Posted: Friday, June 24, 2011
Publication Date: June 24, 2011
(Originally appeared in Medical Progress Today on June 24, 2011)
We may not realize it now, but at some future date the world will look back and recognize May 2011 as a remarkable turning point in the history of the struggle against AIDS.
I say this because of two amazing developments that appeared at a conference in mid-May. Either development alone would qualify as amazing but, taken together, they represent a sea change in AIDS management that would have been considered science fiction only a decade ago.
While extraordinary progress in the past decade has made it possible to treat AIDS, there was little that could be done to halt its spread. Now, for the first time, it is medically feasible to prevent the transmission of the disease in two different ways. This is a game-changer, and it is now possible to, at least, envision the end of the thirty-year epidemic.
AIDS first became treatable in 1995 — 14 years after its reign of terror began — when the first HIV protease inhibitor, saquinivir from Roche, was approved. This provided the first opportunity to demonstrate that an “AIDS cocktail” had a profound effect in reducing the replication of HIV, resulting in the partial restoration of the immune system that had been decimated by the virus. The cocktails also served to reverse the course of the disease and, for the first time, the number of annual AIDS deaths in the U.S. declined.
The following decade was marked by incremental but significant progress, as more than a dozen pharmaceutical companies carried out state-of-the art campaigns to discover newer drugs that were more potent and less toxic than their predecessors. About fifteen new drugs were discovered, achieving these goals and thus reducing the often-brutal side effects of the first cocktails. Other advances allowed the pill burden to be reduced from more than twenty pills per day to just one or two, improving both the quality of life and patient compliance.
Concomitant with these advances was a proportional increase in patient survival time, such that by 2010 the projected life span of those infected with HIV began to approach that of uninfected people. AIDS was coming to be a manageable, though chronic, disease rather than the automatic death sentence it was before the mid-1990s. And it was, in truth, the much-maligned pharmaceutical industry that did the lion’s share of the work in making these advances possible.
Still, two major issues remained. Although AIDS had become treatable, it was still highly transmissible, despite policymaker’s best efforts to change sexual behavior through increased condom use. And the question — “what about Africa?” — that had resonated worldwide for more than twenty years, remained largely unaddressed. But one major clinical study conducted by the NIH managed to address both of these issues in a big way.
On May 12, 2011, at a meeting in Rome, the NIH reported the results of a clinical trial involving 1,700 heterosexual couples at 13 sites on four continents. The data showed that patients taking antiretroviral drugs at an early stage of infection had a 96 percent reduced risk of transferring the disease to their partners. Health ministers from 18 of the hardest hit African countries hailed these results.
Other equally impressive data were gathered from the trial. The very next day, Malawi Health Minister Mary Shaba announced, “The vertical transmission of the virus from [HIV-infected] mother to child is reduced from 33.1 percent to 1.5 percent in Malawi due to treatment.” Not only had these drugs finally penetrated Africa, they had succeeded in bringing the rate of newborn infection down 20-fold. Marco Impagliazzo, head of the Sant’Egidio charity that aided in this program, proclaimed, “A generation of children without this illness is being born [thanks to treatment].” Also noted was that 14,000 healthy children had been born to HIV-positive women.
It is even more remarkable that this was achieved without a vaccine (scientists have been trying to develop an effective AIDS vaccine for 30 years and counting). Communicable diseases, when preventable at all, are usually controlled by the use of vaccines, not drugs. Nonetheless, there is now a viable way to inhibit both the horizontal and vertical means of HIV transmission by using drugs.
While there may never be a cure for AIDS, the events of last month dealt HIV a heavy blow; we may finally be getting the upper hand. What was once unimaginable has, at least on a small scale, actually begun to happen.
Research scientists have done most of their job — providing the tools necessary to stop or greatly slow the epidemic. And the drug companies have begun selling antiretroviral drugs at deeply discounted prices in poor countries, sometimes giving up their own patent rights.
But there still is much uncertainty. New and improved drugs will most likely be needed to improve treatment and minimize resistance. Companies will have to continue to manufacture current (and future) drugs at prices far below market. And an effective vaccine could be used in conjunction with drug therapy, greatly enhancing prevention options.
The rest of the job lies in the hands of world leaders. Can they summon the enormous financial resources to complete this long and arduous journey? It will be difficult. Given the economic climate, the Obama administration cannot meet its promised contribution to the President’s Emergency Plan for AIDS Relief (PEPFAR), launched by President Bush in 2008. Other countries are no doubt similarly affected.
But with sufficient commitment, May 2011 will indeed be remembered as an extraordinary month — the time when we witnessed the beginning of the end of the global AIDS epidemic.
Dr. Josh Bloom is Director of Chemical and Pharmaceutical Sciences at the American Council on Science and Health.