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http://www.nytimes.com/2002/07/16/health/16DOCS.html

The Urgent Search for an AIDS Plan

By LAWRENCE K. ALTMAN, M.D.

ARCELONA, Spain, July 14 — In theory, AIDS is preventable and treatable. But in reality, AIDS has spread so rapidly it rivals the worst epidemics in history.

AIDS has killed more than 20 million people since 1981, when the first cases were discovered in the United States. Today, 40 million people live with H.I.V., the AIDS virus, and most are doomed to die for lack of the powerful combinations of drugs that can control the infection. And because these people lack access to the blood test that can tell if they are H.I.V. infected, they may unwittingly transmit the virus to another 45 million people by 2010.

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The magnitude of the epidemic is a tragedy that speakers at the 14th International AIDS Conference held here last week attributed directly to the failure to make effective preventions and treatments available to vast populations in Africa and elsewhere.

The preventions include relatively inexpensive and simple measures: disease information, sex education, safe sex, condoms, needle exchange programs and blood tests.

Treatments include drugs to counter H.I.V. and the unusual infections that accompany AIDS. Lack of anti-H.I.V. therapy has orphaned at least 11 million children.

"That is why treatment is so important in developing countries," said Dr. Peter Piot, the under secretary general of the United Nations in charge of its AIDS program.

A solution to better control the epidemic, AIDS experts and economists said, is to spend $10 billion a year, largely from donations from rich countries.

But what is the most effective way to spend it? Preventing more people from becoming infected? Or treating those who are infected?

Some AIDS experts had expected vested interest groups at the conference to bitterly debate the priorities. But if the rhetoric from the 17,000 participants from 124 countries at the largest AIDS conference ever held is a valid indicator, there was an overwhelming consensus for supporting prevention and treatment because one cannot work without the other.

"The issue has been widely discussed, and common sense and basic health principles say both need to go together," said Dr. Jordi Casabona, an infectious-disease expert in Barcelona and a co-president of the conference.

Without a vaccine, few epidemics can be controlled by treatment or prevention alone, Dr. Casabona said at the closing news conference.

"The conflict between prevention and treatment has been blown out of proportion," said Dr. Merle A. Sande, an AIDS expert at the University of Utah.

"Most everyone involved in treating AIDS believes that prevention is more important yet feels that the millions of infected people deserve therapy," said Dr. Sande, who resigned as chairman of medicine at the University of Utah to commute to Uganda from Salt Lake City to direct the Academic Alliance for AIDS Care and Prevention in Africa. Pfizer has given a large grant to the alliance, which teaches African doctors how to use the powerful combinations of anti-H.I.V. drugs.

However, Dr. Julio Frenk, the Mexican health minister, introduced a cautionary note by urging participants to do further research to determine what programs work or fail.

"Just as we don't have enough evidence to demonstrate the effectiveness of prevention programs, we don't fully know how to allocate resources among interventions in the most efficient manner," Dr. Frenk said.

With action needed before definitive answers are in, the United Nations is set to issue a plan of attack for the October meeting of the Global Fund for AIDS, Tuberculosis and Malaria. With about $3 billion of its $10 billion goal in hand, it is unclear whether this will be sufficient to support a comprehensive prevention and treatment strategy. So supporters of each are likely to lobby and compete for the available money, just as scientists have long done in seeking grants from the government and private foundations.

The world lost valuable time in controlling AIDS when the epidemic was much smaller. It was a time when experts pinned their hopes on quick development of a vaccine instead of aggressive, large campaigns to stress other prevention measures like H.I.V. testing, safe sex and condom use.

Political leaders contributed to the delay. Bill Clinton said in an interview here that he regretted not having done more to control AIDS while he was president and that he was wrong not to push harder for needle-exchange programs to prevent transmission among injecting drug users and then to their sexual partners. Former presidents rarely make such admissions, particularly so soon after leaving office.

Drug users are fueling the initial stages of epidemics in many countries, including those of the former Soviet Union.

The delay in not responding more effectively and earlier to the AIDS epidemic now makes prevention and treatment even more challenging because of the magnitude of the epidemic.

"We have known what works" in preventing AIDS for several years but it did not get translated into enough action, said Dr. Helene Gayle, who headed the AIDS program at the Centers for Disease Control and Prevention and now is on loan to the Bill and Melinda Gates Foundation.

In a report sponsored by her foundation and the Henry J. Kaiser Family Foundation, Dr. Gayle and more than 30 other experts wrote:

"Effective H.I.V. prevention is more than education, and more than a condom, a clean needle or any other single commodity. Effective H.I.V. prevention involves a thoughtful, planned combination of interventions and policies that work synergistically to reduce overall rates of transmission."

People at high risk for AIDS need to know what causes it and how to avoid it. But "it is staggering how much people still don't know" about AIDS in China, India and the former Soviet Union, where H.I.V. is being transmitted at alarming rates, Mr. Clinton said.

"One of the things that I have been a little concerned about is that they have put too much emphasis on getting the public health network pieces up, which is good, but relatively too little on just putting the stuff out there through the airways and watching the grass-roots people change their behavior," Mr. Clinton said.

In the former Soviet Union, where H.I.V. is being spread through heterosexual sex, Mr. Clinton said, "the extent to which young girls are still engaging in dangerous behavior either because they are constrained to it or think it is their only way out of abject poverty in that part of the world is chilling."

Still, experts say they have much to learn about what messages to send to those at the highest risk of infection.

In the epidemic's infancy, when 150,000 Americans were acquiring H.I.V. each year, most infected people were gay white men. The new face of AIDS in the United States now is largely female and black, as it is elsewhere.

The 40,000 Americans who have become infected in each of recent years is fewer than the 150,000 infected annually in the mid-1980's, but remains far too high and requires delivering new prevention messages in new ways, health officials said.

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To make therapy more effective in the third world, C.D.C. researchers have developed less costly versions of two tests commonly used to determine when to start anti-H.I.V. drugs and to monitor their effectiveness. One is a new method to monitor, at one-fourth the cost of the standard tests, the number of the CD-4 immune cells in the blood that the AIDS virus destroys. The second is a new way to monitor the amount of H.I.V. in the blood at one-fifth the cost of standard tests.

The ideal prevention would be a vaccine that prevents nearly all recipients from becoming infected and unable to transmit the infectious agent to other people. But no such vaccine exists for AIDS and none is likely to be available for several years, if one is ever developed, experts said.

Dr. Lawrence Corey, a vaccine researcher at the University of Washington, said at the conference that there were hints from early studies that the newest experimental AIDS vaccines might lower the amount of H.I.V. in the blood to slow the progression of infection to illness and modify symptoms but not prevent transmission.

It will take years to do the trials to learn whether the experimental vaccines could prevent transmission of H.I.V. and how long they would work. "This is the deck we may be dealt," Dr. Corey said in urging policy makers to start thinking about how to put them in place in the event they are licensed.

Another reason for linking prevention and drug therapy is that studies have shown that lowering the amount of H.I.V. in the blood reduces the risk of its transmission to other people.

But the risk is not zero, a finding that tells health officials they need to bolster anti-H.I.V. treatment efforts with messages to prevent a mistaken belief among patients that they can abandon safe sex practices.

Studies have shown that anti-H.I.V. therapy needs to be taken for a lifetime because the drugs cannot rid the body of the virus. And because H.I.V. has increasingly developed resistance to the drugs, the International AIDS Society, a conference sponsor, and the World Health Organization announced that they were developing a program to monitor H.I.V. drug resistance throughout the world.

Experts say they are uncertain how often resistance makes therapy ineffective. Whatever the frequency, Dr. Stefano Vella, the outgoing president of the International AIDS Society, Dr. Scott M. Hammer, an AIDS expert at Columbia's College of Physicians and Surgeons in New York City, and other leaders cautioned against using resistance as an excuse for not offering treatment in the third world.

At a panel sponsored by the International AIDS Trust, a number of current and former heads of state pledged to encourage more political leaders to speak out on AIDS by fighting denial, discrimination and stigmas and to replace rhetoric with action.

Ali Hassan Mwinyi, a former president of Tanzania, recalled that when AIDS first appeared in his country "it caused panic, confusion and denial among all of us because we all were sexually active."

Leaders are now duty-bound to fight the confusion and educate their people, Mr. Mwinyi said, and "a leader who speaks about condoms will influence people to use condoms."

In underscoring the importance of accountability, Dr. Piot, the United Nations official, said voters should replace the world's political leaders who do not provide what is needed to combat AIDS.

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