Berlin Conference Overview

issue, and will appear later.]

For the last nine years, the International Conference on AIDS
has been the major scientific meeting of the year. The 1993
conference, June 6-11 in Berlin, was like the others in
several ways:

* About 12,000 persons attended, about as many as in recent
years.

* No one expected a major breakthrough, and none was
announced. (This is not surprising, since it would be wrong
to delay announcing an important advance in order to wait for
a conference.)

* A number of potentially important advances in understanding
AIDS came to light; significant progress was reported. But
most of them were not immediately relevant to better patient
care.

* Overall, people left the meeting with the usual annual
disappointment at how little has been accomplished in finding
better treatments for AIDS -- and with worse reports each
year about the rapid spread of HIV in populations around the
world, and the inadequacy of the efforts to stop it.

But the Berlin conference also differed from previous
meetings in several ways:

* Better quality research is now being reported. This
improvement reflects better design of clinical trials during
the last two to three years (compared to those designed
earlier), as well as the availability of better virological
tests. The results of the new trials are now coming in.

But many of these results were negative or inconclusive. The
basic reason is that while the technique of trials has
improved, the vision of what is needed, and the selection of
drugs to study, has not. Major clinical trials, even when
publicly funded, are still driven by commercial pressures in
a game of influence that only large companies can play,
generally assuring copycat products attempting to imitate the
big commercial success (AZT) of the past.

* The situation for physicians and patients making treatment
decisions is more confusing after this conference than
before. Most people seem to be responding by continuing what
they would have been doing anyway, until enough clarity and
consensus develop to support new decisions. This differs from
most previous conferences, where there was less potential
impact on treatment because less accomplishment was reported.

* Another improvement this year is that the top leadership of
AIDS research is more open to new ideas than before -- both
the same ideas dismissed in the past, and new observations
which might or might not turn out to be critically important.

* While figures are not available, reports suggest that there
was less media coverage of this conference than in previous
years. But working journalists were as busy as ever in the
media facilities provided. The fewer column inches this year
could indicate more seriousness rather than less interest,
since during the last two years, much of the coverage
resulted from media feeding frenzies: two years ago, an
unfortunate remark about a "deep kiss" possibly spreading
AIDS; and last year, ICL (idiopathic CD4+ T lymphocytopenia,
meaning AIDS-like immune deficiency with no finding of HIV or
any other known cause), which got media attention because of
the possibility that it could affect people who considered
themselves removed from AIDS. The talk in the press room last
year was that the reporters already knew that ICL was a non-
story (probably reflecting only the fact that more
immunological testing was being done), but were running with
it anyway because everyone else was. This year produced no
comparable false headlines.

What Wasn't in Berlin

Our deepest impression from the conference is that the most
important and productive approach possible to saving the
lives of those already infected was simply not on the table
there -- not among the scientists, not among the physicians,
and not among the activists. The greatest need, everyone did
seem to agree, is for better drugs -- including drugs which
control HIV activity in chronically as well as acutely
infected cells. Existing drugs are largely useless in
chronically infected cells, which maintain reservoirs of
virus to provide a source of endless mutations to escape
control by the drugs we have and also by the immune system
itself.

But there are many potential treatments which do control HIV
in chronically infected cells in laboratory tests, and are
probably safe to use, and could be inexpensive and readily
available. If they can greatly suppress HIV activity in
humans (which is fairly easy to test), then they will
probably be major advances in AIDS/HIV treatment. The last
issue of AIDS TREATMENT NEWS included a background report on
one such possibility, curcumin, which is already in the human
diet because it is contained in curry. Our conference
coverage will include at least two others -- a protease
inhibitor which received much attention at the conference
(although it is limited by major supply problems), and an LTR
inhibitor, topotecan, which is now in human trials for
cancer.

Probably dozens of such candidate treatments, many already in
human use so that basic safety information is available,
could be identified from the published literature alone. It
would take a few weeks and probably less than $50,000 each to
test them for antiviral activity in humans. While the odds
are against each possibility individually, cumulatively it is
very likely that such a program would produce at least one
major treatment advance, entirely changing the current
picture of HIV care. If the treatment was already known to be
safe, it could be in widespread use within months.

The reason this hasn't been done already is because nobody is
pushing for it. Not pharmaceutical companies, which are only
interested in drugs when they have the patent rights, the
marketing prospects, the executive commitment, and the
personnel, capitol, facilities (manufacturing, laboratory,
etc.) and all other resources available. Not government
programs, where good ideas must wait in line along with bad
ones, and where funding reductions are likely to affect both
equally. Not private charity, which usually won't touch AIDS
-- and when it will, usually won't touch research. Not
community-based research, which was intended to address this
gap, but in practice seldom has the funding to be
independent, and must limit itself to funded projects, almost
always drugs which pharmaceutical companies are already
developing anyway. And not established researchers, unlikely
to be attracted to something simple that would highlight a
decade's failure to produce practical HIV treatment advances.
The "alternative" and "underground" treatment movements come
closest to addressing this opportunity (curcumin is already
being tested this way), but they have not had the resources
to do formal trials. The clear impression at Berlin was that
the whole world is accepting the lack of progress in AIDS
treatments as inevitable, and overlooking the fact that the
entire situation could be turned around in a rapid,
straightforward and relatively inexpensive way, if there were
the institutional will to do so.

We will continue to develop this possibility below, and in
future issues.