Abstract
From July 7th to 12th 2002, researchers, scientists, clinicians, senior government officials, representatives of non governmental organisations, AIDS activists and persons living and affected by HIV/AIDS from all over the world met for the XIV International AIDS Conference. The theme: Knowledge and Commitment for Action; the place: the beautiful and hot Spanish city of Barcelona by the Mediterranean Sea. Held at the Fira de Barcelona and at Palau St Jordi adjacent to the Olympic stadium the conference attracted over 15,000 participants with more than 10,000 posters on display.
Conference programme
The main goal of the conference was to ensure the translation into action of knowledge gained from science and experience by means of seven tracks covering Science (Basic sciences, Clinical sciences & care, Epidemiology, Prevention science and Social science) and Action (Interventions & programme implementation and Advocacy & policy). The day kicked off with plenary lectures given by distinguished speakers at the Palau followed by track specific, per reviewed oral abstracts throughout the day with poster presentations and exhibitions, lectures, bridging sessions, symposia, debates, skills building and satellite workshops in between. Sound overwhelming? Exactly. One couldn't help feeling that you were missing out on important areas being presented in another session elsewhere.
Anti retroviral therapy
The when, how and with what to start anti retroviral therapy (ART) in adolescents and adults featured highly in the Clinical Sciences and care track. Treatment should be started in any patient with an AIDS defining illness (irrespective of the CD4 count) or a CD4 count of less than 200 cells. Several studies presented showed that more of those starting treatment with a CD4< 200 progressed to AIDS and death quicker than those with CD4s between 200 and 350 cells. Thus the ideal CD4 range to start patients on HAART would be between 200 and 350 cells. Treatment is unlikely to be initiated for these with CD4 counts greater than 350 unless viral load is >55 000. Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are preferred first line therapy in combination with two Nucleoside reverse transcriptase inhibitors (NRTIs). Efficacy rates for triple NRTI treatment with Abacavir, NNRTI or Protease inhibitor (PI) based were shown to be similar although the side effect profiles do differ.
Thus the regimen chosen must be based on potency, side effect profile, convenience, cost, accessibility, resistance if known and bearing in mind future treatment options. Treatment should of course be started when the patient and provider is ready to ensure maximum compliance and understanding with the primary aim being the reduction of morbidity and mortality and improvement of the client's quality of life in addition to the suppression of viral load and restoration and preservation of immunologic function. There is currently no room for dual therapy and structured treatment interruption is only to be considered in research settings, as the current data does not show sustained control of viraemia in the majority of patients after several cycles. Treatment should be changed if there is toxicity or treatment failure.
Resource limited settings
The argument that ART is not feasible and is likely to be more harmful in resource-limited settings is falling away. In his address at the closing ceremony Prof. Joep Lange, the incoming president of the International AIDS Society (IAS) questioned why we are more concerned about side effects than people lives, why we are more keen not to do harm than to do good. The best we can provide for our patients is anti retroviral therapy and the basic minimum lab investigations necessary are an HIV antibody test and a Haemoglobin level. A total lymphocyte count of <1,200 in the symptomatic patient can be substituted for the CD4 count if the latter is unavailable.
A good history documenting past and current HIV related illness, presenting symptoms and co-existing medical conditions (TB, pregnancy, diabetes) medication and a physical exam are needless to say essential. In those with TB it is recommended that HAART be initiated after the completion of TB treatment or the intensive phase. In those where there is a high risk of disease progression (i.e. CD4 <200 or disseminated TB), ART may be started. The treatment access campaigns for generic drugs from Cipla and Brazil for example mean that many more of our patients can appropriate life saving treatment for themselves and loved ones and using directly observed treatment schedules to enhance adherence, successful ART programmes can be and should be effected in the least developed yet most affected nations that we live in.
What news, what hope?
Using current HAART regimens, it would take more than sixty years to eradicate the HIV reservoir in an infected patient! There is also news of the epidemic on the increase in some parts of Africa with increasing risky sexual behaviour noted in those on HAART and particularly in men having sex with men in the West. There is also evidence that HSV2 infection increases the risk of acquiring HIV and that malarial parasitaemia increases HIV1 RNA levels thus raising public health concerns. Both Nelson Mandela and Bill Clinton dwelt on the stigma which HIV sufferers still face, as this becomes a barrier to HIV prevention methods, which must go hand in hand with treatment. However the development of microbiocides is promising and a vaccine should soon be available although this is more likely to prevent development of disease rather than infection. Several new classes of drugs may also be on the market soon. These include Entry and Integrase inhibitors and others that target cellular proteins involved in HIV replication. Prevention of mother to child transmission (PMCT) is also being given a new arm with PMCT Plus, an effort to extend medication to the immediate partner and children of the infected mum. Governments too do seem to be showing more commitment in the fight against HIV and this together with the Global AIDS Programme (GAP) and international collaborative efforts in research, treatment and prevention do offer us some hope.
Challenges for Malawi
The numbers of patients enrolling for Triomune, in the national ART programme is increasing markedly. This creates considerable but surmountable challenges for Malawi to:
Establish second line therapy to Triomune,
Boost levels of the NRTIs (d4T & 3TC) in the two-week lead-in-time for Nevirapine in Triomune,. Adding Combivir, (AZT & 3TC) is an alternative
Establish a system for resistance testing at regional centers
Re-visit PMCT. Should we introduce it on a national scale?
Revise ART guidelines viz a viz inclusion and exclusion criteria for starting HAART, necessary baseline and follow-up investigations and patient management
Develop protocols on the treatment of opportunistic infections and their primary and secondary prophylaxis
Provide good HIV counselling for patients prior to starting HAART and information on the aims and adverse effects of HAART stressing the need for religious compliance as reported drop out rates of 40% are very worrisome
Embark on training of clinicians in district and mission hospitals in HIV management and look at expanding the programme to Mzuzu and Zomba
Maintain adequate drug supplies. Unstructured treatment interruptions as are frequently seen at QECH are not ethically justifiable and pose serious threats to the entire programme nationally
Good operational research is vital for the development and sustenance of the national programme. A Malawi national HIV conference ought to discuss these and other issues and share and disseminate information.
A Call for Action
Talk and advances in scientific knowledge need to be turned into purposeful action on a global scale. The IAS goal is to have three million people on HAART by July 2004. In the last plenary session of the conference, Graca Machel asked some pertinent questions that we must answer come the next International AIDS Conference in Bangkok in 2004.
How many people are on ART successfully?
What resources have been mobilized?
How much research has been translated into meaningful policy in the hands of practitioners?
How many lives have been saved?
Indeed HIV has brought fundamental legal, moral, ethical and human rights issues to the fore. The evidence in support of nationwide implementation of HAART is overwhelming yet today alone over 6,000 people will die as a result of HIV/AIDS. How many more need to die? Can we really continue to say to the afflicted “Sorry there is nothing else I can do?” Have we not come to be caregivers in this age and place for such a time as this? Let us commit ourselves to play our part in treatment and prevention, to fight this pandemic that has claimed more lives than all past wars, natural disasters and diseases put together.