Barcelona 2002: A Retrospective, and a Look Ahead

This issue of the IAVI Report is devoted to a collection of articles on key themes in vaccines at the XIVth International AIDS Conference

By Patricia Kahn, Ph.D.*

This time around, the world’s largest AIDS conference had a very different tone than its predecessor. While Durban 2000 was a turning point in galvanizing global momentum for an all-out response to the epidemic, Barcelona was permeated with the hard reality that the world has not yet risen to that bold challenge, either in terms of political will or committed funding. So once again, this bi-annual gathering was focused on the epidemic’s unrelenting spread and the world’s woefully inadequate response.

Yet at the same time, the conference spelled out plainly what can be achieved now, by using proven prevention measures and tackling prevention and treatment together rather than pitting them against each other.

“We’re still hearing a lot of words, but not the scale,” Columbia University economist Jeff Sachs told the audience. “The scale of what’s needed has never been more clearly understood. The number of deaths on the line has never been clearer.”

“In Barcelona, people were coming to realize that there are no magic bullets in this epidemic,” said Jose Esparza, who heads the WHO/UNAIDS HIV vaccine unit. “We have to accept that there are no ideal interventions, and use what is in our hands.”

Barcelona also marked the debut of Richard Feachem at the helm of the Global Fund on HIV/AIDS, Tuberculosis and Malaria, on which many hopes are pinned. In a much-anticipated speech, Feachem vowed to fight for a “massive increase” in donations, to support treatment as well as prevention, and to run the Fund in an accountable manner with built-in outcome measurements. He also expects to release multi-year projections of resources needed and anticipated rates of expenditure following the Fund’s Board of Directors meeting in October.

We begin our coverage with a brief look at a study released just before the conference, on what a comprehensive response would entail, what it could achieve, and how much it would cost. We also speak with the conference’s community track co-organizer, South African advocate Shaun Mellors, about the challenges this entails, and about what was and wasn’t accomplished at Barcelona.

On the vaccine front, many speakers focused less on recapping progress than on mapping the way forward, identifying gaps and proposing solutions to some of the thorny challenges ahead—topics that provided the meat of a one-day vaccine satellite meeting. The main conference offered updates of ongoing clinical trials, reports onnewer vaccines in the pipeline and presentations on the difficult task of designing efficacy trials for candidates that may be only partially effective.

Underscoring the growing recognition of links between prevention and treatment, it was striking that some of the most provocative talks for vaccine developers focused on infected people or animals. Topping the list was Bruce Walker’s report of an HIV-positive man who became “superinfected” with a second HIV strain, despite an immune response that controlled the first virus—a finding widely portrayed in the press as a major blow for vaccines. Here we take a closer look at the case and its lessons, and at the broader issue of HIV double infections. Last, we look at a new therapeutic vaccine that’s showing some hints of success in chronically infected monkeys—where there’s been precious little success with immune-based treatments so far.

The Epidemic’s Future: Two Scenarios

The international AIDS conferences traditionally begin with an update on the global epidemic, and Barcelona was no exception (see p. 8). But there was a difference: This year, Bernhard Schwartländer (WHO, Geneva) also presented a study on projected numbers of new infections, but with two sets of predictions: one, if the global response remains at today’s levels, and another, if it scales up to meet the targets set at the United Nations General Assembly Special Session on HIV/AIDS in June 2001. The analysis was based on reviewing the impact of prevention activities in 126 middle- and low-income countries, while the comprehensive response assumed a package of proven prevention and treatment interventions costing about $9.2 billion yearly by 2005. (The study was published in Lancet 360:73;2002.)

The result was stark and simple (see figure above): without a comprehensive response, another 45 million people will become infected by 2010; with it, 29 million of these infections (nearly two-thirds) can be prevented. The analysis also found that a one-year delay in mobilizing a response will cost 5 million of these preventable infections; a three-year delay, half of them.

Other speakers referred repeatedly to this blunt message. For example, Helene Gayle of the Bill and Melinda Gates Foundation, pointed to a 1993 WHO projection that spending $1.5 billion on prevention could halve the number of new infections by 2000 and save $90 billion in related costs. “Will we continue to wait until the cost has doubled, tripled, quadrupled and tens of millions more lives are lost?” she asked. “Ultimately, we will pay now or pay later.”

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*Patricia Kahn, Ph.D., is editor of the IAVI Report.