TWENTY years ago this month, New Scientist reported that researchers had identified the cause of AIDS: the retrovirus we now call HIV, the human immunodeficiency virus. Back then, AIDS was thought to be mostly a disease of homosexuals, Haitians, haemophiliacs and drug addicts. About 4000 people had been affected and nearly half of them had died. Today, the WHO estimates that some 40 million people live with HIV, most of whom caught it through heterosexual sex. In 2003, HIV infected another 5 million people worldwide and contributed to the deaths of 3 million in sub-Saharan Africa alone.
In the intervening years, HIV has taught us many things: from the frightening ease with which society can stigmatise homosexuality to the power of consumers to influence not only healthcare but also the direction of research. Through those who claimed HIV was not the cause of AIDS, we found that mavericks can wield disproportionate influence. Mainstream scientists can be equally reckless by proclaiming unrealistic timetables for cures and vaccines; in 1984 some predicted they would emerge within three years.
The mission to understand HIV and prevent the harm it causes has taken us all on a roller-coaster ride in which bouts of optimism have been followed by spells of deep gloom. Real excitement followed the discovery that the drug zidovudine (AZT) disrupted viral replication. Then in 1993 depression set in when research showed that it did not delay the onset of AIDS. By the mid-1990s, combined therapy with zidovudine plus a couple of other anti-retrovirals cut levels of HIV in the blood to such an extent that one leading researcher talked of a cure. Disappointment followed when drug-resistant HIV strains emerged. Today we are on a high again as new anti-retrovirals show their promise and researchers have devised ways to kill the virus wherever it hides in the human body (see 鈥淣owhere to hide鈥�).
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The search for a vaccine is a similar story of optimism followed by depression. In the early 1990s, hopes for vaccines that boosted production of antibodies to the virus鈥檚 outer proteins were dashed when they failed to kill wild strains. Nor have vaccines based on spurring killer T-cells into action lived up to expectations. Yet today, optimism rules again, based partly on the discovery of antibodies that really do neutralise HIV. There is a feeling that combining antibody and killer T-cell approaches will yield that elusive vaccine.
There is optimism too over microbicidal gels, which are applied vaginally before sex and kill the virus or stop it infiltrating the body (see New Scientist, 8 February 2003, p 42). These are expected to have their greatest benefit in poorer countries, especially where men refuse to wear condoms. According to estimates, the gels could cut infection rates by hundreds of thousands a year. The one blot on the landscape is a large shortfall in the funding needed to finish development of the gels (The Lancet, vol 363, p 1002).
Here is where depression sets in again. If we cannot find the money to get cheap creams to women in developing countries, what hope is there for high-tech vaccines and therapies? While science has progressed, albeit in fits and starts, rich countries and international agencies have failed miserably to prepare the ground for delivering the benefits to people in poor countries. Today, fewer than 5 per cent of those 40 million HIV-positive people have access to anti-retroviral drugs.
The WHO and UNAIDS belatedly launched the 鈥�3 by 5鈥� programme to get anti-retroviral therapy to 3 million people in poor countries by 2005. The agencies describe it as an attempt to learn how to provide healthcare in developing countries 鈥渂y doing鈥�. The learning curve will be steep. This programme is too little too late, and may well fail anyway: it needs $5.5 billion, but so far rich nations have given less than half that amount.
Governments of those countries are guilty of meanness and a lack of imagination. Efforts to get anti-retrovirals to more people simply by lowering their prices are clearly not working. Meanwhile it is often still a condition of international loans that poor countries cut expenditure, even if that means diverting money away from healthcare. So the sick stay sick and do not contribute to the economy.
We need more generosity and joined-up thinking from the rich world. That really would be a cause for optimism.
