The importantand the overlooked

All the latest from the AIDS 2010 Conference in Vienna, Austria Important: The C Word Scientists have long complained that science takes a back seat at the International AIDS Conference, but it came back with a vengeance in Vienna. Drugs to treat HIV/Aids are getting much better: Researchers are getting closer to a pill-a-day that has few side effects and lessens the risk of resistance. Several sessions were devoted to the notion that HIV can be eliminated from the body or suppressed permanently – meaning a cure. Until recently, no one dared utter the C word. Overlooked: The other C word Studies conducted in southern Africa show that male circumcision can reduce a man’s risk of HIV infection by 60%. In the dozen countries with the highest HIV/Aids rates in the world, circumcision rates are less than 10%. The conference heard of ambitious, if vague, plans to raise that to 80%. In practical terms, that means removing the foreskins of 41 million men, but fewer than 150 000 operations have been done since the data were first published a few years back. Circumcision is a cause that has potential, but does not have an obvious champion. Important: The invisible condom Scientific sessions are rarely interrupted with repeated applause, but that is what happened when South African researchers presented data showing that using a simple gel can cut a woman’s risk of contracting HIV by more than 40%. While a commercially available product is years away, this is potentially the biggest advance in the field of HIV/Aids since the introduction of antiretroviral drugs in 1996. Microbicides matter because, in large parts of the world, women simply do not have the ability to refuse sex or to insist on the use of condoms. The new gel also works remarkably well at preventing herpes infection, which means it will have a market in Western countries such as Canada, too. Overlooked: The really invisible condom One of the cheapest, most effective and proven prevention methods is the condom. Yet, as new measures come along – microbicides, antiretrovirals (ARVs), circumcision, etc. – investments in condoms and safer-sex campaigns have fallen off. According to the United Nations Population Fund, 2.7 billion condoms were distributed last year. It is estimated that 13 billion condoms are needed. Important: South Africa rising It is the country with the most people living with HIV/Aids, a staggering 5.5 million in a population of 48 million. Yet, it was long a pariah in the HIV/Aids world because political leaders aligned themselves with fringe groups that argue HIV does not cause Aids, and sat on their hands as the epidemic ravaged the country. Today, the HIV infection rate has levelled out, more than one million people are on treatment, and the country has an aggressive campaign to prevent mother-to-child transmission and promote male circumcision. Aaron Motsoaledi, South Africa’s Minister of Health, attended the conference – a symbolic message that the country is finally taking the epidemic seriously. That is a sea change. Overlooked: The missing giants Between them, China and India account for 37% of the world’s population. Yet, news from the two countries was virtually nonexistent at the AIDS Conference. Why? On a per capita basis, their HIV/Aids epidemics are modest: an estimated 700 000 people living with HIV/Aids in China and 2.4 million in India. A decade ago, there were dire predictions of 100 million HIV/Aids infections in India alone, but there were aggressive initiatives in high-risk groups such as commercial sex workers and migrant workers. In China, there is little HIV testing and much stigma so the official numbers may be deceiving, but the country has no-nonsense campaigns promoting condom use and methadone treatment for intravenous drug users. Regardless, the Aids world cannot afford to avert its eyes from these two behemoths. Important: The war on the war on drugs The Vienna Declaration – a scientific statement that argues the criminalisation of drug use is fuelling the HIV/Aids epidemic and countries need to adopt scientifically proven methods such as needle exchange, methadone treatment and the like – was one of the most talked about initiatives at the conference. In fact, there was unprecedented attention paid to HIV/Aids among drug users, an issue that has long been overlooked because it makes politicians – who ultimately fund programmes – very uncomfortable. Overlooked: Glastnost? Glast-not Russia is home to one of the most explosive epidemics of HIV/Aids in the world, one fuelled by IV drug use. Yet, the country’s political leaders are virtually silent. Russia has among the most draconian drug policies in the world: Prisons are overflowing and public-health initiatives such as methadone treatment are illegal. Russian officials have said, essentially, that they will not fund HIV/Aids programmes for drug users, prisoners and sex workers, and they blatantly thumbed their nose at the AIDS Conference in Vienna. Important: We are all for access Just before the Vienna conference, the United Nations Joint Programme on HIV/AIDS unveiled a bold call for a “prevention revolution”, dubbed Treatment 2.0. The plan is to get 15 million HIV-infected people on treatment – up from five million today. The idea has been much talked about and the notion that treatment for HIV is a human right enthusiastically endorsed. One of the most enticing aspects is that treating everyone could lead to a sharp drop in new cases. But there is a dangling sword of Damocles – money. Treatment 2.0 would cost $26 billion annually, about $10bn more than wealthy countries currently contribute to HIV/Aids treatment. Overlooked: Access for all The challenge of ARV treatment was once cost. But the cocktails of drugs that cost about $10 000 a year in the Western world can now be had for as little as $100 in the developing world. The new challenge is to keep millions of people on treatment in an uninterrupted manner indefinitely – or until there is a cure. If treatment is interrupted, the virus becomes resistant to drugs and more expensive drugs are required – with the cost going up tenfold with each level of failure. It has been demonstrated that millions can be treated, but can it be sustained? The answer to that question will ultimately be the legacy of the Vienna conference. André Picard Picard is a public health reporter with Canada’s “Globe and Mail” newspaper