HIV and ID Observations

The international AIDS meeting finds its way today to South Africa, the country with arguably the greatest needs for HIV prevention and treatment.

This is not the first time the meeting was in this country, of course — in 2000, the World AIDS Conference took place in Durban, a truly landmark event in the history of the epidemic.

Aside from the obvious fact that HIV/AIDS was at that time largely ignored by the South African government, so that having the conference here was a major symbolic step forward, what else transpired?

• President Mbeki, in his opening speech, continued to focus on poverty — not HIV — as the cause of AIDS, with no concrete mention of antiretroviral therapy as either treatment of HIV nor as a way of preventing perinatal transmission.
• By contrast, Judge Edwin Cameron — openly HIV positive — stood up in front of thousands as the picture of health, describing how this was all due to his taking two pills twice a day.  (His regimen:  ZDV/3TC + NVP.)  He pleaded to make treatment more widely available.  It was riveting.
• Tony Fauci introduced us to the idea of “STI’s” — structured treatment interruptions — with several purported benefits, including decreased toxicity of treatment, “auto-immunization”, and lower cost.  No, it didn’t work out so well, but it became a major research agenda for the next 5-plus years. The paradox of STI was perfectly encapsulated by my colleague Abie Zuger, who noted that while Aftricans were desperate for treatment, her patients in the US were almost as desperate to stop, so bad were the side effects of therapy at that time.
• There was yet another study comparing ZDV/3TC plus either ABC or indinavir; ATLANTIC compared d4T/ddI plus one of either IDV, 3TC, or NVP; lopinavr/r was still called “ABT-378”; and the “next frontier” in antiretroviral therapy was correctly identified as entry inhibitors, with enfuvirtide right around the corner, and CCR5 antagonists already in development.
• The whole issue of mitochondrial toxicity, and its link to lipoatrophy and lactic acidosis, was coming into clearer focus.  Although many studies had begun to target d4T as a main culprit, there was still some debate.
• Nelson Mandella closed the conference with a beautiful speech — there was a general sense of hopefulness that contrasted markedly with the opening ceremony.

I also remember that the conference was superbly run from the technical perspective, and that the Durban beaches were gorgeous.  I purchased a pair of plastic flip-flops that my son still wears, and a cute bowl for my wife that has a giraffe handle.  The sun set very early in July way down here in the southern hemisphere.

Oh, and I learned then that South Africa is a long long way from Boston, and I was just reminded of that fact after a 24 hour trip here.  I am in awe of the stamina of my colleagues who make this trip on a regular basis.

Updates on interesting stuff here to come.

As I’ve noted here several times (some might say ad nauseum), I am convinced that Massachusetts’ arcane law requiring written informed consent prior to HIV testing is a barrier to more widespread screening — an opinion that is shared by virtually every clinician I’ve asked about this issue.

Last week, there was an announcement about progress (of sorts):

Clearing the way for HIV testing to become almost as routine as checking for cholesterol, state public health officials issued an advisory yesterday saying that the written consent required by law can be included in general permission forms patients sign for medical care.

Until now, Massachusetts doctors have typically given patients separate consent forms to authorize HIV testing, but yesterday’s directive makes clear that one form is sufficient, as long as the general consent form explicitly mentions HIV testing. Separate permission forms pose a barrier to testing for patients and healthcare providers alike, health officials said.

I’m of two minds about this.  On the one hand, we could simply do away with the law — something that most other states have already done, with Connecticut’s pending legislation providing a wonderfully common-sense approach on how to do this.

In addition, putting HIV in with the general consent for medical care seems both 1) kind of sneaky (does anyone actually read all that paperwork?) and 2) perpetuating HIV exceptionalism, since no other specific diseases are mentioned.

These concerns notwithstanding, I’m all for anything that makes it easier for people to find out their HIV status.  As noted in this article, 31% of people in MA find out they have HIV within 2 months of an AIDS diagnosis.

And that’s 31% too high.