Is AIDS vaccine the best solution?

By Chris W. Green

JAKARTA (JP): A recent news report from Reuters in The Jakarta Post (Test of AIDS vaccine in Thailand, Feb. 10) notes that "Experts agree that, long term, a vaccine is the only answer to HIV." While it is true that most support the urgent need to develop a vaccine, there is at least a percentage of experts who question whether a vaccine is indeed the solution.

First, let us be aware that it is most unlikely there will be a widely available vaccine against HIV, the virus which causes AIDS, within the next ten years -- indeed many experts question whether it will be possible to produce such a vaccine at all. At best, it is probable that early vaccines may be selective, working against a small proportion of the strains of HIV -- and HIV has shown a devious ability to develop new strains very rapidly. Thus at least initially, it is unlikely a vaccine will provide 100 percent protection. While this may go some way to reducing the global incidence of AIDS, for individuals it may not offer much peace of mind.

And anyway, with 16,000 people becoming infected with HIV around the world every day, we can expect to see more than 50 million more people infected while we wait for a vaccine -- on top of the more than 30 million already living with the virus. Clearly we need to at least take some interim action.

But the concern over relying on a vaccine goes deeper. As one expert, Professor Daniel Halperin from the Community Health Systems Department at University of California San Francisco, has noted, the germ itself is only one aspect of any epidemic. Just as crucial is the environment -- biological, social and cultural -- in which the disease develops. For example, allowing sewage to contaminate drinking water sources will eventually lead to a cholera epidemic. While it is possible to vaccinate against cholera, clearly the main public health goal should be to remove the source of the epidemic.

Halperin asked what we will do about the next sexually spread pandemic which will inevitably arise. "Will we wait umpteen years to develop a vaccine against that disease too, and the next and the next after that, while millions die or become ill?" The better answer has to be prevention, based upon behavioral changes.

Halperin admitted that this is no easy task, But, he said, "if we put all our hopes into a vaccine, we could end up reinforcing the basis for future epidemics," including some like Hepatitis B and C, "not to mention the massive global epidemic of teenage/unwanted pregnancies." We must avoid spreading the message that says "as soon as we get that vaccine, you'll be able to stop worrying about unsafe sex again."

Halperin is not alone in these concerns. Sam Avrett, director of the AIDS Vaccine Advocacy Coalition, said, "Vaccines can only be a small part of the AIDS agenda. To control the epidemic we will need good health care infrastructure, strong traditional HIV prevention efforts and continued treatment research and access."

James Chin, Director of California-based Communicable Disease Prevention & Control and an acknowledged expert on the AIDS epidemic in the developing world, is even more forthright. Noting that there are no magic bullets, Chin professed that he is unable to see how a vaccine is the answer to the almost unabated HIV epidemic in Africa. He worried that a vaccine will reduce the efforts being put into prevention. "Condoms cannot be abandoned when a vaccine is available," he stressed, but added "it will be more difficult to motivate people with high risk behavior to use them consistently." An AIDS vaccine is unlikely to be cheap, and Chin doubts that international donors will be willing to pay for the huge vaccination programs in addition to supporting the meager prevention programs currently in place.

Prevention programs based on behavior change do work -- this has been proved in Senegal, in Uganda and in Thailand. And they can work immediately; we do not have to wait ten years for results. But, as James Chin noted, "insufficient support has been given to public health programs which try to reduce risk behavior."

Mark Schoofs, writing recently in the Washington Post, examines the success of the programs in Senegal, which "has one of the lowest rates of adults infected with HIV of any country south of the Sahara -- just 1.77 percent." And he concluded: "While the molecular biologists toil toward a cure and a vaccine, we need to heed the wisdom of countries that are succeeding with the humbler, human resources that are available right now."

Are we in Indonesia heeding this wisdom? Certainly great efforts have been made, both by government and non-governmental organizations (NGOs). These prevention efforts can take some of the credit for the apparent low prevalence of HIV infection in Indonesia. And despite the monetary crisis, funds are still being made available for AIDS prevention programs.

But many feel that we are still walking on tiptoe around several sensitive issues, such as condom promotion and sex education -- issues which were firmly grasped from the start in Senegal. With a predominantly Muslim and residually Catholic population, much like Indonesia, they face similar challenges. Schoofs noted, "right from the start, their program enlisted the help of unlikely allies: religious leaders."

AIDS program managers in Senegal held two national meetings, one for imams and the other for Christian priests. "You can preach fidelity and abstinence," the religious leaders were told, "but permit us -- NGOs and the government -- to promote condoms. We came to this agreement, this modus vivendi: No organization should be a barrier to the others." Although some progress has been made along these lines in Indonesia, many would question whether we have yet reached this modus vivendi.

The writer is editor of Warta AIDS news bulletin.