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Outlook 2000: AIDS Treatments

By John S. James
AIDS Treatment News

research3.gif - 14.48 K Each January we publish our overview of the AIDS treatment outlook for the coming year.

The current picture is unclear; we have heard less scientific news recently, but that does not mean less is happening. Much more will be known after the Retroviruses conference, January 30 - February 2 in San Francisco. (The earliest overviews and summaries of treatment news will be on the Web during or shortly after the conference; an accessible one-hour summary will also be available by telephone conference on February 2- -see "Retroviruses Conference Report by Telephone Conference" below, in this issue.) Here is our view of some of the important research areas, and treatment-access issues, as of today.

HIV-Specific Immunity

When first infected, the body itself can control HIV much better than any known drug combination. But gradually this ability is lost, for reasons which are in large part unknown. If we could understand the mechanisms involved, it may be possible to retain or restore this natural immunity, and keep HIV infection under control with much less intensive use of drugs than now required.


But meanwhile it is the antiretrovirals which are saving lives (and these drugs will probably also need to be used with immune-based therapies as well). Medical research on antiretrovirals can generally be divided between looking for small improvements (developing the next protease inhibitor with marginal benefit over existing treatment, or conducting the huge, slow trials often needed to prove that this benefit exists), vs. looking for fundamentally new treatments which exploit different points in the viral life cycle or the pathogenesis of HIV infection. Both kinds of research are necessary, and are proceeding.

We are concerned, however, that large institutions are structurally biased toward seeking the small but more predictable advances; pharmaceutical companies get another pill to sell, and university research centers get large, standardized trials with predictable staffing demands. The result is an overall misdirection of research effort and resources.


fat.gif - 16.83 K Lipodystrophy research has produced some theories, but no clear picture of what is going on--and no clearly superior treatments, although there are treatments which do work sometimes. Our view is that the research is suffering from a large-institution bias, leading to a focus on creating a definition so that different researchers' reports will be comparable, and on obtaining reliable statistics, in part to justify funding.

Our choice would be to start from the other end--with sophisticated, well-funded research projects each studying a single well-selected patient, or at most a few patients, to use every means possible to discover the mechanisms behind that person's problems, and what can be done to treat them. Of course one patient will not be representative of all, but almost certainly any effective treatment found to work well for him or her will also work for many others, leading to a significant advance in the field.

Then the next step is to find a patient for whom the new treatment does not work, and repeat the process, looking for another new treatment which works for a different component of the problem. Note that it is not necessary to identify the components ahead of time.

This idea may seem unusual in a treatment-research context, but it is well known in other fields as a bottom-up vs. top- down strategy. Both approaches have their advantages. Our view is that lipodystrophy research has not been successful because of an overemphasis on top-down thinking, which so far at least has not proved feasible in this area.

Nutrition, and Supplements

More attention is needed to reports that certain nutritional deficiencies may be associated with faster disease progression in some patients.

Such associations do not necessarily imply causality; the way to find out for sure if providing the nutrient would reduce progression would be to run a randomized trial. Clearly the large clinical-endpoint trials will seldom if ever be done for nutrients, for both economic and ethical reasons--who would want to go into a trial where they would maintain a known deficiency in order to see if they get sick faster than a comparison group? But clinical trials could look at viral load, or other parameters which can change quickly.

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1999: Basic AIDS Issues

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Other Issues

Treatment in prison: The U.S. now has 2,000,000 people in prison, a huge increase during recent years, and a new study by the U.S. Centers for Disease Control and Prevention found an AIDS rate among prisoners six times that of the nation as a whole (23 times the national rate for women prisoners). The disproportionate rates among minorities are even worse in prison than in the general population.

U.S. drug pricing: Prices keep going up, reaching insupportable levels, and Congress is listening to elderly and other constituents who cannot obtain the treatment they need.

Treatment in developing countries: About 90% of people with HIV live in developing countries and have little or no access to modern treatment. 1999 was notable in bringing intellectual-property obstacles to public attention in developed countries; this issue will continue, but there are other major obstacles (and opportunities for progress) as well.

Risk of non-B HIV clades? The AIDS epidemic in the U.S., Europe, and some other areas is caused by a variant of HIV known as clade B; there are several other clades in different parts of the world. Some clades (for example clade C, which is now causing the world's largest epidemic in southern Africa) may be more heterosexually transmissible than others; no one knows for sure. This year may be an important time to review precautions against the spread of different viruses into areas where they are not already present.

Retroviruses Conference Report by Telephone Conference, February 2

The annual Retroviruses conference, which this year is January 30 - February 2 in San Francisco, is one of the world's most important scientific meetings on AIDS; this year it will also include a session on hepatitis C (HCV) infection. Just after the conference ends, a telephone conference will bring together a panel of experts who will review some of the information presented, and answer questions submitted by the teleconference participants. The telephone meeting will occur Wednesday, February 2, 5:00 p.m. Pacific time (6:00 p.m. Mountain, 7:00 p.m. Central, 8:00 p.m. Eastern time).

The panelists for this teleconference are:

  • Stephen Becker, M.D., in private practice in San Francisco;

  • Karen Beckerman, M.D., Assistant Professor of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, and Director of the Bay Area Perinatal AIDS Center (BAPAC).

  • David Cooper, M.D., Professor of Medicine and Director, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia

  • Steven Deeks, M.D., San Francisco General Hospital AIDS program.

  • Michael S. Saag, M.D. (moderator), Professor of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, and director of the AIDS Outpatient Clinic at the University of Alabama.

  • Ronald Baker, Ph.D., Editor-in-Chief,

    To join the teleconference, you need to register in advance (first name only); call 1-800-880-5121 Monday through Friday, 9 a.m. to 5 p.m. Eastern time.

    Anyone can hear the tape or read a transcript later (no need to register). The tape will be available starting 24 hours after the teleconference; call 1-888-207-2647, and use pass code 5371. An edited transcript will be available about 14 days later at:

    This teleconference is supported by an unrestricted educational grant from Roche Laboratories.

    AIDS Treatment News Published twice monthly

    Subscription and Editorial Office: P.O. Box 411256
    San Francisco, CA 94141
    800/TREAT-1-2 toll-free U.S. and Canada
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    Editor and Publisher: John S. James
    Associate Editor: Tadd T. Tobias
    Reader Services: Tom Fontaine and Denny Smith
    Operations Manager: Danalan Richard Copeland

    Statement of Purpose: AIDS Treatment News reports on experimental and standard treatments, especially those available now. We interview physicians, scientists, other health professionals, and persons with AIDS or HIV; we also collect information from meetings and conferences, medical journals, and computer databases. Long-term survivors have usually tried many different treatments, and found combinations which work for them. AIDS Treatment News does not recommend particular therapies, but seeks to increase the options available.

    Subscription Information: Call 800/TREAT-1-2 Businesses, Institutions, Professionals: $270/year. Includes early delivery of an extra copy by email. Nonprofit organizations: $135/year. Includes early delivery of an extra copy by email. Individuals: $120/year, or $70 for six months. Special discount for persons with financial difficulties: $54/year, or $30 for six months. If you cannot afford a subscription, please write or call. Outside North, Central, or South America, add air mail postage: $20/year, $10 for six months. Back issues available. Fax subscriptions, bulk rates, and multiple subscriptions are available; contact our office for details. Please send U.S. funds: personal check or bank draft, international postal money order, or travelers checks.

    ISSN # 1052-4207

    Copyright 2000 by John S. James.

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