Brown University News Bureau

The Brown University Op-Ed Service
Tracie Sweeney, Editor
Distributed July 1996
Copyright ©1996 by Kenneth H. Mayer, M.D.

Promising Paradigms, Limited Resources

Dr. Kenneth Mayer is professor of medicine and community health, director of Brown's AIDS Program and chief of the Infectious Disease Division at Memorial Hospital. He attended the recent international AIDS conference in Vancouver, B.C.

"We must be painfully aware how economic apartheid could separate those with a 'treatable chronic infection' who can afford the new medication and monitoring from those who will die young from [AIDS]"

M ore than 30 years ago, the late science philosopher Thomas Kuhn wrote of paradigm shifts - acute revolutions in scientific understanding that facilitate progress by rapidly redefining perceptions and dogma. At the recent annual International AIDS conference in Vancouver, the newest paradigm shift in our understanding of AIDS and the clinical approaches needed to make AIDS a manageable infectious disease were very publicly formalized.

But the conference's optimism may be premature, and the paradigm shift limited.

The new realities about AIDS have several underpinnings. We now know that there is much more virus present in the body than previously thought, and that the daily turnover of infected cells and viral particles is in the billions. Thus, the analogy between HIV and rapidly growing malignancies emboldened researchers to feel that combination chemotherapy might be of particular benefit, much in the way that several previously deadly malignancies have become serious but manageable problems with the advent of attacking tumors with combination therapies.

Data presented in Vancouver showed that drug combinations were potent in patients who had just become HIV-infected as well as in those with more advanced disease, and in the latter group survival benefits were demonstrated. Some researchers suggested that if early intervention with newer, potent combinations could result in rapid HIV clearance from the blood (even if it may still lurk in deeper body tissues, like lymph nodes) and if treatment later in disease could extend survival, then why not treat all HIV-infected people with multiple drugs as soon as their infection is discovered. Several companies demonstrated HIV home test kits using either saliva or drops of blood from a pricked finger, which could let people know within days after a risky contact whether they had become infected with HIV.

Some would argue that such advances finally make HIV a manageable, albeit serious, public health concern. Unfortunately, life is not so simple. The long-term benefit of these aggressive interventions needs to undergo the test of time. Very few people have taken these drugs for more than two years, and reports at the meeting discussed HIV strains becoming resistant to these drugs in some patients, and unacceptable side effects developing in others.

Moreover, the cheapest of these newer agents is more than $4,000 a year, and because they are most efficacious when given in combination, the advent of this new era could mean that the world's 20 million HIV-infected people each will need to shell out more than $10,000 a year to join the ranks of those who have a "manageable disease."

We must be painfully aware how economic apartheid could separate those with a "treatable chronic infection" who can afford the new medication and monitoring from those who will die young from the ravages of a chronic, debilitating immunosuppressive virus.

On one level, the Vancouver conference is likely to be considered a key event in the annals of this epidemic - the first time a global convocation of scientists, clinicians, the affected communities and their advocates realistically reviewed the promise that most, if not all, HIV-infected persons could lead unabbreviated lives.

Yet the full benefit of the paradigm shift will be limited by governments, industry and academia unwilling to take leadership and ownership of the problems caused by inequitable distribution of resources. The majority of people living with HIV will be doomed and disenfranchised. Concrete action predicted on the understanding that we are a global community confronting a lethal pandemic would have been the greatest paradigm shift of all.