmission of the HIV virus during delivery, but a number of factors make it very difficult to do so in resource-limited settings.
The XIII International AIDS Conference, held July 9-14, 2000, in Durban, South Africa, was praised by participants for its focus on inclusion: of delegates from resource-limited countries, of community representatives, and of women. The presence, voices, and experiences of African women in particular set the Durban conference apart.
One world. One hope. That was the theme of the XI International AIDS Conference, held in Vancouver, Canada, several years ago. The words came to mind while I chaired a session on innovative models of care provision at the XIII International AIDS Conference, held July 9-14, 2000, in Durban, South Africa.
In a matter of weeks, US voters will go to the polls to choose a new president. When the votes are tallied Albert Gore Jr. or George W Bush will occupy the White House, taking on what arguably is the most complex job in the world. The new president will face an AIDS pandemic that has shifted dramatically since 1992, when the United States last ushered in a new presidential administration.
The International Association of Physicians in AIDS Care is a nonprofit professional association representing 10,000 physicians and other healthcare professionals in 52 countries. Founded in 1995, IAPAC develops and implements global educational and advocacy strategies to improve the quality of care provided to all people living with HIV/AIDS and other coinfectious diseases.
Africa is a land of vast wealth. Especially south of the Sahara, these riches reach fairy-tale proportions. Half of the world's gold comes from South Africa, Ghana, and Zimbabwe--half the diamonds from South Africa, Botswana, and Congo. Uranium, platinum, and petroleum abound. Copper, cobalt, and antimony teem. Almost all the world's chromium rests in the continent's southern end.
Acquired immune deficiency syndrome is a disease wrought with social, political, and scientific controversies that predate even the naming of the scourge. HIV has withstood an unprecedented assault of money and scientific talent to tame its nature, remaining unconquered after almost two decades of research.
As the epidemic's second decade lurches toward its close, HIV headlines have been hogged by issues unanticipated even three years ago: adiposity with fat wasting, hyper lipids and hapless insulin, swashbuckling new strategies like structured treatment interruptions (STIs), and the high cost of importing anti-HIV meds into countries where oft-buried disbelievers in HIV are promenaded from sepulcher to soapbox.
As the epidemic's second decade lurches toward its close, HIV headlines have been hogged by issues unanticipated even three years ago: adiposity with fat wasting, hyper lipids and hapless insulin, swashbuckling new strategies like structured treatment interruptions (STIs), and the high cost of importing anti-HIV meds into countries where oft-buried disbelievers in HIV are promenaded from sepulcher to soapbox.
"It was appalling to me that I could list on one slide more or less everything that we know about HHV-8 prevalence and transmission," Harold Jaffe told the 4th International AIDS Malignancy Conference, which met on the campus of the US National Institutes of Health in Bethesda, Maryland, May 16-18, 2000.
Something was not quite right. Yet the Abbott Laboratories delegation could not immediately identify the source of the discord. The small group, headed by William G. Dempsey, Abbott's senior vice president of international operations, was visiting a Tanzanian village in the course of learning more about the local population's HIV-related needs.
Take a step back in time. The day is July 7, 1996. In a darkened lecture room of the Ford Centre for the Performing Arts in Vancouver, British Columbia, Canada, hundreds of scientists, physicians and media are gathered to hear David Ho unravel the mysteries of HIV infection.
"The problems caused by HIV disease in the developing world are so enormous and so grave that it makes sense for us to devote substantially more of our human and financial resources there," says José M. Zuniga, president of the International Association of Physicians in AIDS Care (IAPAC).
A standard lament at any meeting on HIV-related lipodystrophy concerns the lack of consensus on a case definition and even on whether these strange fat changes reflect one or two or more syndromes. Don't even mention the still uncertain gropings toward mechanisms. Attempts to get a handle on lipodystrophy can seem very much in the very-like-a-whale stage.
The Queen Saovabha Memorial Institute in Bangkok is best known to tourists for its snake farm. People watch in fascination as poisonous venom is extracted from cobras, vipers, and kraits at daily "milking" sessions.
AIDS in Africa has reached such catastrophic levels that analogies to past wars or plagues no longer drive home the present-day urgency. AIDS on the continent is not only affecting so many, but even more catastrophic, of course, is that adequate care and treatment for HIV infection is essentially nonexistent in most African settings.
No, it's not that ardent research or innovative regimens have solved the salvage riddle. Indeed, version 3.0 of this workshop confirmed yet again the difficulty of reining in a runaway virus that has stampeded through just a couple of combos.
Microbicides 2000 brings "a level of seriousness and credibility that the field hasn't had before," UNAIDS Executive Director Peter Piot, MD, told the opening session of the conference. "We cannot wait until the day we have a vaccine. . . . We have to apply today what we know works" in reducing the spread of HIV.
Does a one-dose-fits-all strategy work for antiretrovirals? Or, as Northwestern University's Concepta Merry, MB, PhD, asked a roomful of pharmacologists at a rain-swept North Sea resort, will that monolithic tactic so speed the pace of treatment failure that HIV will once again go unchallenged?
Ever since blue-ribbon panels and big AIDS meetings began inviting Charles Flexner to speak, the wider HIV community has found out what his Johns Hopkins colleagues already knew: Flexner possesses not only an acute understanding of antiretroviral pharmacokinetics, but also a rare knack for explaining this complicated field to the uninitiated, and for warning us what those complications may portend.
Molecular aspects of HIV pathogenesis and transmission in vivo have been analyzed in detail for two decades, and understanding of these aspects of HIV infection has increased greatly over this period. As a result, many successes in anti-HIV therapy have been rationally designed, based on a clear understanding of the viral life cycle and HIV pathogenesis.
It is intolerable that limited economic resources, so often experienced at the present time, should in fact have repercussions mainly on the weaker sectors of the population and on the less well-off areas of the world, depriving them of necessary healthcare.
Our ward rounds are interrupted by the frantic motions of nurses in the next cubicle. Their insistence makes it clear that a serious problem demands our immediate attention. We arrive at the bed of a wasted, motionless infant with obvious signs of aspiration.
Adefovir dipivoxil (trade name Preveon) is the first HIV antiviral drug that the Antiviral Drugs Advisory Committee of the Food and Drug Administration (FDA) did not recommend for accelerated approval. (The Committee deadlocked 4-4 on delavirdine, which the FDA subsequently approved.)
"It is clear to many people in developing countries that researchers from elsewhere do not come to visit us predominately for altruistic reasons," said Solomon Benatar, MD, head of the department of medicine at the University of Cape Town in South Africa. "There is a widely held perception by many vulnerable people that they are being exploited."
I have been thinking a lot about a report I read recently indicating that there are today more than a quarter-billion regular Internet users. Indeed, the birth of the World Wide Web in 1991 ushered in a new era in the Information Age, providing people access to the structured delivery of issue-specific information at the stroke of a key or the click of a mouse button.
Years from now, how will the 7th Conference on Retroviruses and Opportunistic Infections be remembered? For many who winged westward from other parts of the USA for the January 30-February 2 San Francisco meeting, the most cherished memory may be the escape from cruel winter.
Maintaining a quality publication in a competitive market is tough. Raising the quality is even tougher. Since 1995, the International Association of Physicians in AIDS Care (IAPAC) has published a monthly journal aimed at offering our members and non-member subscribers access to cutting-edge clinical and public policy information in a digestible format.
David J. Back, PhD; Sara E. Gibbons, MPhil; Saye H. Khoo, MB, MD; Concepta Merry, MB, PhD; Michael G. Barry, MB, PhD; Fiona Mulcahy, MB, MD
The introduction in 1995 of protease inhibitors (PIs) as a component of antiretroviral therapy dramatically decreased mortality and morbidity due to HIV infection, most clearly demonstrated by the reduction of opportunistic infections and hospital admissions. More recently, nonnucleoside reverse transcriptase inhibitors (NNRTIs) have shown impressive sustained antiviral effects.
Although much of this conference has focused on testing for antiviral resistance, the main problem confronting many less industrialized countries continues to be diagnosis of HIV with antibody tests. Great progress has been made in screening blood to prevent transfusion-associated HIV transmission. However, in many countries, HIV antibody testing is not widely available.
After ganciclovir (GCV) and foscarnet were introduced into clinical use in the late 1980s for the treatment of human cytomegalovirus (CMV) disease, several groups reported the appearance of clinical resistance to these compounds.
Clive Loveday, MB BS, PhD
Department of Retrovirology, Royal Free and University, College Medical School,
London, United Kingdom
Drug resistance testing has supported therapy for infectious diseases for many years. The use of resistance testing in HIV/ AIDS has been limited until recently by a need for appropriate technology and a lack of evidence from randomized controlled trials.
Hubert G.M. Niesters, PhD Molecular Diagnostics, Department of Virology, University Hospital Rotterdam,
Rotterdam, The Netherlands
Understanding of the pathogenesis of HIV/AIDS has advanced considerably in the last few years. Reliable laboratory testing and accurate measurement of viral RNA by polymerase chain reaction (PCR) or branched DNA (bDNA) hybridization assays have revealed much about the relation between disease progression and viral replication.
Gaby E. Pfyffer, PhD Swiss National Center for Mycobacteria Department of Medical Microbiology, University of Zurich
Zurich, Switzerland
According to the World Health Organization (WHO), more people will die of tuberculosis (TB) this year than in any other year in history. Of equal concern, however, are the emergence and nosocomial transmission of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis.
Renslow Sherer, MD Director, Coordinated HIV Services, The CORE Center, Cook County Hospital, Associate Professor of Medicine, Rush Medical College
Chicago, Illinois, USA
Retrospective studies done in the past few years show that genotypic and phenotypic resistance testing of HIV can predict virologic outcome. More recently, two prospective studies documented short-term improvement in virologic outcome when genotyping was used to help select a new regimen for patients in whom highly active antiretroviral therapy (HAART) had failed.
I believe that the moral value of saving people's lives is still recognized. In a world which offers few opportunities for courageous acts, helping the most vulnerable in our society is perceived as one. Indeed, in many situations, people living with life-threatening illnesses, including HIV disease, are still successfully "rescued" through humanitarian efforts spearheaded by individuals, organizations, and governments.
In the midst of a growing wave of riots, protests, and other forms of rebellion, a group of delegates from twelve of the thirteen original colonies (Georgia was absent) met in Philadelphia's Carpenter's Hall in 1774 at the First Continental Congress to discuss how to return to a state of harmonious relations with the Mother Country. Revolution was not the agenda at this initial meeting, but radical thinking eventually won out.
For most in the audience, it was a sight rarely seen at an international AIDS conference. Seated side by side on the dais were representatives from some of the world's major pharmaceutical companies: Glaxo Wellcome, Merck, DuPont Pharmaceuticals, Abbott Laboratories, and Bristol-Myers Squibb.
There are few individuals I consider true heros. Gordon Nary, who at age 65 retired as executive director of the International Association of Physicians in AIDS Care (IAPAC) in January 2000, is among them.
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