A tale of two timeframes: Short- and long-term agendas for the response to AIDS

At times, the XV International AIDS Conference in Bangkok (11-16 July 2004) crackled with the outrage and activism that enlivened the 2000 meeting in Durban; at other moments it echoed the 2002 Barcelona conference where there was frustration at how little progress there had been in making life-saving antiretroviral (ARV) drugs available in many parts of the world. Ultimately, however, the Bangkok gathering moved beyond both of these meetings and was the first of its kind to take place since many developing countries launched ARV treatment programs with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President’s Emergency Plan for AIDS Relief (PEPFAR), the World Bank and other sources. The conference provided a first glimpse of both the inspiring possibilities and the significant shortcomings of the first efforts now underway to “scale-up” ARV treatment in the world’s resource-poor countries.

With its packed program and diverse array of participants, Bangkok also provided a first indication of ways that the relationship between prevention and treatment efforts may change in the era of treatment scale-up. The overall message was clear: as treatment programs roll out, prevention is as important as ever. “Without a greatly expanded prevention effort, treatment is simply not sustainable,” said Peter Piot, head of UNAIDS, during the conference’s closing ceremony. Released at the conference, the most recent UNAIDS statistics underscore this point: in 2003 the number of HIV infections was higher than ever— five million new HIV infections worldwide.

How should this expanded prevention effort be developed? Many speakers emphasized the importance of expanding access to available, proven prevention strategies such as condoms and clean needles while also continuing research on other interventions which could provide additional protection, like vaccines, microbicides and pre-exposure prophylaxis with drugs.

However Bangkok also highlighted some of the challenges to merging the treatment and prevention agendas. Perhaps more than any other previous world AIDS conference, this year’s in Bangkok illuminated the contrast between the timeframes for short-term responses (such as treatment scale-up and expansion of existing prevention programs) and long-term responses, which largely focus on developing and testing new technologies like AIDS vaccines and microbicides.

When it comes to short-term goals, the overwhelming opinion is that the deadline for action passed long ago: the slogan “Time’s Up” was stamped on the side of a giant blue balloon that bounced above thousands of people who took part in a march for treatment access hours before the opening ceremony. The urgency was also voiced by global leaders who warned that greater investments of funding, political will and human resources are needed to meet targets for expanded treatment programs, such as the “3 by 5” program of the World Health Organization (WHO) that aims to have 3 million HIV-infected individuals on treatment by 2005. With that deadline only 15 months away, WHO AIDS director Jim Kim said, “By these measures of human life, the ones that really matter, we have failed. And we have failed miserably to do enough in the precious time that has passed since Barcelona.”

Yet while the treatment field is thinking in terms of months, the AIDS vaccine field is preparing for an effort that will take many years, if not a decade or more. “The development of an HIV vaccine represents one of the most difficult challenges that modern biomedical science is confronting,” said Jose Esparza, Senior Advisor on HIV Vaccines at the Bill & Melinda Gates Foundation in his plenary speech on AIDS vaccines. Esparza’s comments echoed the assessment of IAVI’s 2004 Scientific Blueprint for AIDS vaccine research, which was released at the conference and stated that, “The progress of the past few years is outweighed by critical scientific, operational and resource challenges.” The Blueprint also noted that the field will not know whether the current vaccine candidates being tested will provide any protection until “late 2007 at the earliest.”

The microbicide field is working on a similar timeframe. As many as six large-scale trials involving five candidates could start by the end of 2004, and early results from these studies will be available two to three years after they begin.

Can the world muster the necessary resources and political will to address both long- and short-term agendas? Bangkok provided mixed answers to this question. On the one hand, AIDS vaccines received relatively little attention outside of non-vaccine related sessions and—for the first time in some years—were not mentioned at all during the conference’s opening ceremony. On the other hand, many speakers made strong forward-looking statements that addressed research along with treatment and prevention. In a speech at the closing ceremony, Sonia Gandhi, chair of India’s National Advisory Council, said, “We are aware that vaccines will not be available for quite some time, but we realize their enormous potential.”

The need to balance short- and long-term priorities was at the heart of “AIDS Vaccines: Global Progress, Global Challenges,” a “Meet the Leaders” panel discussion where UN Special Envoy on AIDS in Africa Stephen Lewis observed that the field had “failed to make AIDS vaccines a central issue” in the global response to HIV/AIDS.

Global spending on AIDS vaccine research is still less than one percent of all health product research and development, a fact still far from common knowledge. During this session’s discussion, a 23-year-old audience member raised his concerns saying, “For the last 15 years I’ve been hearing about AIDS and HIV and for all those years, I’ve been thinking ‘Where is a vaccine?’ It is not until this morning that I realized why we don’t have a vaccine — that only US$600 million a year is being spent on AIDS vaccine research. It is appalling.”

Maintaining and expanding momentum among communities and politicians is also important. South African treatment activist Zackie Achmat, another panelist at the “Meet the Leaders Session”, urged the vaccine field to build better bridges with the treatment access movement saying, “I think most of us have felt mystified by what an AIDS vaccine is or how to find it. The most important challenge is to de-mystify vaccines.”

Another key element is increased coordination within the various groups involved in AIDS vaccine research and advocacy. “This is about a nonpartisan, business-like approach to a candidate [vaccine] regardless of who is developing them and where they are being developed. Let’s steer away from funding tied to certain institutions,” said Dutch HIV/ AIDS ambassador Laetitia van den Assum.

Ultimately, the ability to meet both long- and short-term goals will depend on strengthening collaborations between treatment and prevention programs and between groups involved in scale-up and research sites in developing countries, said IAVI President and CEO Seth Berkley. “The AIDS vaccine agenda needs to be owned by the members of the broader global AIDS community because they are the ones who have to take the lead on this.”