5 questions: Katzenstein on AIDS conference
David Katzenstein
For years, David Katzenstein, MD, professor of infectious diseases, has attended the International AIDS Conference. He shares some thoughts about this year's event in Toronto.
1. How did this event compare with past ones?
Katzenstein: It was bigger and broader, as in more inclusive, with a wide range of participants. The organizers should be credited with catering to a very multidisciplinary and multicultural audience. It lacked clinical and scientific "breakthroughs" from a scientific or clinical perspective, though favorable results of some of the newer pipeline drugs were presented. It was largely directed towards prevention, policy and finance, with an emphasis on sustainability of prevention and treatment.
In contrast to earlier meetings, I could recognize less than 1 percent of the delegates, and there was a significant increase in the number from developing countries. "The torch has been passed to a new generation" to quote JFK—altogether a good thing.
2. Bill and Melinda Gates and Bill Clinton were featured at the conference. How would you describe the importance of them and their foundations in the effort to combat AIDS?
Katzenstein: The Gateses are experimenting with a new and enlarging paradigm of public health philanthropy. They're trying not to substitute for or replace market mechanisms and government commitments. Similarly, Clinton's foundation has tried to support existing mechanisms and paradigms for treatment roll-out and prevention strategies. Most significantly, they are filling the gaps in prevention, largely through vaccine development, production and distribution, which have not attracted a market-driven approach.
3. Was AIDS in the United States discussed?
Katzenstein: There was discussion of Medicare part D coverage and the sustainability of increasingly expensive therapy in the United States. And that, of course, included discussion of the pharmaceutical companies' position, how not to jeopardize their core business in the United States and Europe, while controlling their I.P. for the other 95 percent of those affected by AIDS in the developing world.
4. Some scientists at the conference said it will be more than 10 years before an AIDS vaccine is developed, if ever. What's your perspective on vaccine development?
Katzenstein: More basic research in immunology, vaccinology and virology is needed. We still don't understand the most fundamental questions in the quest for an HIV vaccine: "What kind of immune response is likely to be protective?" and then, "If a protective vaccine is not found or possible, is a vaccine that did not prevent infection but limited disease a feasible approach?" The answer to the latter question may depend on therapeutic vaccine trials, which examine the effect of vaccines on those already infected and now receiving drugs. To my mind, this has been a neglected area of HIV vaccine research that needs further support and encouragement.
5. Given the emphasis on prevention, which strategies are most likely to work?
Katzenstein: Community-based treatment using antiretroviral therapy, which would reduce AIDS stigma and denialism as well as potentially lower patients' infectiousness, has the greatest prospect for prevention. Circumcision, condoms and empowerment of women, all emphasized at the conference, are still insufficiently "evidence based" to inspire much confidence on a policy level, though they are important steps for the long term.