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A school without a teacher. A home with no parents. Thousands of communities in Africa, Asia, and other developing areas of the world face this outcome from the greatest development, socioeconomic, and health crisis in history: AIDS.Millions are infected with HIV, the virus that causes AIDS--roughly 50 million according to Dr. Gro Brundtland, Director-General of the World Health Organization. Hundreds of millions more are at risk for the virus itself and billions for the effects of AIDS on the family and society. Grim projections into the next 10 years of the number of AIDS orphans spawned by the AIDS crisis reach 44 million. AIDS is the number one killer in Africa and number four in the rest of the world.Gathered at the XIII International AIDS Conference in Durban, South Africa, more than 12,000 of the world's leading scientists, health care and social workers, government and community leaders ask themselves, "What more can we do?" Many begin plenary sessions and workshops stating, "I said this already eight years ago … "Despite the rally cry of the conference, "Break the Silence" (referring to the lingering stigma and inaction surrounding AIDS), the mood is somber. Little satisfies the thirst for a cure or easily administered and cheap treatment. Prevention remains the critical component to control of the epidemic.

Bits of hope spring from the fact that in the developed world, AIDS may now be treated as a chronic disease among people and nations that can afford treatment and keep to a tight drug regimen. Drug combinations completely reduce detection of the virus in the body. But we know the virus does not disappear entirely. It merely hides and is able to change it's configuration to avoid detection by drugs. As soon as medications are stopped due to toxicity, expense, or poor compliance, the virus bares an ugly presence again. Some are exploring an alternative approach of a cyclic protocol, intentionally interrupting drug treatment for a season to make the drugs more tolerable and less expensive. Results are promising, not leading to compromise in improving the health of HIV-positive persons. This will surely be under consideration as possible approaches for developing countries.Research for an AIDS vaccine continues for prevention, for protection of a sexual partner, or for prolonging life. Much work needs to be done before results of clinical trials of vaccines presently under study in Africa, North America and Asia are available. It will be years before a vaccine is feasible, but the drive to produce what will likely be a variety of vaccines relating to the different genetic types of the virus is firmly on the global agenda. Even when a vaccine is available however, most of the world will not have easy access. A cacophony of voices at this conference demanded that vaccines be available to all nations at an affordable cost. Yet vaccine compliance even for childhood immunizations for polio or tetanus is a challenge in many developing countries, sometimes for something as simple as lack of refrigeration.The study and treatment of new drugs to prevent the spread of HIV to infants born to HIV positive mothers was clearly one of the most significant highlights of the conference. This option is already feasible for many mothers and infants in the developed world. While affordability (about $4 per HIV-infected mother) is no longer the barrier to preventing mother to child transmission of HIV as it once was. Still it is out of reach for most mothers in the hardest hit countries where per capita health spending for some is less than $5 a year. The drugs are not available in most countries, let alone in remote rural clinics. A devastating complication rises from the fact that HIV may be passed from an HIV positive mother to child through breast milk. Withholding breast milk from infants in Africa may well bring death sooner than AIDS.

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July (Web-only) 2000, Vol. 44