Faculty Bibliography

Of the 12,058 adults that Medecins sans Frontieres has treated with antiretroviral drugs in 21 countries in Africa, Central America and Asia since 2002, 6,861 received fixed-dose combinations. Since March, 80 percent of the group's new AIDS patients have received fixed-dose combinations. Among the fixed-dose combination recipients, the probability of survival after one year was calculated as 82.4 percent, [Alexandra Calmy] reported. About 60 percent of the deaths occurred within the first three months after therapy began. The deaths occurred largely among patients so ill that the antiretroviral therapy began too late to protect them from the infections that often kill patients as a complication of AIDS. Among the 6,861 fixed-dose combination recipients, there was a significant rise in the number of immune cells, known as CD-4 cells, that are destroyed by the AIDS virus. The CD-4 count rose by an average of 137 cells within in a year, in about half the patients. Because of logistical reasons in treating patients in slums and rural areas in countries like Malawi with bad roads and poor transportation, Medecins sans Frontieres does not routinely monitor each patient with the tests that measure the amount of virus in the blood. Doctors in developed countries routinely use such tests, known as viral loads, to determine the effectiveness of therapy

Of the 12,058 adults that Doctors Without Borders has treated with antiretroviral drugs in 21 countries in Africa, Central America and Asia since 2002, 6,861 received fixed-dose combinations. Since March, 80 percent of the group's new AIDS patients have received fixed-dose combinations. Among the 6,861 fixed-dose combination recipients, there was a significant increase in the number of immune cells, known as CD-4 cells, that are destroyed by H.I.V., the virus that causes AIDS. The CD-4 count rose by an average of 137 cells in a year, in about half the patients. In a separate part of the study conducted in Malawi, Dr. Arno Jeannin's Doctors Without Borders team randomly tested the amount of H.I.V. in the blood of 477 patients who had received fixed-dose combinations there for six months or longer. Of these, H.I.V. could not be detected in 85 percent, showing the overall effectiveness of the fixed-dose combinations

A microbicide is at the top of health workers' wish list to protect those women in poor countries whose husbands won't use condoms. A microbicide would also protect an infected woman's sex partners from infection. The need for a microbicide is even more urgent because there is no vaccine for HIV. 'Microbicides will not be magic bullets, and microbicides probably will never be as effective as condoms,' which are considered nearly 100 percent protective, Dr. Zeda F. Rosenberg, chief executive of the nonprofit International Partnership for Microbicides, said in an interview. For example, Rosenberg said, an ideal microbicide would not kill the bacteria that are normally present in healthy vaginas and that produce hydrogen peroxide, a natural disinfectant. Also, scientists do not want a microbicide to change the acidity of the vagina because it could allow unwanted bacteria to flourish

Experience has taught scientists that there is no guarantee of an effective microbicide. At the AIDS Conference in Durban, South Africa, in 2000, health workers had fully expected that a large trial of a spermicide, nonoxynol-9, would prove that the drug was effective. But the trial showed that nonoxynol-9 may increase the risk of HIV infection rather than protect against it. So scientists have shifted their focus to drugs that specifically aim at separate parts of HIV's life cycle. An ideal microbicide would work in three ways. First, it would kill HIV in the vagina and cervix. Second, the microbicide would prevent any virus that escapes from attaching to a woman's cells, the way HIV starts to infect. Third, for any virus that does enter cells, the microbicide would block an enzyme, reverse transcriptase, that HIV needs to replicate

A microbicide is at the top of health workers' wish list to protect the many women in poor countries whose husbands refuse to use condoms. A microbicide would also protect an infected woman's sex partners from infection. The need for a microbicide is even more urgent because there is no vaccine for H.I.V. An ideal microbicide would work in three ways. First, it would kill H.I.V. in the vagina and cervix. Second, the microbicide would prevent any virus that escapes from attaching to a woman's cells, the way H.I.V. starts to infect. Third, for any virus that does enter cells, the microbicide would block an enzyme, reverse transcriptase, that H.I.V. needs the enzyme to replicate. Viread, a drug made by Gilead Sciences that is prepared as a topical gel, is the only licensed antiviral drug being tested as a microbicide. Viread is a member of the class of drugs known as nucleoside reverse transcriptase inhibitors. The National Institutes of Health is about to begin the second of the three-stage testing system for topical Viread, Dr. [Zeda F. Rosenberg] said

Private-sector donations exceed government donations in the AIDS effort, said Hank McKinnell, the chief executive of Pfizer, who moderated the session. 'Like a flywheel gaining speed, the global donor community is now pledging, moving and disbursing funds and materials at unprecedented rates,' McKinnell said. That influx creates tensions. The government staffs of most poor recipient nations are small, yet they have to respond to myriad expectations from the donors. At the same time, donors and recipients often become overwhelmed by the massive paperwork and reporting that come with donations. Donors tend to become too involved in the day-to-day management of AIDS projects, [Biziwick Mwale] said, and 'donors want coordination, but many of them don't want to pay for it,' preferring other donors of the recipient country to meet the cost

As donors compete for prominence, said Dr. Biziwick Mwale, executive director of the National AIDS Commission in Malawi, ''lack of agreement on approaches and key issues among the donors themselves has also led to delays or problems in program implementation and coordination.'' Gregg Gonsalves of the Gay Men's Health Crisis in New York City said that scaling-up services through the public sector was essential to controlling the epidemic but that volunteer groups had ''played a key role in the response to AIDS, all too often filling in where governments have reneged on their duties'' to infected people and those at risk. Despite progress in the battle against AIDS in New York City in recent years, middle-aged black men are nearly three times as likely as other New Yorkers to be infected with the virus that causes AIDS, according to a new report by the New York City Department of Health and Mental Hygiene

The reasons vary. Some countries mistrust donor motivation in pushing co-ordination, he said. Countries may have 'real fears' that donor co-ordination could be used as 'a tool for control.'

That influx creates tensions. The government staffs of most poor recipient nations are small. Yet they have to respond to myriad expectations from the donors. At the same time, donors and recipients often become overwhelmed by the massive paperwork and reporting that come with donations. Donors tend to become too involved in the day-to-day management of AIDS projects, [Biziwick Mwale] said, and 'donors want co-ordination, but many of them don't want to pay for it,' preferring other donors of the recipient country to meet the cost. As donors compete with one another for prominence, Mwale said, 'lack of agreement on approaches and key issues among the donors themselves has also led to delays or problem in program implementation and coordination.'

UNAIDS has emphasized the need to put AIDS on the agendas of political meetings such as those of the Group of 8, a coalition of the world's top industrialized nations. At the same time, [Peter Piot] and others have tried to get heads of state to attend meetings so as to combine politics and public policy with the science of AIDS