September 25, 2002
HIV researchers are being kept unusually busy during even years now that there are more conferences than usual with the addition of the large International AIDS Conference.
This particular meeting began four years ago as an avenue for researchers to discuss the metabolic complications associated with HIV and its treatment. It has quickly become the most important meeting in the world to discuss these problems. There is also another meeting with similar goals in Europe during the spring, and I think an important goal would be to merge the two. The representation of Europe at this meeting is large, and it is usually held at each side of the Atlantic in alternate years. In fact, the next meeting will be in Paris next year. Merging meetings and reducing the number of them will improve the quality of the presentations, their significance and quality of life for all of us. I hope the new self-regulation in the pharmaceutical industry, which began in July of this year, will help with this task. The current proliferation of AIDS conferences has nothing to do with the industry and much more to do with some investigators who feel that their meeting is not the one that should be sacrificed; they see the meeting they are running as some sort of personal recognition. Unfortunately, our field is full of examples of this, such as the two infectious disease meetings -- ICAAC and IDSA -- which have an incredible amount of overlap and are planned to both take place in the fall of 2002, only one month apart.
The lipodystrophy meeting is by all means a small meeting compared to the large International AIDS Conference. There were only 100 presentations compared to the more than 10,000 presented in Barcelona. So, it was possible to see every presentation and every poster, and one never had the feeling that one was missing something important. This is supposed to be a workshop, which means that it allows the free interchange of ideas between attendees, and that is why it is important that this meeting maintains its relatively small size.
Because of its small size, not many abstracts are submitted and the organizing committee accepts most of what it is sent. This leads to remarkable differences in the quality of the presentations.
One of the main limitations of this meeting is its focus on basic science, so few large clinical studies are presented. Large clinical studies are typically presented in different venues. This year was probably an exception because some large clinical studies were presented here: the final analysis of TARHEEL, the DEXA A5005s substudy, the switch study of nelfinavir (NFV, Viracept) to atazanavir (BMS-232623, Zrivada) and Dr. Nolan's study in western Australia.
The basic science was very good. It is clear that we have come a long way in our understanding of the mechanisms behind these complications. The evidence points to the mechanism of insulin resistance as affected by protease inhibitors (most likely, their effects on glucose transport in the periphery). It is also clear that the mechanism of the lipid disturbances is related to disturbances in the SPREB pathway. However, it is less clear whether we have come close to understanding lipoatrophy and what the role (if any) is of mitochondrial toxicity or disregulation of some cytokines such as tumor necrosis factor (TNF), or a combination of both.
We clearly have a problem translating this very strong basic science into clinical applications for humans. It is in the link between basic and clinical sciences where we need to work harder. There are limits to the questions that we can ask in an in vitro system or in a mice model. The main message after this meeting should be: "let's try to confirm some of these findings in humans."
We also need more therapeutic trials. Although the new drugs on the block seem to be less toxic than the old ones, it is more than likely that our patients are going to need several of the old medications, and more than likely some of the new drugs will also have some toxicity associated with their use. However, it is extraordinarily difficult to enroll patients for clinical trials that evaluate the therapeutic interventions used to treat the metabolic-associated complications of HIV. Clinicians should realize that the only way we are going to learn how to treat these problems is by conducting large randomized trials.
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