Australia must re-energise its response to HIV/AIDS, not just rest on its laurels as an early leader, the 2004 ASHM Conference was told in October.

Although Australia has a proud record of quickly responding to the emergence of AIDS in the 1980s, changing patterns of transmission, new treatments and a worsening epidemic in our region mean that innovative new approaches are needed.

Speaking at the opening ceremony in Canberra, High Court Justice Michael Kirby said that, despite 20 years of experience, stigma, discrimination and hatred continue to be major problems for people living with HIV/AIDS.

In a controversial speech, the internationally respected human rights advocate confessed to misgivings about the relevance of voluntary testing and counselling in every situation. When entire communities are threatened, and where stigma prevents people from coming forward for testing, an entirely voluntary approach allows some people’s infections to go undetected, he said.

Justice Kirby reinforced the need for strong leadership.

“From the very beginning,” Justice Kirby told the crowd, “HIV/AIDS has not been a matter of statistics or of theory. It has been a matter of close personal involvement.”

Australia had been fortunate to have its early response led by two “true princes in the art,” Neal Bluett and Michael Baume, he said, but “You cannot assume that lessons learned 20 years ago will continue to be learned.”

The global community finds itself at an “absolutely critical moment in the fight against HIV/AIDS,” Kirby said, and called on the conference participants to “lift out thoughts from our own struggles and see our struggle in the global context.”

Justice Kirby’s opening remarks set the tone for a conference which has increasingly focused on global and regional issues in recent years.

AFAO President Dr Darren Russell warned that a revitalised and more robust response to HIV was desperately needed. “In the last few years it has become apparent that the federal government and some state governments have dropped the ball,” he said. The draft Fifth National Strategy “does virtually nothing” to change what Russell called a “business-as-usual response.”

In another session, Professor Dennis Altman of La Trobe University echoed Justice Kirby’s message, arguing that Australia’s approach to dealing with HIV/AIDS is flawed because it treats the Australian and overseas epidemics as separate issues. “You can’t think of it any longer as the Australian epidemic and then the rest of the world,” he said. “Viruses don’t respect national boundaries.”

While Australian community HIV organisations were doing “extraordinary work,” Altman said that the government response to HIV/AIDS had become stale.

“I have never been as impressed or as proud of ASHM, AFAO and NAPWA as when I see what, with limited resources, they are doing internationally,” he said, “But I don’t think we can any longer say that Australia is a model, I don’t think we can any longer claim that we are providing international leadership. I think that is tired rhetoric.”

‘Learn from your patients’

Professor Michael Kidd, the President of the Royal Australian College of General Practitioners, told the conference that the theme of the meeting — ?From policy to primary care” — should be reversed, that better HIV/AIDS policy would result from the experiences of general practitioners.

Kidd listed “12 lessons from general practice” which he said should be understood by policymakers. As well as delivering front-line treatment, GPs play a key role in HIV prevention, have a detailed and sophisticated understanding of the impact that HIV treatments have on individuals and communities, and have developed close partnerships with the HIV community, he said.

“Learn from your patients, and become a better doctor,” he told the audience.

David Menadue, vice-president of NAPWA, argued that GPs need to be properly supported in the work that they do. “We can’t stand by and watch GPs move out of HIV care or new ones not come along because it’s not financially sustainable to run a high HIV case load practice,” he said.

Coordinated care models and special HIV practice grants are desperately needed for GPs to continue to do their work, Menadue said. Increasing numbers of positive people with complex needs mean that “the community can simply not do this work in volunteer mode any longer.”

Salvage — just guess?

Dr Brian Gazzard of the Chelsea and Westminster Hospital in London gave an overview of approaches to salvage therapy in people with multiple treatment failure.

While salvage studies and increasing use resistance testing were important, Gazzard said, most practitioners continued to base treatment decisions on educated guesswork. Referring to the GUESS study into resistance testing, Gazzard said “it’s not just an acronym but an activity, and for some it’s a way of life.”

There have been too few relevant trials into salvage therapy, Gazzard said, and too great a focus on lowering viral load rather than increasing CD4 counts. Multiple drug resistance, while it remains a problem in a small number of patients, is not the only reason for treatment failure, and researchers need to broaden their focus from looking only at resistance, he said.

Even in people with multiple resistance, Gazzard said that “treatment is better than no treatment,” adding that treatment interruptions were rarely helpful. ‘Maxi-HAART’ regimens, combining numerous different drugs, were promising, and useful even when the patient has resistance to some of the drugs in the combination, but side effects were a problem.

There is a need for new drugs with better resistance profiles, he said, but in the meantime the best approach to salvage is to avoid it by giving people better treatment in the first place.

Toxicities and treatments

Numerous presenters discussed their work in dealing with long-term treatment side effects. In an open-label trial of polylactic acid (New-Fill) at the Alfred Hospital in Melbourne, Dr Anne Mijch and colleagues interviewed the 28 participants prior to starting treatment, and again after six months. While three-quarters experienced improvements in their facial appearance, several participants expressed a degree of disappointment with the outcome of this treatment. While New-Fill continues to show great promise, it needs to be stressed that the treatment cannot totally reverse facial fat loss, the authors said.

Dr Matthew Law presented a new analysis of the D:A:D cohort, a large international study looking at cardiovascular disease risk in people with HIV which has found that the risk of a heart attack increases by about 26 percent for each year on treatment. The researchers applied existing risk models to the participants in the study, and found that the rate of heart attacks was only slightly higher than the rate predicted by existing risk factors. The authors believe that the increased number of heart attacks is not due to HIV treatment alone, but a flow-on effect from changes in existing risk factors (such as increased cholesterol and triglyceride levels) as a result of treatment.