Experts See Hope, Despair at AIDS Meeting

Global AIDS experts begin gathering in Amsterdam today for the opening of the eighth International Conference on AIDS in a mood buoyed by the pace of scientific advances, but tempered by the sobering reality that the pandemic is still raging out of control in many regions of the world.

In hundreds of papers and other presentations throughout the week, more than 9,000 scientists, clinicians and other experts from 125 countries are expected to report steady progress in therapies, vaccine development and in understanding the workings of the human immunodeficiency virus.

But the news from the developing countries, where AIDS continues to spread unabated, is expected to be exceedingly grim.

“The global effort against HIV/AIDS has reached a dangerous impasse,” said Dr. Jonathan Mann of Harvard University’s AIDS Institute and chairman of the international meeting. “A realistic analysis reveals that the gap between the expanding . . . epidemic and lagging national and international response is increasing rapidly, leaving the world more vulnerable to the spread of HIV.”

Recently, Mann released a report from the Harvard-based Global AIDS Policy Coalition that projected 110 million adults would be infected with HIV by the turn of the century, a figure three times that predicted by the World Health Organization. Mann is the former director of WHO’s AIDS program.

Now, as many as 2.6 million people worldwide are suffering from AIDS, and nearly 13 million are infected.

In the United States, as of June, there have been 230,179 AIDS cases since the epidemic began in 1981, and 152,153 deaths. About 1 million Americans are believed to be infected with HIV.

“The pandemic is moving right along, but the efforts against it are plateauing, and in some cases declining,” Mann said in an interview. “While a tremendous amount has been accomplished, somehow we have not been able to move it to the next level--the one that would reassure us we’re bringing it under control and care for people who need care.”

It is especially frustrating because “we know we have the capacity to control AIDS (through prevention and education) and care for all affected,” he added.

Dr. Anthony S. Fauci, who heads the U.S. government’s AIDS research effort, agreed that the disease is spreading worldwide at a disturbing rate.

“If you look at what’s happening in Africa and what will happen in Asia, you have reason to be very pessimistic,” he said. “All the signs indicate that the pandemic is not slowing down at all.”

On the scientific front, however, he and others said the news is much more encouraging.

“We’re learning an incredible amount. . . . It’s a very exciting and rapidly evolving field,” said Fauci, who is director of the National Institute of Allergy and Infectious Diseases.

Since the first international AIDS meeting was held in Atlanta in 1985, the annual conference has evolved as the most important global forum for the exchange of knowledge about the deadly disease.

Nevertheless, it has undergone some rocky times, particularly this past year when its sponsor, Harvard University, was prompted to move the meeting from Boston--where it had been slated to take place--to a country without restrictive immigration rules against HIV-infected travelers.

“I think the conference will be looking at the immigration issue, but not just at the United States in isolation,” said Dr. Mervyn F. Silverman, president of the American Foundation for AIDS Research. “We are not standing alone as the only black sheep in the bunch. But we should be more enlightened, based on what we know (about AIDS transmission), and considering the history of civil rights in our country.”

The policy, which forbids entry into the United States by HIV-infected individuals, was imposed by Congress in 1987. Lawmakers amended the law, giving the secretary of health and human services the authority to decide what medical conditions should bar travelers and immigrants from coming into the country. The Bush Administration was poised to remove AIDS from the list, but backed down after heavy political pressure from conservatives.

Unless the U.S. policy changes, it is unlikely that any international AIDS meeting will be held in the United States. The conference is scheduled for Berlin next year and Japan in 1994. After 1994, the meetings will take place every other year.

This year’s meeting has already yielded some intriguing results. On Saturday, in a pre-conference session sponsored by the American Medical Assn., UCLA researchers released the first international comparison of physicians’ attitudes toward treating AIDS patients. The study found “significantly higher” levels of reluctance among medical residents in the United States than in France or Canada, two other countries with a considerable AIDS caseload. The study will appear in the July 22 issue of the Journal of the American Medical Assn.

Dr. Martin F. Shapiro, associate professor of medicine at the UCLA School of Medicine and the lead author of the study, said cultural norms and public perceptions of the epidemic “may profoundly affect physicians’ responses to it.”

Furthermore, the study showed that Americans were far more likely to view caring for AIDS patients as “dangerous.” French physicians expressed the least reluctance to care for homosexual men, intravenous drug users and other AIDS patients, compared to Americans, who expressed the most.

The study was conducted with researchers from the University of Michigan in Ann Arbor, the Assn. for the Prevention of AIDS and the Regional Center for Information and Prevention of AIDS, both in Paris.

Researchers also reported Saturday that a contraceptive sponge containing the common spermicide nonoxynol-9 proved ineffective in preventing the transmission of HIV in women at high risk for AIDS and other sexually transmitted diseases.

The spermicide, which has shown some evidence of inhibiting HIV infection in the laboratory, showed no protective effect against HIV in a placebo-controlled study of HIV-negative prostitutes conducted by researchers at the University of Washington. Forty-five percent of the nonoxynol-9 group and 36% of the placebo group became infected, the researchers said. This study will appear in the same issue of JAMA.

Researchers said that use of the sponge, with its high dose of spermicide, was also associated with a more than threefold increase in genital irritation and ulcers among the women--conditions which may increase the danger of HIV transmission.

In an accompanying editorial, JAMA called for additional studies of vaginal spermicides for reducing the chances of HIV transmission, but said that “in the meantime, we should redouble our efforts to facilitate condom use among men and women at risk.”

Other areas expected to receive attention at this week’s meeting:

* Vaccines. There are about 15 experimental HIV vaccines being tested in humans, including preventive and therapeutic vaccines. Dr. Robert Redfield of Walter Reed Army Hospital and Dr. Fred Valentine of New York University Medical Center are expected to discuss the results of their studies.

Also, Dr. Abdelizsiz Benjouad of the Institut Pasteur in Paris and Dr. Run-Hou Lee of Harvard are scheduled to present research involving the development of a vaccine that involves the removal of sugar from the HIV molecule, a process that may be important in the quest to develop a vaccine.

Dr. June Osborn, a virologist who chairs the National Commission on AIDS, is scheduled to give a talk speculating on “what we would be able to do with a vaccine if we had one--and the answer is, ‘not much,’ ” she said.

“Many think about a vaccine as something that--when it comes--we can all relax,” she said. “The truth is, a vaccine will never be able to bring under total control an epidemic of this nature.”

* Early stages of infection. Fauci plans to discuss the growing knowledge of what happens to the virus during the earliest stages after infection, when it is difficult to detect HIV in the blood. His research shows that considerable viral replication occurs during that time, particularly in the body’s lymph nodes.

The work is likely to raise questions about whether treatment with antiviral agents at this point could have an impact on the rate at which individuals become sick. The National Institute of Allergy and Infectious Diseases is planning to begin a placebo-controlled study soon to determine whether AZT given in an extremely early stage can slow viral replication and extend the time that individuals remain free of symptoms. The greatest difficulty will be in identifying people at that extremely early stage of infection.

* AZT. There have been several conflicting studies in recent months over the risks and benefits of using AZT and combination therapy to treat individuals who are infected but do not show symptoms. Several presentations are scheduled to clarify the issues.

* Gene therapy. This is a new area of exploration, in which white blood cells are genetically altered to increase their ability to combat HIV and interfere with its replication.

* New classes of drugs, such as protease and TAT inhibitors, which bind to key proteins manufactured by the virus and, it is hoped, will interrupt the process of viral replication.

* Funding. AIDS activists and people with HIV are expected to be highly visible during the meeting, and are scheduled to release a report analyzing AIDS spending at the National Institutes of Health. It was prepared by Mark Harrington and Greg Gonsalves, members of the Treatment Action Group.

* The definition of AIDS, and whether a single standard should be adopted worldwide. This is an issue that is being debated in the United States; it is considered extremely important because in industrialized nations it is often the basis for determining health benefits and care, particularly for women with HIV. Conversely, some evidence is expected to be presented that, outside the United States and Europe, those defined as having AIDS receive less care.

* Women and HIV. Conference organizers have scheduled about 20 sessions to discuss various aspects of AIDS and women, feeling that the topic has been neglected. Several studies are expected to show that effective preventive and educational programs for women must deal with issues of power, particularly those involving non-consenting sex.

Doctors’ Survey

In the first international comparison of physicians’ attitudes toward treating AIDS patients, UCLA researchers found “significantly higher” levels of reluctance among medical residents in the United States than in either France or Canada.

The survey was conducted among internal medicine and family practice residents in three regions of France, all 10 Canadian provinces, and 10 American states, including the three (California, New York and New Jersey) with the nation’s highest rates of AIDS. QUESTION: Percentage strongly agreeing it is unethical to refuse to provide care:

U.S. CANADA FRANCE Because patient might have AIDS 56% 87% 64% Because of patient’s sexual orientation 69% 78% 88%

QUESTION: Percentage who, if given a choice, would not take care of:

U.S. CANADA FRANCE Patients with AIDS 23% 14% 4% Homosexual patients with AIDS 23% 16% 5% Intravenous drug users with AIDS 42% 26% 7% Homosexual men 11% 6% 2% Intravenous drug users 41% 22% 9%

QUESTION: Percentage who believe caring for AIDS patients is dangerous:

U.S. CANADA FRANCE 37% 21% 24%

QUESTION: Percentage who had an HIV-infected patient previously refused care by a surgeon:

U.S. CANADA FRANCE 39% 13% 8%

QUESTION: Percentage believing that their training in AIDS ambulatory care was deficient:

U.S. CANADA FRANCE 58% 76% 62%

QUESTION: Percentage who feel clinically competent to provide usual/primary care for AIDS patients:

U.S. CANADA FRANCE 68% 40% 34%

SOURCE: UCLA