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My father is an infectious disease specialist who has spent the last 30 or so years working on HIV in research, patient treatment, and education. The following

My father is an infectious disease specialist who has spent the last 30 or so years working on HIV in research, patient treatment, and education. The following thought comes from my casual conversations with him, and probably does not represent his professional opinion. It certainly does not reflect his specific thoughts in regards to this trial, as we haven't yet discussed it. The progress in treating HIV since it first entered the popular psyche has been significant. It is no longer a death sentence in the developed world, and those infected with HIV - who get treatment and adhere to that treatment - can live long and relatively normal lives. The real problem is in the developing world, and amongst populations in the developed world that cannot or will not seek/adhere to treatment. Treatment is sufficiently advanced that, while further developments of a vaccine are unbelievably exciting, they are not necessarily a game-changer in terms of worldwide infection. We have a long way to go in terms of beating this virus. Theoretically, we could follow the same route as with [edit: smallpox], unifying and mobilizing the world to isolate and then eradicate pockets of the disease, but this is a much larger effort than the one taking place in the lab, and is a question of government & administration, rather than medicine. Edit: Bringing it up from a comment I made below, here is a relevant TED Talk on stopping pandemics: http://www.ted.com/talks/larry_brilliant_wants_to_stop_pandemics.html http://www.ted.com/talks/larry_brilliant_wants_to_stop_pande...

gst 15y ago
Shouldn't this be more of a temporary problem? As soon as there is a vaccine its patents will expire at least 20 years afterwards. And then lots of much cheaper vaccines will flood the market.
- burgerbrain 15y ago
  And with any luck by that time everyone who has it but refuses to seek treatment will be dead, and everyone else will have been exposed to years of news about the vaccine.. and years of people refusing to take it dying. I think things should work out well in the end, but it might take a while.
  - joshklein 15y ago
    "Refuses to seek treatment" is not necessarily a fair description of these people's actions. They can get HIV at birth through their mother without engaging in any "at risk" behavior. They can have it and not know it. They can lack education. They can lack resources. They can have received misinformation. There are places where the official government-endorsed treatment for HIV was sex with a virgin. There are religious notions that declare use of birth control sinful. There are moral police that call education about safe sex (instead of abstinence) wrong, despite its proven efficacy.
- joshklein 15y ago
  The tough part about vaccines is that they only protect the recipient from the disease if they get the vaccine, and they only eradicate the virus if everyone on the planet is vaccinated. The Science (making the vaccine) and cost (creating enough vaccine) are only two barriers. Getting everyone (and it really must be EVERYONE) to take the vaccine is a very challenging project. That's what makes the story of [edit: smallpox] so fascinating. Here's a relevant TED Talk about pandemics: http://www.ted.com/talks/larry_brilliant_wants_to_stop_pandemics.html http://www.ted.com/talks/larry_brilliant_wants_to_stop_pande...
  - rdl 15y ago
    You don't need to get 100% vaccination to eliminate the disease; somewhere around 90% works, unless it's incredibly contagious and in a high density environment. "Herd immunity" protects the others -- basically, the disease itself can't spread if a sufficient number of people are vaccinated, so it dies out in a few generations (of the disease, not of humans).
    - ComputerGuru 15y ago
      From my classes in veterinary medicine, I believe the herd immunity is around the 80% mark, at least for livestock and their diseases.
      - rdl 15y ago
        It depends on a lot of factors -- how many people will catch the disease, assuming no one is vaccinated, per infected individual is the primary one). I think most livestock diseases are aerosols (foot and mouth disease, etc.), and so are a lot of human diseases, but thankfully not AIDS. The problem is the standard models of herd immunity depend on some simplifying assumptions which may be true in livestock, but are not true in humans -- specifically, that it's a homogenous population with equal chance of giving any other individual the disease, and that vaccines will be distributed fairly randomly as well. If you have backwater villages which never get vaccinated, and are highly interconnected, you can end up with persistent reservoirs of disease, even if it's only 1% of your overall population. Then, you can have periodic epidemics when an individual from that area travels to an unvaccinated area elsewhere (because compliance rates on vaccination go down once the disease is "cured" in a population). (I know about this from drinking with some of the UN/WHO vaccination people in Afghanistan)
- byoung2 15y ago
  Shouldn't this be more of a temporary problem? As soon as there is a vaccine its patents will expire at least 20 years afterwards. And then lots of much cheaper vaccines will flood the market. I think his point is that much of the problem of preventing the spread of HIV has less to do with the science of killing the virus, and more to do with the difficulty of actually getting it in the hands of people who need it. There are already very cheap, readily-available ways of preventing HIV transmission (condom use comes to mind), but people aren't using those. The reasons are varied, but some cite misinformation, cultural misconceptions, government ineptitude, and so on. Even if there were a 99% effective HIV vaccine that were as cheap as water, it still wouldn't make it into the hands of every person in the developing world. Proof of that is the fact that we can't even get water to all of these people.
  - rflrob 15y ago
    Proof of that is the fact that we can't even get water to all of these people. Not sure how good an analogy this is. I suspect it would be moderately expensive (i.e. on the order of a few billion dollars), but possible to deliver a liter of clean water to nearly everyone in the developing world. The problem is, that solves their water problem for about 12 hours, if you're being generous. Solving their problem long term is the hard part. With vaccines, you only need to visit the people a finite number of times, and then you're done. Given that HIV is sexually transmitted (and assuming that the vaccine can be given relatively young), you wouldn't even need especially frequent visits to immunize the next generation of people.
    - spp 15y ago
      In the context of this discussion, I believe "a few billion dollars" would be pretty cheap.
- rdl 15y ago
  Patents aren't the problem here, but it's an interesting thought experiment to think about what commercial terms a vaccine for AIDS or other diseases which at this point mainly affect poor, third-world people would be distributed under. India would probably just violate the patent, claiming national security reasons, and sell it for ~production cost throughout the world. The USA might enforce a patent domestically, and it would be a rational economic choice for insurers to pay for it for many patients instead of long-term treatment if someone contracts AIDS otherwise -- if you have a 0.1% risk of contracting AIDS in a lifetime, and lifetime treatment costs $1mm, it's worthwhile to pay $100-$1000 for it. A charity (or government) might pay for full rights to the vaccine globally, and then distribute it for the good of humanity (and to burnish their reputation), but the really out of the box thing would be for a consumer product company to distribute the vaccine cheaply, purely as a form of PR. Imagine: "Coca-Cola, the drink that is good for you. Remember, we cured AIDS."
  - nihilocrat 15y ago
    Insurance would not be quite as clear-cut, but I suppose it would be a sensible option. Companies would point to herd immunity (linked in the comments above) to avoid paying for vaccination for 30% or so of the population. I'm sure they have ways to put people into that 30%, and knowing them, they will try to cheat their customers of every penny they can.
scott_s 15y ago
I'm confused by the statement that a vaccine would not be a game changer in terms of worldwide infection. Right now, the only way to reliably prevent HIV infection is through changing behavior, which is extremely difficult. But widespread use of a vaccine would just require a one-time injection, which is relatively easier. I'm further confused by your polio reference, because that sort of effort would only be possible with a vaccine.
- burgerbrain 15y ago
  Not to be pedantic, but is it the case this would only be a single injection? I believe that some vaccines can need repeat/regular treatments over a (relatively short I think) period of time. If that were the case here it would make vaccination much harder, though still possible of course.
  - scott_s 15y ago
    That's a fair point, but I still think that's an order of magnitude easier than changing life-long behavior regarding sex partners.
- joshklein 15y ago
  EDIT: I actually meant smallpox when I was talking about polio. That's a big error; corrected it above. Thanks rdl. I should have been more specific - I meant that if we did develop a vaccine, then it makes following the [smallpox] example theoretically possible, but this is still extremely challenging due to the reasons given. Although you and I might have the vaccine, not everyone has it - not by a long shot - because not everyone is born in a modern westernized hospital. These people are protected by virtue of an extreme mobilization to literally isolate every single instance of the virus. It (hopefully) only exists in the lab at this point.
  - rdl 15y ago
    You may be thinking of smallpox, which exists in one or two declared labs (and probably a few more black labs). Polio is unfortunately still "in the wild" in certain areas (Afghanistan/Pakistan/India, Sub-Saharan Africa), and had a bit of a resurgence lately. The Gates Foundation is putting a lot of effort into finishing up polio eradication. Relevant TED talk: http://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio.html http://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio.... One of the main issues is that the polio vaccine requires a cold chain (presently; I think they have a new shelf-stable one); the smallpox vaccine, at least one of them, does not.
Alex3917 15y ago
"those infected with HIV - who get treatment and adhere to that treatment - can live long and relatively normal lives." The adherence part is the most interest bit of the story. The adherence to HIV medications is ~93%, much greater than the adherence to almost every other drug or behavioral treatment. If diabetes patients or cardiac patients had adherence rates anywhere near that high then the life expectancy of the average American would be dramatically higher.
- eru 15y ago
  Do you know why they reach +93%?
  - Alex3917 15y ago
    There are lots of different variables that influence adherence, including but not limited to: - expected or actual efficacy - regimen complexity - knowledge, commitment, and ability - doctor-patient relationship My understanding is that with HIV a lot of money has been spent on actually implementing the adherence research in order to reduce the spread of the disease, whereas for most other diseases no one really cares. I think getting diagnosed with HIV also encourages some people to grow up a little bit in a way that getting diagnosed with high blood pressure or whatever doesn't, though maybe less so now that infection vectors are changing.
    - cdavoren 15y ago
      It might also be worth noting that adherence with HIV medication is also motivated by simple fear: if you don't take it, you will die. Painfully, from secondary infection. Diabetes (type 2) and cardiac disease are scenarios where people can still kid themselves to a certain extent.
crag 15y ago
"The progress in treating HIV since it first entered the popular psyche has been significant. It is no longer a death sentence in the developed world, and those infected with HIV - who get treatment and adhere to that treatment - can live long and relatively normal lives." Except the side effects (as with any drug therapy) can be severe. And the effects of long term use is anybody guess. Many patients who lived, just now reaching their 50's; are experiencing everything from diabetes to chronic kidney and liver disease to macula edema. Course the trade off is death. So maybe it is a good deal.
smn 15y ago
Just to confirm this, at work (http://github.com/praekelt http://github.com/praekelt & http://praekeltfoundation.org http://praekeltfoundation.org) this exactly the problem we are up against in Africa.
thisrod 15y ago
There's an important difference between HIV and smallpox. To eradicate smallpox, it suffices to vaccinate all the humans. But to eradicate HIV, you have to vaccinate all the apes. This family of viruses has already jumped species twice, so no doubt it will do so again.
Tichy 15y ago
Aren't infections more likely to go up if people can survive HIV with medication indefinitely. More survivors means more people who can infect other people?
dlikhten 15y ago
Quick question: I thought that vaccines were supposed to be a problem for HIV. They trigger the immune system response which quite literally forces the food of the HIV virus to come to it faster. Vaccines were supposed to speed up the rate of infection. That was supposed to be the paradox of HIV. So question is, is this vaccine really news or just another one of these? Sorry I am not that well versed in this sort of topic.

gst 15y ago

Shouldn't this be more of a temporary problem? As soon as there is a vaccine its patents will expire at least 20 years afterwards. And then lots of much cheaper vaccines will flood the market.

burgerbrain 15y ago
And with any luck by that time everyone who has it but refuses to seek treatment will be dead, and everyone else will have been exposed to years of news about the vaccine.. and years of people refusing to take it dying. I think things should work out well in the end, but it might take a while.
- joshklein 15y ago
  "Refuses to seek treatment" is not necessarily a fair description of these people's actions. They can get HIV at birth through their mother without engaging in any "at risk" behavior. They can have it and not know it. They can lack education. They can lack resources. They can have received misinformation. There are places where the official government-endorsed treatment for HIV was sex with a virgin. There are religious notions that declare use of birth control sinful. There are moral police that call education about safe sex (instead of abstinence) wrong, despite its proven efficacy.
joshklein 15y ago
The tough part about vaccines is that they only protect the recipient from the disease if they get the vaccine, and they only eradicate the virus if everyone on the planet is vaccinated. The Science (making the vaccine) and cost (creating enough vaccine) are only two barriers. Getting everyone (and it really must be EVERYONE) to take the vaccine is a very challenging project. That's what makes the story of [edit: smallpox] so fascinating. Here's a relevant TED Talk about pandemics: http://www.ted.com/talks/larry_brilliant_wants_to_stop_pandemics.html http://www.ted.com/talks/larry_brilliant_wants_to_stop_pande...
- rdl 15y ago
  You don't need to get 100% vaccination to eliminate the disease; somewhere around 90% works, unless it's incredibly contagious and in a high density environment. "Herd immunity" protects the others -- basically, the disease itself can't spread if a sufficient number of people are vaccinated, so it dies out in a few generations (of the disease, not of humans).
  - ComputerGuru 15y ago
    From my classes in veterinary medicine, I believe the herd immunity is around the 80% mark, at least for livestock and their diseases.
    - rdl 15y ago
      It depends on a lot of factors -- how many people will catch the disease, assuming no one is vaccinated, per infected individual is the primary one). I think most livestock diseases are aerosols (foot and mouth disease, etc.), and so are a lot of human diseases, but thankfully not AIDS. The problem is the standard models of herd immunity depend on some simplifying assumptions which may be true in livestock, but are not true in humans -- specifically, that it's a homogenous population with equal chance of giving any other individual the disease, and that vaccines will be distributed fairly randomly as well. If you have backwater villages which never get vaccinated, and are highly interconnected, you can end up with persistent reservoirs of disease, even if it's only 1% of your overall population. Then, you can have periodic epidemics when an individual from that area travels to an unvaccinated area elsewhere (because compliance rates on vaccination go down once the disease is "cured" in a population). (I know about this from drinking with some of the UN/WHO vaccination people in Afghanistan)
byoung2 15y ago
Shouldn't this be more of a temporary problem? As soon as there is a vaccine its patents will expire at least 20 years afterwards. And then lots of much cheaper vaccines will flood the market. I think his point is that much of the problem of preventing the spread of HIV has less to do with the science of killing the virus, and more to do with the difficulty of actually getting it in the hands of people who need it. There are already very cheap, readily-available ways of preventing HIV transmission (condom use comes to mind), but people aren't using those. The reasons are varied, but some cite misinformation, cultural misconceptions, government ineptitude, and so on. Even if there were a 99% effective HIV vaccine that were as cheap as water, it still wouldn't make it into the hands of every person in the developing world. Proof of that is the fact that we can't even get water to all of these people.
- rflrob 15y ago
  Proof of that is the fact that we can't even get water to all of these people. Not sure how good an analogy this is. I suspect it would be moderately expensive (i.e. on the order of a few billion dollars), but possible to deliver a liter of clean water to nearly everyone in the developing world. The problem is, that solves their water problem for about 12 hours, if you're being generous. Solving their problem long term is the hard part. With vaccines, you only need to visit the people a finite number of times, and then you're done. Given that HIV is sexually transmitted (and assuming that the vaccine can be given relatively young), you wouldn't even need especially frequent visits to immunize the next generation of people.
  - spp 15y ago
    In the context of this discussion, I believe "a few billion dollars" would be pretty cheap.
rdl 15y ago
Patents aren't the problem here, but it's an interesting thought experiment to think about what commercial terms a vaccine for AIDS or other diseases which at this point mainly affect poor, third-world people would be distributed under. India would probably just violate the patent, claiming national security reasons, and sell it for ~production cost throughout the world. The USA might enforce a patent domestically, and it would be a rational economic choice for insurers to pay for it for many patients instead of long-term treatment if someone contracts AIDS otherwise -- if you have a 0.1% risk of contracting AIDS in a lifetime, and lifetime treatment costs $1mm, it's worthwhile to pay $100-$1000 for it. A charity (or government) might pay for full rights to the vaccine globally, and then distribute it for the good of humanity (and to burnish their reputation), but the really out of the box thing would be for a consumer product company to distribute the vaccine cheaply, purely as a form of PR. Imagine: "Coca-Cola, the drink that is good for you. Remember, we cured AIDS."
- nihilocrat 15y ago
  Insurance would not be quite as clear-cut, but I suppose it would be a sensible option. Companies would point to herd immunity (linked in the comments above) to avoid paying for vaccination for 30% or so of the population. I'm sure they have ways to put people into that 30%, and knowing them, they will try to cheat their customers of every penny they can.

scott_s 15y ago

I'm confused by the statement that a vaccine would not be a game changer in terms of worldwide infection. Right now, the only way to reliably prevent HIV infection is through changing behavior, which is extremely difficult. But widespread use of a vaccine would just require a one-time injection, which is relatively easier. I'm further confused by your polio reference, because that sort of effort would only be possible with a vaccine.

burgerbrain 15y ago
Not to be pedantic, but is it the case this would only be a single injection? I believe that some vaccines can need repeat/regular treatments over a (relatively short I think) period of time. If that were the case here it would make vaccination much harder, though still possible of course.
- scott_s 15y ago
  That's a fair point, but I still think that's an order of magnitude easier than changing life-long behavior regarding sex partners.
joshklein 15y ago
EDIT: I actually meant smallpox when I was talking about polio. That's a big error; corrected it above. Thanks rdl. I should have been more specific - I meant that if we did develop a vaccine, then it makes following the [smallpox] example theoretically possible, but this is still extremely challenging due to the reasons given. Although you and I might have the vaccine, not everyone has it - not by a long shot - because not everyone is born in a modern westernized hospital. These people are protected by virtue of an extreme mobilization to literally isolate every single instance of the virus. It (hopefully) only exists in the lab at this point.
- rdl 15y ago
  You may be thinking of smallpox, which exists in one or two declared labs (and probably a few more black labs). Polio is unfortunately still "in the wild" in certain areas (Afghanistan/Pakistan/India, Sub-Saharan Africa), and had a bit of a resurgence lately. The Gates Foundation is putting a lot of effort into finishing up polio eradication. Relevant TED talk: http://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio.html http://www.ted.com/talks/bruce_aylward_how_we_ll_stop_polio.... One of the main issues is that the polio vaccine requires a cold chain (presently; I think they have a new shelf-stable one); the smallpox vaccine, at least one of them, does not.

Alex3917 15y ago

"those infected with HIV - who get treatment and adhere to that treatment - can live long and relatively normal lives." The adherence part is the most interest bit of the story. The adherence to HIV medications is ~93%, much greater than the adherence to almost every other drug or behavioral treatment. If diabetes patients or cardiac patients had adherence rates anywhere near that high then the life expectancy of the average American would be dramatically higher.

eru 15y ago
Do you know why they reach +93%?
- Alex3917 15y ago
  There are lots of different variables that influence adherence, including but not limited to: - expected or actual efficacy - regimen complexity - knowledge, commitment, and ability - doctor-patient relationship My understanding is that with HIV a lot of money has been spent on actually implementing the adherence research in order to reduce the spread of the disease, whereas for most other diseases no one really cares. I think getting diagnosed with HIV also encourages some people to grow up a little bit in a way that getting diagnosed with high blood pressure or whatever doesn't, though maybe less so now that infection vectors are changing.
  - cdavoren 15y ago
    It might also be worth noting that adherence with HIV medication is also motivated by simple fear: if you don't take it, you will die. Painfully, from secondary infection. Diabetes (type 2) and cardiac disease are scenarios where people can still kid themselves to a certain extent.

crag 15y ago

"The progress in treating HIV since it first entered the popular psyche has been significant. It is no longer a death sentence in the developed world, and those infected with HIV - who get treatment and adhere to that treatment - can live long and relatively normal lives." Except the side effects (as with any drug therapy) can be severe. And the effects of long term use is anybody guess. Many patients who lived, just now reaching their 50's; are experiencing everything from diabetes to chronic kidney and liver disease to macula edema. Course the trade off is death. So maybe it is a good deal.

smn 15y ago

Just to confirm this, at work (http://github.com/praekelt http://github.com/praekelt & http://praekeltfoundation.org http://praekeltfoundation.org) this exactly the problem we are up against in Africa.

thisrod 15y ago

There's an important difference between HIV and smallpox. To eradicate smallpox, it suffices to vaccinate all the humans. But to eradicate HIV, you have to vaccinate all the apes. This family of viruses has already jumped species twice, so no doubt it will do so again.

Tichy 15y ago

Aren't infections more likely to go up if people can survive HIV with medication indefinitely. More survivors means more people who can infect other people?

dlikhten 15y ago

Quick question: I thought that vaccines were supposed to be a problem for HIV. They trigger the immune system response which quite literally forces the food of the HIV virus to come to it faster. Vaccines were supposed to speed up the rate of infection. That was supposed to be the paradox of HIV. So question is, is this vaccine really news or just another one of these? Sorry I am not that well versed in this sort of topic.