Anyone who has never attended the semi-annual International AIDS
Conference (IAC), can’t possibly imagine what those of us who are repeat
attendees have come to expect. It’s always “different” than
other medical conferences, but this year was truly special and by far the most
upbeat since the first of these meetings held in Atlanta in 1985.
Advantages of open door policy
The International AIDS Society (IAS) — a global professional
organization governed by elected regional representatives — convenes the
global HIV conference. Just before the 1990 IAC in San Francisco, we learned
that the United States Government had passed legislation barring foreign
visitors here unless they disclosed their HIV infection status. This was
rightly seen as discriminatory and the IAS voted to boycott the United States
as a conference site until the legislation was overturned. This was
accomplished by the Obama administration in 2009 and Washington, D.C. was
chosen promptly as the site for this year’s meeting, AIDS 2012, making the
first time in 22 years that we were able to demonstrate our leadership in
combating the epidemic here in the country that has contributed so much to this
Paul A. Volberding
The IAC is a scientific conference with the usual oral and poster
presentations, but it is much more. It has grown in size over the years —
20,000 attended this year — but it provides a unique stage for political
leaders, patients and community organizations all covered by an extremely large
international media. The IAC often highlights the regional impact of the
epidemic, but also provides a very visible opportunity for individuals and
organizations to advocate for correcting perceived gaps in research and care
funding or to counter inequities or injustices adversely affecting HIV-affected
communities. In years past, the fear and anger expressed in demonstrations and
protests nearly drowned out the scientific content of IAC.
AIDS 2012 was very different. The conference organizers worked hard to
include the community in planning the conference, and also tried to organize an
agenda that presented new research results and ample time for a dialog that
addressed the policy and clinical application of new data. Recent political
decisions also aided the success of the conference in more effective debate.
Repeal of the US military is “don’t ask, don’t tell” policy
and the administration’s endorsement of same-sex marriage were undoubtedly
popular with attendees, as was the decision to infuse additional funds in the
AIDS Drug Assistance Program to eliminate state wait lists for HIV medications.
Finally, the prospect of moving many uninsured HIV-infected persons to Medicaid
as part of the health insurance reform legislation is also widely favored in
Data takes center stage
The political developments, though, were overshadowed by the science
reviewed or newly presented at the conference. Well covered in previous issues
of Infectious Disease News, many new clinical trials are creating a consensus
much discussed at the conference that every HIV-infected person should be
treated regardless of CD4 cell count. This conclusion is based on clinical
research and experience that ever-earlier treatment is of value to the infected
person, but that it simultaneously is a potent public health measure.
Suppression of the HIV viral load in the plasma is almost completely effective
in blocking transmission to sexual partners. And for those unable to otherwise
protect themselves against HIV exposure — often women sex workers whose
clients refuse to use condoms — antiretroviral therapy, as pre-exposure
prophylaxis is also effective if used regularly.
New data at IAC extended confidence in previous reports by showing even
more personal health benefit to very early treatment with reduced rates of
tuberculosis and other infections. Also, we are beginning to see data that
document the benefits of community-wide efforts to treat all infected persons,
both in reduced new infections and in an impact on education, employment and
other social and economic indicators.
Even prior to IAC, the US DHHS antiretroviral guidelines panel
recommended HIV treatment regardless of CD4 cell count. At IAC, the
International Antiviral Society-USA updated their guidelines in a special issue
of JAMA and also endorsed treatment for all infected persons. Still, the
debates at IAC were sober and well informed. Most appreciated that resources to
treat all infected persons don’t exist. But the conclusion was that we
finally have the tools needed to actually not just slow but actually begin to
reverse the epidemic. We can, with will and resources effectively deployed,
prevent transmission to newborns of infected women. We know that sexual
transmission is essentially eliminated in those with HIV viral loads suppressed
below assay detection limits and that infection risk can be substantially
reduced by male circumcision and, where necessary, oral pre-exposure
prophylaxis or vaginal antiretroviral microbicides.
No one should think the next battle in the war against HIV/AIDS will be
easy. The global economy remains weak and political support for foreign health
assistance is always subject to challenge, particularly in an election season.
Still, some signs are good. The major US program PEPFAR is committing to
substantial expansion in treatment coverage, and other donor countries are
still engaged and supporting the Global Fund. The next phase in our campaign
will require much more research with data, if positive, used to support
policies and funding for universal HIV treatment. A true end to the epidemic
remains far off, but we are entering a crucial new phase all on display at AIDS
- Paul A. Volberding, MD, is director of the AIDS Research Institute at the University of California San Francisco, and Co-Director of UCSF-GIVI Center for AIDS Research and is the Chief Medical Editor of Infectious Disease News. Disclosure: Dr. Volberding is an adviser to BMS and on data and safety monitoring boards for Gilead, TaiMed and the NIH.