STOCKHOLM — The Fourth International Conference on AIDS dashed any remaining illusions that a quick-fix solution is possible.
The good news, as Nobel laureate David Baltimore pointed out, is that more researchers are now studying the human immunodeficiency virus, or HIV, and any other potential cause. In the United States, total federal AIDS spending has increased from $60 million in fiscal year 1983 to about $200 million in the mid-'80s to $1.47 billion for fiscal '89.
The bad news at the June 12-16 meeting was the observation by conference chairman Dr. Lars Olof Kallings that the whole picture is now "even more frightening than we have expected."
The emphasis is no longer just on people who are sick with the fatal acquired immune deficiency syndrome. It is now equally on all those with HIV infection, whether they have developed AIDS symptoms or not.
All the long-term follow-up studies of infected individuals are showing that the percentage who become ill and die increases with each passing year. The average period of time between initial infection and the development of AIDS appears to be between seven and 10 years.
Minus better drugs and a vaccine, there were urgent calls to prevent new infection while researchers intensify efforts to find better treatment for those already carrying the virus.
In practical terms, this would focus public-health programs on people with sexually transmitted diseases and intravenous drug users. In many countries, these are the two groups most likely both to become infected with HIV and to transmit the virus.
The rationale for this strategy--particularly in the United States--was evident from new data presented at the conference. The Americans most likely to acquire HIV infection in 1988 are no longer homosexual or bisexual men or blood transfusion recipients.
Rather, they are inner-city minorities and prostitutes, who have high rates of intravenous drug use and sexually transmitted diseases. An increasing number of HIV infections in adolescents and young adults from these groups will also lead to a larger number of AIDS cases in newborns.
According to Dr. King K. Holmes of the Harborview Medical Center in Seattle, prostitution and intravenous drug use are "closely interrelated" in causing the spread of sexually transmitted diseases.
In addition, new studies from Nairobi, Kenya, show that venereal diseases, specifically those that cause open sores on the genital organs, dramatically increase the risk of both transmitting and acquiring HIV infection. The three most important causes of so-called genital ulcer disease are syphilis, herpes and chancroid.
These studies, conducted by an international research team, show that men with genital sores had about a fivefold increased risk of contracting HIV from an infected prostitute, compared with men with no sores. And female prostitutes with genital sores have 2 1/2 times the risk of acquiring the virus from the infected client than prostitutes with no sores.
At a widely praised plenary address, Holmes, one of the world's leading authorities on sexually transmitted diseases, described "an emerging pattern of heterosexual (HIV) transmission" in inner-city American minority populations. This is in addition to the transmission of HIV from intravenous drug users to their sexual partners.
Researchers have documented the new pattern in Baltimore and Miami. For example, University of Miami researchers reported that 5% of sexually active inner-city heterosexuals were asymptomatic carriers of the AIDS virus in their continuing study. (Prostitutes, intravenous drug users and homosexual men were specifically excluded from this analysis). Johns Hopkins Medical Center researchers reached a similar conclusion earlier this year.
Concentrations of heterosexual cases are expected to develop in other cities. "Programs which fail to integrate AIDS prevention with sexually transmitted disease control are blueprints for disaster" Holmes said. "The unfortunate story so far in much of the world is that AIDS control activities have not gotten down to the nitty-gritty of educating and modifying the behavior of those who are the hardest to reach."
The nitty-gritty would include improved drug treatment services, extended confidential testing and counseling programs and the promotion of condom use--plus increased spending on public health programs to detect and treat syphilis, gonorrhea and other genital infections.
In addition, an ad hoc group of health-care workers at the conference called for "urgent" measures throughout the world "to increase the availability of sterile injecting equipment," including needle-exchange programs.
Reports from Amsterdam and various cities in Britain suggested that such programs do not increase the number of intravenous drug users but, rather, bring more drug users into contact with potential treatment services. The effectiveness of needle exchange, however, in reducing the rate of HIV transmission remains to be established.
Even with sufficient funding for new prevention programs, changing drug-injection and sexual behavior in the groups now at greatest risk for HIV infections poses a formidable challenge. Gay men in San Francisco and elsewhere have apparently been successful in curtailing the spread of the virus. This is reason for encouragement, but may be difficult to duplicate in other socioeconomic settings.
The unfortunate reality in 1988 is that prevention remains the best way to treat HIV infection.