STD Quarterly-13th International AIDS Conference report: Complacency eroding gains in war on epidemic
Some are dropping guard against infection
Antiretroviral drugs are creating complacency in some developed countries and reversing gains in the AIDS epidemic, said Roy Anderson, FRS, of Wellcome Trust Centre for the Epidemiology of Infectious Disease at the University of Oxford in Oxford, England.
Addressing attendees at the recent 13th International AIDS Conference in Durban, South Africa, Anderson said, "Complacency is the main worry in many Western countries for the coming decade with increases in risk behavior already apparent in young gay men, as reflected, for example, in the rise in the incidences of various sexually transmitted diseases [STDs] such as rectal gonorrhea in San Francisco and a concomitant recent rise in the incidence of HIV."
Success creates its own challenges
Anderson attributed the problem partly to the perception that AIDS is a treatable condition. That idea has arisen from the advent and success of combination drug therapies. The slow and steady increase in the incidence of HIV among heterosexuals and the explosive epidemic of AIDS in many Eastern European countries such as Russia also are of major concern, he said.
Public health authorities, therefore, face many challenges in the coming decade, Anderson noted. They include:
• intensifying AIDS educational campaigns for the young;
• combating the spread of drug-resistant strains of the virus;
• promoting good adherence to recommended drug regimens for those infected and on combination drug therapy;
• finding the necessary resources for enhanced surveillance to detect a higher percentage of infections early on;
• stimulating more research in the development of vaccines.
Successful public health campaigns have reduced the impact and spread of HIV, but that progress varies in different countries, Anderson said. While Sweden has made remarkable progress in limiting the spread, countries such as Spain and certain areas of the United States have achieved much less success, he said. "Each country has a unique epidemic formed from varying contributions by infections in gay men, IV drug users, and heterosexuals."
While little variability has occurred in general patterns of the distribution of age-related sexual partner acquisition, much heterogeneity exists in patterns of mixing within and between major risk groups and the degree to which educational messages have penetrated certain sectors of society in industrialized countries, Anderson said.
Successes on record
Many success stories have been recorded, including effective needle exchange programs, reports of frequent use of condoms, and a reduction in the number of new sexual partners for those at risk for HIV, Anderson noted. Drug therapy also has significantly reduced the likelihood of vertical transmission of the virus.
"What typifies the most convincing cases is the quantitative study of behavior change, concomitant with the monitoring of HIV incidence and seroprevalence," he said.
The widespread use of highly active antiretroviral therapy during the past five years in developed countries has greatly reduced the incidence of AIDS, Anderson said. That change is concomitant with an increase in the pool of HIV-infected persons, as combination therapy has prolonged the lives of those infected, he stated. However, it also brings the associated risks of an enhanced net rate of transmission, Anderson observed.
And while aggressive drug therapy could lower viremia to undetectable levels and create improvements in immune status, even the combination of five drugs doesn't seem to eliminate the virus from the host, he pointed out. Cessation of therapy, therefore, typically results in rapid growth of the virus and associated diseases while poor adherence to treatment has created multidrug-resistant strains that are difficult to treat, Anderson said.
"Tight adherence to prescribed drug regimens is key to long-term suppression of viral load," said Anderson. "Since the net rate of viral evolution is proportional to total viral load, poor adherence early on post the initiation of combination therapy [when viral load is declining from high levels] carries the greatest risk of the evolution of resistance."
Once viral load is very low, a short period of poor adherence is less serious, he said. However, the general messages for those on treatment are that good adherence is vital, as is the adoption of safe sex practices at all times, he added.
Need for action is now
The development of vaccines, the focus of much attention at the conference, is seen as a long-term solution to the epidemic. Anderson cautioned, however, that the path to this goal will be difficult, largely due to the great genetic diversity of the virus and its propensity for rapid evolution.
"The clear need is for action now, at a scale and degree of international collaboration not seen before in the history of the fight against infectious disease," he said. "International collaboration and political leadership are key ingredients for promoting this goal."
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.