Waltzing with death

The XVIII International AIDS Society meeting
第18届世界艾滋病大会

Waltzing with death
与死神共舞

AIDS still kills 2m people a year. But the rate of new infections is falling and it is possible to imagine bringing the disease under control
艾滋病每年仍导致200万人死亡。但新染此病的人数正在下降，控制艾滋病已成可能

Jul 22nd 2010 | vienna
2010年7月22日| 维也纳




TEN years ago, when the International AIDS Society (IAS) met in Durban, there was a lot of fractious debate between those who wanted to spend money on treating the sick and those who thought that stopping the epidemic was more important. It took another six years to realise that you might be able to do both. Suppressing the virus in someone’s body clearly saves his life, but it ought also to make him less likely to pass on infection. The latest evidence that this might be true was released at this year’s IAS meeting, held in Vienna on July 18th-23rd.

十年前，当国际艾滋病协会（IAS）在德班举行会议时，在以治病为主还是以防病为主的两派之间爆发了一场激烈的争论。六年后才认识到，两者也许可以并行不悖。抑制某位病人体内病毒的繁殖显然可以挽救他的生命，但同时也应该降低他的传染性。7月18日至23日在维也纳召开了本年度的世界艾滋病大会，会上公布的最新证据表明，现在确实可以抑制艾滋病人的传染性了。

The meeting brought news of another long-sought breakthrough: a vaginal microbicide that will allow women to protect themselves from men who do not wear condoms. There was also much hand-wringing about money, as governments and taxpayers in rich countries feel the pinch. But even here there was a refreshing honesty, as the international agencies charged with combating the disease queued up to suggest ways of doing more with less. That businesslike approach was apparent, too, in discussions over focusing treatment on those who are most at risk.

会上还传出了另一则消息，人们长期以来所希盼的阴道内杀菌剂研究取得了突破性的进展，这样，即使男人不戴避孕套的话，女人也能有办法使自己免遭爱滋病毒感染。由于各富国政府和纳税人普遍感到手头拮据，会上对目前艾滋病防治领域资金短缺的严重状况反响强烈。大会期间，负责防治艾滋病的各国际组织真心实意地排着队争相提出少花钱多办事的妙方，这真是一个令人耳目一新的景象。将防治艾滋病的重点放在染病风险最高的人群上的讨论也表现出了这种务实的做法。

As the meeting opened, it was announced that a study by Julio Montaner, a researcher at the University of British Columbia, had shown that ramping up treatment in that Canadian province halved the rate of new infections. Dr Montaner’s study, published in the Lancet, was the strongest confirmation yet that treatment and prevention are two sides of the same coin. The study showed that the annual rate of infection in 1996—the year when the modern regime of highly active antiretroviral therapy (HAART) was introduced—had, by 2009, fallen by 52%. During that period the number of people on treatment rose by 547%.

会议开幕后宣读的第一份研究报告是由加拿大不列颠哥伦比亚大学的研究人员胡里奥•蒙泰纳（Julio Montaner）撰写的，该报告指出，不列颠哥伦比亚省加大了对艾滋病的防治力度，使新感染者的人数下降了一半。蒙泰纳博士的研究报告发表在《柳叶刀》杂志上，该报告肯定了治疗与预防是一枚硬币的两面，因而不可分割的观点，是对这一观点迄今为止最有力的支持。这项研究表明，自从1996年推出了高效抗逆转录病毒疗法（highly active antiretroviral therapy，HAART）这一最新治疗方法后，截至到2009年， 艾滋病的年感染率下降了52％。在此期间，进行治疗的人数上升了547％。

Taking heart
鼓起勇气

Of course correlation is not causation. But the rates of other sexually transmitted diseases did not fall, suggesting that British Columbians are just as promiscuous now as they were then. Nor did the rate of hepatitis C alter, suggesting that people there are injecting just as many drugs with just as many dirty needles. And a detailed look at the numbers shows that the biggest falls in infection rates were during periods when the rise in HAART was fastest. The study, together with previous work showing that HAART reduces the rate of transmission between discordant couples (in which only one partner is infected) by more than 90%, points to the conclusion that widespread use of antiretroviral drugs helps to explain the 17% fall in the rate of new HIV infections seen around the world between 2001 and 2008.

当然相互有关连并不等同于有因果关系。但其它类型性病的感染率并没有下降，这说明在不列颠哥伦比亚省性乱的人数并没有减少。丙肝的感染率同样没有下降，这说明那里使用肮脏的针头注射毒品的人数也没有减少。仔细研究一下这些数字就可明了，艾滋病感染率下降最快的时期正是HAART疗法普及最快的时期。此项研究连同以前的研究成果一道表明，在单感染夫妇（夫妻中只有一方染病）中采用HAART疗法进行治疗后，夫妻间的交叉感染率下降了90％以上，这证实了在2001年至2008年间全球范围内广泛使用抗逆转录病毒药物导致新的艾滋病毒感染者减少了17％的结论。

The new microbicide, too, depends on an antiretroviral drug—tenofovir. Previous attempts to make vaginal microbicide gels that block the passage of HIV have involved long-chain molecules called carrageenans, thickening agents found in seaweed. It was hoped these would tangle the virus particles up.

上面提到的杀菌剂也依赖于一种抗逆转录病毒药物——泰诺福韦（tenofovir）。人们以前曾试图使用凝胶型阴道杀菌剂封堵艾滋病毒的传播，这种药物含有一种叫做卡拉胶（carrageenans）的长链分子，它是在海藻中发现的一种增稠剂。人们希望用卡拉胶吸附住病毒颗粒。

That strategy failed. Instead, Quarraisha Abdool Karim and her colleagues at the Durban-based Centre for the AIDS Programme of Research in South Africa tested a gel that contains tenofovir. Their study, published in Science on the second day of the meeting, looked at rates of infection with HIV over three years in two groups of women. Those in one group were given the microbicidal gel. Those in the other were given a placebo. The rate of infection in the first group was almost 40% less than in the second; the gel’s most diligent users saw a reduction of over 50%. And no adverse side-effects were observed.

这种做法失败了。作为替代方案,卡拉伊莎•阿卜杜勒•卡里姆（Quarraisha Abdool Karim）和她的同事在南非德班的艾滋病研究中心测试了一种含有泰诺福韦的凝胶。他们对两组妇女的艾滋病感染情况进行了三年多的观察，根据观察得出的研究报告在会议的第二天就刊登在《科学》杂志上了。他们给一组妇女使用的是杀菌凝胶。给另一组妇女使用的则是安慰剂。头一组妇女的艾滋病感染率比第二组几乎低40％，经常使用凝胶的妇女的感染率降低了50％以上。而且没有观察到不良的副作用。

Nor was another fear realised. Tenofovir is widely used, and people are understandably concerned about the emergence of resistant strains of HIV. Some opposed tenofovir’s use in a microbicide because they worried that it would encourage the emergence of such resistance. Dr Karim and her colleagues have, so far, seen no sign of this in women who were infected.

在这项试验中也没有出现另一个令人担心的现象。泰诺福韦正在被广泛使用，可以理解人们非常关注艾滋病毒是否会出现耐药性。一些人反对在杀菌剂中使用泰诺福韦，因为他们担心这会使艾滋病毒形成抗药性。但到目前为止，卡里姆博士和她的研究团队在被感染的妇女身上还没有发现形成了抗药性的迹象。


On the question of who pays for all these drugs, the feeling at the meeting was glum but not despondent. Global health budgets have done well in the past decade, in particular those dedicated to AIDS. Such rapidly rising expenditure would surely have come under sharper scrutiny even without the prompting of an economic crisis. With it, the increases have come to a sudden halt (see chart).

谈到谁来为这些药物买单的问题时，会议的气氛阴沉，但还谈不上沮丧。过去10年里全世界在医疗保健方面的支出巨大，特别是艾滋病防治项目的支出更是增长迅猛。即使没有出现经济危机，支出如此高速的增长也必然会导致严格的审查。而出现了经济危机，艾滋病防治方面支出增长的势头就一下来了个急刹车（见下图）。



No one likes to have their cash cut off but it does concentrate the mind wonderfully on doing more with less—especially with regards to the additional costs that come with treating patients. As is well known, drug costs have already declined dramatically. Treatment that in 1995 cost $10,000 a year is now less than $100. But the other annual costs of delivery—staff, infrastructure and so on—are about three times this amount.

没有人希望自己负责的项目预算资金被削减，但本次会议确实做到了集思广益，着力探讨如何少花钱多办事，尤其是有限的资金还要考虑到治疗艾滋病人的额外费用。众所周知，药物成本已经大幅下降了。1995年每个患者一年的的药物费用需1万美元，而现在只要不到100美元。但每年需要支出的其它费用（人力、基础设施等）是药物费用的3倍左右。

The consensus at the conference seemed to be to take things out of the hands of expensive doctors and give them to nurses or, better still, paramedics. In part that means more training; it also means simpler treatment regimes (fewer pills per day); and it means changing expectations about who will do what. Christoph Benn of the Global Fund, an international body formed to fight AIDS, tuberculosis and malaria, reckons that this could bring the additional, non-drug costs down to $100 per course of treatment per year. That would please donors.

会议上的一致意见是在艾滋病的防治工作少用高薪水的医生，而用护士，最好是护理人员来进行这类工作。在某种程度上这意味着需要做更多的培训工作；意味着简化治疗方案（减少每天的服药量）；意味着期待凡事都有人专职负责的想法要改变了。全球基金是一个防治艾滋病、肺结核和疟疾的国际机构，该机构的克里斯托夫•本（Christoph Benn）估计，采取这些措施会使每年每个疗程的非药物成本再额外降低100美元。这将使捐助者感到宽心。

Another change, proposed by Michel Sidibé, head of UNAIDS, the United Nations body charged with combating the epidemic, is to be more honest about who is at risk. The history of the disease has created a numbing political rhetoric around it. AIDS was first recognised in homosexuals, is spread by prostitutes and drug addicts, and is found above all in poor, African countries. When people with AIDS were demonised in the early days of the disease, the strategy was to repeat the mantra that almost anyone could get infected. Technically, this is true. In practice, however, some people are at much greater risk, and they may be ill-served by such political correctness.

联合国艾滋病规划署（UNAIDS）是联合国负责艾滋病防治工作的机构，该机构的负责人米歇尔•西迪贝（Michel Sidibé）建议，要开诚布公地告知哪些人属于染病高危人群。艾滋病的历史就是一个制造使人感到麻木的政治辞令的过程。艾滋病首先被发现存在于同性恋者身上，卖淫和吸毒导致了病毒的扩散，而且主要是在贫困的非洲国家传播。在艾滋病出现的早期，人们将该病的患病妖魔化了，谈之色变。而应对策略则是重复这句“几乎任何人都可能感染”的陈词滥调。从技术层面上讲，这没错。然而在实际生活中，某些人染病的风险要大得多，那种政治上貌似正确的言论可能欺骗了这部分人。

Although the roll-out of drugs to the infected has been a great success, with 5.2m people of the poor being treated, Dr Sidibé fears things are slowing down. His solution is to seek out those at greatest risk of infection, such as the growing numbers of Russian drug users, and offer prompt treatment rather than waiting for them at clinics. He wants the number of people starting treatment each year to exceed the number that are newly infected. At the moment the ratio is 2:5. He will not say when that will happen, but he believes that universal treatment is possible.

虽然新推出的药物在治疗520万已被感染的穷人身上取得了巨大的成功，但西迪贝博士担心成果难于进一步扩大。他提出的解决方案是找出艾滋病感染的高危人群，如俄罗斯越来越多的吸毒者，对他们提供及时的治疗，而不是坐等他们到诊所来。他希望每年开始进行治疗的人数要超过新感染者的数量。在目前这一比例是2:5。虽然无法预测这种期盼何时能够实现，但他认为实施普遍的治疗是有可能的