HIV Vaccine: With New Hope Comes The Potential Dangers of Complacency

"It is frightening because no one knows what's causing it, said a 28-year old law student who went to the St. Mark's Clinic in Greenwich Village last week complaining of swollen glands, thought to be one early symptom of the disease. Every week a new theory comes out about how you're going to spread it." - The New York Times , August 8th 1982. Unaccompanied by anything like a true understanding of the virus until years later – or even a proper name for it – 1981 witnessed the first signs of a public, or even scientific, awareness of AIDS in America. First, several cases of an increasingly aggressive form of Kaposi's Sarcoma (KS) – a relatively benign cancer that typically occurred in older people – were recorded in young gay men in New York. Second, and at approximately the same time, there was a sharp increase in the number of young men contracting the lung infection, Pneumocystis carinii pneumonia (PCP). The Centers for Disease Control had been given real reason to worry; the beginnings of the HIV/AIDS outbreak had finally come alive on the shores of the United States of America and there was no avoiding it. Two of the first labels for the condition, "gay compromise syndrome" – appearing in a letter in The Lancet in 1982 – and GRID (gay-related immune deficiency) signify an early indictment on the ways in which the HIV/AIDS crisis would go on to haunt the homosexual community for decades. "Gay cancer" was another. In late 1982, the condition was referred to as ‘AIDS’ for the very first time and by 1986, scientists had come to the conclusion that LAV retrovirus (lymphadenopathy-associated virus) and HTLV-III (Human T-Cell Lymphotropic Virus III) were essentially the same thing. They came up with the fresh designation of Human Immunodeficiency Virus or HIV. Yet, from its earliest inception in the ‘80s, our understanding of the disease has undergone both a cultural and a medical revolution. In the latter stage of the decade, the years of 1986 and 1987 proved tremendously significant to an improved understanding of the virus. In 1986, Ronald Wilson Reagan, a President often lambasted for his ignorance of the AIDS crisis, made specific note of the word ‘AIDS’ for the first time in his Presidency. In his annual State of the Union Address, Reagan said: “We will continue, as a high priority, the fight against Acquired Immune Deficiency Syndrome (AIDS). An unprecedented research effort is underway to deal with this major epidemic public health threat. The number of AIDS cases is expected to increase. While there are hopes for drugs and vaccines against AIDS, none is immediately at hand. Consequently, efforts should focus on prevention, to inform and to lower risks of further transmission of the AIDS virus. To this end, I am asking the Surgeon General to prepare a report to the American people on AIDS”, he said. A year later, on March 20th, 1987, GlaxoSmithKline’s AZT (or Retrovir and Retrovis) became the first FDA-approved drug for the treatment of HIV/AIDS. With a little history in mind, then, it should come as no surprise that the recent discovery of an experimental HIV vaccine has been greeted with euphoria and skepticism in almost equal measure. Hailed by some as a significant, clinical breakthrough, results from Phase III Clinical Trials show the new vaccine to be around 31% effective at preventing infection, in addition to being relatively well-tolerated under its current regimen.Beneath the surface, the new vaccine is an innovative prime-boost pairing of two existing vaccines. Namely, the modified canarypox vaccine, ALVAC-HIV (prime), developed by Sanofi Pasteur of France and AIDSVAX B/E (boost) vaccine, a glycoprotein 120 vaccine now licensed to Global Solutions for Infectious Diseases (GSID) in California. Carried out in Thailand and sponsored by the U.S. Army – alongside the National Institute of Allergy and Infectious Diseases (NIAID), Sanofi Pasteur and GSID - over 16,000 people were involved in the placebo-controlled study. Having killed over 25 million people – and brought great pain and suffering to many others - since initial recognition of the virus in 1981, it is hardly startling that there are still many skeptics amongst the cheerleaders. Back in June of this year, Paul Thorn, a 15-year-long veteran activist and HIV expert was denied entry to the United States due to his HIV-positive status. Scheduled to speak at the Pacific Health Summit in Seattle, Mr. Thorn became yet another victim of the United States’ now seemingly primitive laws on the issue. This is but one example of the many ways in which sufferers are discriminated against on a daily basis and provides an apt illustration of why feelings still run high on the topic. False hope can be a torturous illusion for many. Is this false hope? Simply put, yes and no. In commenting on the findings Dr Richard Horton, editor of the Lancet, combined encouragement with caution in delivering his assessment. "This result is tantalisingly encouraging. The numbers are small and the difference may have been due to chance, but this finding is the first positive news in the Aids vaccine field for a decade”, he said. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/Aids (UN/Aids) heralded the results as having “instilled new hope in the HIV vaccine research field". Lt. Gen. Eric Schoomaker, the U.S. Army Surgeon General echoed such sentiments, saying ''This is truly a great moment for world medicine”. For others, however, while meaningful progress is welcomed, the results also provide an empirical basis for skepticism. Writing for the Huffington Post, U.S. physician, Peter Klatsky astutely pointed out that a single digit amendment to the figures would have rendered the results almost non-newsworthy. “After vaccinating 16,000 people, there were 23 fewer new infections in patients receiving the vaccine (51 cases versus 74 cases). If one additional patient who received the vaccine became infected (52 instead of 51) the results would no longer be "statistically significant”, he said. Deeming it the ‘worst kind of good news’, in an article for the Times, Elizabeth Pisani, an epidemiologist specialising in HIV prevention, threw some pragmatism into the mix: ‘…a vaccine that reduces the risk of infection by a third presents an agonising public health dilemma’, she said. ‘With most infectious diseases, reducing everyone’s risk by a third would make quite a difference across a whole population. But the problem with HIV is that it is both an infectious disease and a behavioural one. I can get it by sharing needles with other drug injectors, I can avoid it by using condoms every time I have sex. If I know I have been vaccinated, will that make me more likely to share needles, or less likely to use condoms? And if it does, will that change outweigh the 30 per cent reduction in risk that comes with the vaccine?’ All things considered, this is positive news for the clinical research community. In comparison to the failure of previous studies, these latest results certainly look impressive. Going forward, several questions will still remain. For one, this is not the be-all-end-all cure for the HIV/AIDS pandemic that some might hope it to be. A 30% reduction, while also remaining purely experimental in terms of proven efficacy, is no where near the levels needed to permanently eradicate the virus from the face of the planet. As has always been the case, culture and behavioral tendencies will continue to provide much of the backbone for the fight against the condition. Experimentation is one thing, a cure for one of the gravest human pandemics in history is quite another. Only time will tell.