Post-AIDS, but not post-HIV in the North: a report from the AIDS Impact conference

AIDS Impact, the fourth international conference on the biopsychosocial aspects of HIV infection, took place in Ottawa, Canada between July 15 and 18. The conference covered adherence, HIV prevention, the psychosocial impact of HIV infection and work in high risk settings such as prisons.

Abstracts from the conference can be downloaded in pdf format from www.aidsimpact.com.

Adherence has become the bogey man of living with HIV infection. Reams of paper on this subject uncovered little new. Indeed the only point worthy of highlight from these sessions was that one key predictor of non-adherence is gender. Women have greater problems with adherence due to the demands of daily life: family and child rearing responsibilities, as well as concerns about disclosure and lack of gender-appropriate information complicate their abilities to integrate such complex regimens with their daily tasks. Adherence guru Dr Margaret Chesney called for researchers to pay attention to good adherers (of any gender) and to attempt to identify successful strategies that could be replicated.

A joint investigation by the Community Research Initiative of Toronto and Ottawa Hospital revealed that adherence levels of 91% or greater were associated with the best chance of maintaining viral suppression below 50 copies/ml. Keeping viral load below 50 copies is associated with the best long-term chances of preventing viral load rebound and drug resistance, and the most durable long-term response to therapy.

In comparison, individuals who achieved viral load below 500 copies/ml but above 50 copies/ml had an average adherence rate of 79%. These findings suggest that interventions which result in marginal improvements in adherence may still have an important long-term impact.

Should treatment optimism lead to prevention pessimism?

For Australian workers, familiar with Professor Gary Dowsett’s "post-AIDS" analysis there was little new data presented at the Ottawa AIDS Impact conference, where some US researchers appeared to be discovering that things had moved beyond a crisis mentality. Eric Rofes made spirited comments about US gay men feeling torn between a Crisis-Cure polarity, and argued that the "AIDS industry" was heavily invested in trying to recreate the former, while the bulk of gay men were choosing to live life at the other end of the spectrum. Professor Graham Hart of Glasgow University speculated on the need to avoid overuse of the post-AIDS concept, arguing that some places are currently pre-AIDS and others mid-AIDS. Certainly for such a cultural analysis to be valid, local specificity is crucial, and timing and scale of the epidemic is everything.

The few papers that attempted to unpack the real significance of post-AIDS in places with well established epidemics were, unsurprisingly, the most interesting. There was encouraging unanimity - if disturbing results - from researchers in San Francisco, London and Sydney about the impacts of HIV treatments awareness on the sexual practice of HIV-uninfected gay men.

Doctors Maria Ekstrand from San Francisco, Dr Lorraine Sherr from London and Professor Sue Kippax of Sydney all reported that HIV-negative gay men who expressed the most optimism about new treatments were also the most likely to have unprotected anal intercourse with a partner of different or unknown HIV status. None of the three were willing to speculate on whether the optimism was a trigger, or a post-hoc self-justification for risk taking. More research is necessary - and Kippax proposed some standard inter-country questions to enable systematic gathering of data, and presented a validated set of attitude statements, such as "An HIV+ person on combination therapy is unlikely to transmit HIV" and "I’m less worried about HIV than I used to be".

Kippax reported that the only statement significantly associated with unprotected anal intercourse amongst HIV-positive men in Sydney was "undetectable viral load cannot pass on the virus". This finding was not replicated in the London survey, conducted in May 1998 amongst 1018 gay men.

Maria Ekstrand argued vigorously for those involved in HIV treatment education to be aware of the impact of their work on the general population of gay men. Integrating education for PLWHA with HIV prevention work is standard for Australians who have always accepted the centrality of PLWHA in such a way. Yet it was chilling to hear about the complexities of such an approach in San Francisco where pharmaceutical companies buy bus shelter ad sites to promote images of mountaineering as the latest side effect of HIV infection. Bombarded by such health-enhancing images it may be difficult for uninfected men to perceive HIV as something that particularly needs to be avoided.