In June of this year, the 12th Annual International AIDS conference was held in Geneva. It was a meeting both celebratory and somber. The predictions from the last conference, held in 1996 in Vancouver, Canada, have largely come true. But an entire class of unexpected complicationshas arisen as well. Here then are the bright spots, and some rumblings of the gathering storm to come. 

The Silver Lining
There are more treatments available for those who are HIV positive than ever before. Richard Horton, in the Clinical Science and Care Meeting,noted that "Currently, we have 11 approved antiretroviral compounds. Soon we will have 15 - that means 204 possible triple-drug combinationsand 1028 4-drug combinations." These therapies, referred to as highly active anti-retroviral therapy (HAART), give a higher quality of lifethan previously expected.  In fact, AIDS deaths are down over 45% from the 1996 meeting. 

The 1996 meeting presented the hopeful finding that number of new HIV infections overall dropped by 6% for the first time. In the gay community we have seen the rates of new infection drop twice, once by 2% in 1995, and again in 1996 by nearly 11%. Education efforts, shifting toless formal, community based programs, saw some progress.

HAART has changed the world. People at death's door have returned to work, school, and life. But all is not what the pharmaceutical advertisements would have us believe. Rex Wockner, a long time gay journalist and commentator, calls this contrast between living with HIV and pharmaceutical promotions "Get AIDS, look great, climb mountains." 

The Clouds
This new life is not without it's travails. Patients beginning HAART can expect considerable side effects, including nausea, diarrhea, and a variety of odd sensations collectively called peripheral paresthesia. After this, they must contend with the therapy itself. There are manyoptions and caveats for each patient. Each drug comes with it's own dosing regimen and unique side effects. Not everyone can take a given drug combination. Some side effects can be severe enough to discontinuea drug. The regimens are tough, drugs must be taken at rigid intervals,some with food, some without. Studies indicate that as many as 42% ofpatients on HAART fail to follow their treatment regimen due to complexity or side effects.

These drugs are incredibly expensive. Treatment on combination therapy can cost thousands of dollars a month. A common problem faced by patients is that they can get subsidized medication while on disability,but when they return to work, the cost of these drugs is astronomical. For insurance companies, this has become an especially complex issue:Can plans afford these drugs? How long with this Lazarus effect last? Outside of the developed world, where AIDS continues to ravage, will this therapy be available? It has been calculated that the worldwidecost of triple antiretroviral therapy would be US $36.5 billion, two-thirds of which would have to be spent in Africa.

Even more disturbing than the cost are the side effects of these drugs. These drugs have been tested only at the most preliminary levels, andbecause of FDA accelerated testing, many are feeling that they are really participating in an extended clinical trial rather than a treatment regimen. Indeed, many at the conference in Geneva called for drug companies to be more rigorous about collecting long term safetydata on drugs that undergo accelerated approval.

The most common side effects are GI disturbances, both short and long term. More worrisome is a collection of inexplicable changes in the bodies of many on HAART. For an unknown reason, protease inhibitors affect the metabolism of fat in some people. In this syndrome, called lipodystrophy syndrome, fat is lost in one place, only to reappear in another. Some experience wasting in the face and extremities, but acquire a potbelly (protease paunch) or a lump behind the neck (buffalohump.) Women on HAART report drastic changes in breast size, some gain huge amounts, while others lose their breasts completely. Another keyhighlight from the conference was the disparity between data for men compared to women with HIV. Some patients have such radical changes in their metabolism of fat that they run high risk for caridovascular disease and heart attack. Other side effects have included drug-inducedkidney stones and diabetes.

Larry Kramer, HIV positive novelist and playwrite, calls the mix and match process of patients and treatments Drug Combo Roulette. He advocates the development of an Internet based network for the HIV positive to share information regarding their treatments and side effects. Kramer is the founder of Gay Men's Health Crisis (GHMC) and AIDS Coalition to Unleash Power (ACT:UP), and he wants people to "hitthe keyboards like we once hit the streets."

The Coming Storm
In some cases, even the new therapies are not enough. The epidemic is not over, and it's nature continues to change. When AZT first appeared,it was hailed as a breakthrough in treatment. Yet it was only a matterof months before AZT resistant strains of HIV began to appear. John Mellors, a researcher the University of Pittsburgh, opened a seminar on viral resistance by reporting that multi-drug resistant strains of HIVare already circulating. This brings to light another of the problems with the new treatments. In a simple, and non-judgmental statement; HIVpositive people have sex. Since they are living longer and better lives,the chances of transmission to others are increased. Statistically, thatmeans that as the number of people living with HIV increases, the opportunity for new infections also grows. In no way does this imply that we should not treat the HIV positive, only that extra care must nowbe taken to educate and limit risky behavior. When someone becomes HIV positive today, it may be crucial to know what strain infected them, andwhat drugs it is resistant to. Patients can, at huge cost, be "genotyped" for the particular strain of HIV that has infected them, which can help with the choice of therapies. This test is not availableeverywhere.

The worst thing about the AIDS epidemic is that it continues to grow. In a report to congress regarding AIDS, the Centers for Disease Control(CDC) state that while AIDS deaths are down, the numbers of HIV positivecontinue to swell. This trend is reflected locally. According to Jim Alosi, Senior Supervisor for the Sexually Transmitted Diseases clinic atthe Jefferson County Department of Health, there are between 130 and 160 NEW cases of HIV reported each year in Jefferson County. 1997 was a goodyear; the number of cases reported dropped by 18% from the year before.However, the numbers for 1998 indicate that we have lost ground, and newcases will be up at least 10%. 

Birmingham, according to the CDC, has 1538 cases of HIV infection. Statewide, a total of 5,186 AIDS cases have been diagnosed in Alabama. Alabama requires reporting of HIV status, and most recent reports show between 8,000 and 10,000 people living with HIV or AIDS in the state.

AIDS is totally preventable. You would be hard pressed to find someone who didn't at least know what AIDS is. Why then do people continue toengage in risky behavior? A recent survey of men-who-have-sex-with-men(because they all don't identify as gay.) in public places (restrooms) in England, gave some startling findings. First, most of the men knewhow to prevent HIV transmission. This information was learned primarilythrough friends and the local press rather than formal prevention programs. Second, they simply didn't discuss their HIV status or precautions. Taking risks, they felt, was situational "If he looks healthy, he is and he wouldn't put me at risk if he were HIV positive."

In his book Sexual Ecology, Gabriel Rotello argues that HIV arose because of the nature of gay male sexual behavior. His interpretation puts an opposite spin on risk taking. The HIV positive person might reason "If they want precautions, they will mention it, it's their riskto take." Indeed, in a large study of gay men in New York, both HIV positive and negative, conducted by Levine and Siegel, researchers foundthat many who engage in risky behavior do indeed know better, but have developed extensive rationaliztions to justify their behavior.

So, what has happened? Studies presented in Geneva on risk behavior before and after HAART's introduction were split. Many questions remained. Ana Luis Liguori reported on the Social and Behavioral Sciences meetings, and wondered: "Has news of the new therapies made people less willing to practice safer sex and safer drug use? The evidence presented at the Conference was far from clear on this issue. Conflicting accounts were given about the effects of treatment advance on behavior change - with some studies indicating increased risks, andothers failing to do so. This is clearly a field where further researchis urgently needed."

Perhaps the easiest answer is that we are bored. Tired of safe sex = hot sex, we simply don't ask. Billy Tingle, an AIDS educator and vaccineresearcher here in Birmingham sums it up this way "It's 1998 and people know better. They are still putting it where they shouldn't be puttingit. They are not wearing condoms, they aren't asking anybody anything. Don't nobody ask, don't nobody want to know. Nobody's got a condom, andcould care less, because if you look good, they figure you are healthy."

I asked Dr. Mark Mulligan, a UAB AIDS researcher and clinician: Should a gay man be unconcerned with infection because of the new treatments?"That would be a mistake." He responded, "At the international meeting in Geneva, there were increasing reports of people becoming infectedfrom the start with viruses that don't respond to currently available treatments. So, the issue of viral resistance to therapy is one we continue to struggle with." New HIV infections are actually a form of "double jeopardy." If you are infected now, the strain you get may be multi-drug resistant, and even the most advanced therapies may fail.

Nearly a generation has passed since AIDS devastated the gay community. Many come out into a community where AIDS is background noise or something only whispered about. The rates of new infection show that clearly isn't the case. Early in the epidemic, we taught our selves, with hard won knowledge from a mysterious foe, how to prevent HIV. Thedata on prevention and sexual conduct is controversial, but clearly indicate infection rates are climbing again. Many are predicting a second wave of HIV infections. Lulled by treatments and numb to education, we're making the same mistakes again.

Consider this: The CDC reports that about 2/3 of HIV positive people are aware of their disease. The other third remains invisible. In the gaycommunity, the rate of HIV positive men is around 8%. Your odds of having sex with an HIV positive person are about 1 in 10.

Put down the poppers and put on a condom.

The Alabama AIDS hotline number is: 800-228-0469
You can reach Birmingham AIDS Outreach at: 322-4197
AIDS Task Force Alabama is available at: 786-5448

This and my future columns regarding AIDS are dedicated in loving memory to Doug; first love, best friend, gone these seven years.

Tod Companion is a Ph.D. Candidate at UAB in Biochemistry and Molecular Genetics. For more information about the 1998 International AIDS Conference and other related issues, please see his web page: www.geocities.com/~todc, or email him at todc@geocities.com.