ICAAC 1995: New Perspectives on Treatment

Most AIDS conferences leave a sense of disappointment, of how little new or significant work has been done. But ICAAC 1995 -- the 35th annual Inter-Science Conference on Antimicrobial Agents and Chemotherapy, in San Francisco September 17-20 -- was clearly different -- and important. ICAAC focuses on new antibiotics for all infectious diseases -- perhaps a fifth of the 1800 presentations were relevant to AIDS -- but the 1995 meeting was especially necessary since the International Conference on AIDS has begun a two-year schedule and, for the first time, will not occur this year. ICAAC was pivotal not so much for the meeting itself (and certainly not for how the meeting was administered), but as a marker of far-reaching changes which were already happening. The conference included important new information, and it brought key people together, allowing new thinking and new controversies to be more readily grasped.

Treatment information is changing rapidly, and experts often disagree on what it means. Anything we say may soon be obsolete -- even as soon as next week (after the Fifth European Conference on Clinical Aspects and Treatment of HIV Infection, September 27-29 in Copenhagen). Readers should note that what we report is not established truth, but rather a collection of theories or views which may -- or may not -- prove helpful for understanding AIDS treatment developments. Remember that this article was written in late September 1995; next month or next year the picture will be different.

Since we must be selective in reporting hundreds of research presentations and what people are saying about them, readers should know what our emphases and/or biases are:

* As a result of ICAAC, we have come to believe that the single most important research direction now is to test protease inhibitors in patients, in the most promising combinations -- both with other protease inhibitors, and with other kinds of treatments for HIV disease. Instead of trying less promising combinations first, as has often been done in the past, we should move straight to the best ones which are in view. The trials required can usually be small, fairly simple, and inexpensive; they can report results in weeks or months, although long-term followup will be needed in addition. The main obstacles to running these trials are organizational -- especially in getting different pharmaceutical companies to work together. As researchers learn what the drugs can do at their best, they can also learn how to deliver the best possible care under real-world constraints.

* The most important immediate result of new information released at ICAAC (and the major conference the following week in Copenhagen) will be that the current "standard of care" that most treated patients receive today -- starting with AZT alone -- will go away. Instead, physicians will use combinations (often including AZT), and they will have a menu of possible treatment choices, with little data to prove which choice is best on the average. This situation will greatly increase the need for practical guidance on how to individualize patient care -- for example, by using viral load, CD4 count, and other tests to tell when a regimen is not working, so that a different regimen can be tried instead.

* Treatment failure -- especially but not only the development of drug resistance by HIV -- will become more central, since physicians will need guidance on planning sequences of treatments to minimize these problems.

Several of the following articles focus on the single most important session of ICAAC 1995, the "late breaker" meeting on September 18. Late breakers are research reports which arrived too late for the regular program, but were important enough to be included anyway; in recent years some conferences have set aside a special session for this purpose. Of 80 papers submitted for this late-breaker section, only 10 were accepted, because of limited time in the program; the others are unlikely to see the light of day at least until the Human Retroviruses conference in early 1996 (journal publication would usually take even longer than that). We also cover one of the reports not accepted for the late breakers ("Protease Inhibitor in Combination -- Sustained Viral Load Drop," below), since it is particularly important, and the principal investigator was willing to share it with us.

[Scientists in many fields are now doing much of their professional communication on the Internet -- publishing their results, organizing their own peer review when necessary. Because it is immediate, the Internet establishes better proof than journal publication of who originated an idea; at the same time, it makes the latest work available almost anywhere throughout the world, allowing feedback and participation regardless of location. Scientists and scholars can be free of the arbitrariness of journals and conferences, no longer required to keep their work secret for months or years of unnatural delay, able to communicate freely without regard to publication schedules, limited time in meeting halls, or professional rivalries and gamesmanship.

[For the Internet to catch on as a mainstream professional forum, it needs enough critical mass of colleagues using it in this way. In AIDS, most researchers do use email at this time; but the momentum for widespread initial publication of original AIDS research on the Internet has not yet developed. When it does, everyone will benefit.]