AIDS TREATMENT NEWS Issue #248, June 7, 1996
   phone 800/TREAT-1-2, or 415/255-0588

CONTENTS:

Viral Load Approved; Free Test Offered to
All in U.S. with HIV

Viral Load: New Recommendations for Clinical Practice

Viral Load: New Proof of Importance for
Disease Staging and Prognosis

Op Ed: Viral Load FDA Approval Delays

PMPA: New Information

3TC: Glaxo Wellcome Broadens Patient Assistance

Prison: California Conference on HIV and Prison Issues, Oakland,
June 27

AIDS TREATMENT NEWS New Index Available

Activist Communications, Activities at Vancouver Conference

"Access for All": Communication Strategy Proposal for 
International Conference


***** Viral Load Approved; Free Test Offered to
All in U.S. with HIV

by John S. James

On June 3 the FDA approved the Hoffmann-La Roche Amplicor 
HIV-1 Monitor(TM) viral load test, the first viral load test 
officially approved for clinical use in the United States. 
(The same test has already been marketed in Europe, and in 
some other countries, for over a year.) And Hoffmann-La Roche 
announced that it will offer two free baseline tests to 
everyone with HIV in the U.S. (regardless of finances, and 
regardless of what treatments they may have used or now be 
using), but only during a 60-day period starting June 17.  
Patients or physicians who want more information about this 
free testing program should call 888/TEST-PCR, a toll-free 
number.

It is recommended that two tests be used to establish a 
baseline. Because some illnesses and vaccinations can 
temporarily stimulate HIV (as much as 300 fold) and produce 
misleading viral load results, "HIV RNA levels should not be 
measured within a month of acute illnesses or within a month 
after influenza and pneumococcus immunizations," according to 
clinical practice recommendations published this month in 
NATURE MEDICINE (see "Viral Load: New Recommendations for 
Clinical Practice," below).

The newly-approved test is based on PCR, one of three 
different methods for measuring viral load which have been 
widely used in research. (The other two methods are branched 
DNA, and NASBA; it is widely agreed that all three measure 
basically the same thing, although there can be variations in 
how sensitively the different methods detect a particular 
patient's viral subtypes. For this reason it is usually 
better for a patient to stay with one kind of test, not use 
the different tests interchangeably.)

In the U.S., viral load testing has already been available to 
physicians for about two years, but there have been 
disadvantages which appear now to have been overcome. PCR was 
available through "home-brew" tests (meaning that the 
laboratory which offered the service had to prepare its own 
reagents), and there have been questions about the quality 
control at some labs. In contrast, the approved PCR test is 
provided to the labs in a kit with the reagents strictly 
standardized, and now the quality control has been checked by 
the FDA. Also, viral load using branched-DNA technology has 
been and is available through Chiron Corporation, which 
recently applied for official FDA approval (the FDA has not 
acted on Chiron's application yet). The Chiron tests are 
reliable, but the version now available to physicians 
(outside of research) cannot measure viral load counts below 
10,000 copies. (The newer second-generation branched-DNA 
test, used by researchers for about two years, can measure 
down to about 500 copies, and is basically equivalent to the 
Roche test just approved. An advantage of the Chiron test is 
that it has been carefully standardized to accurately measure 
the different subtypes of HIV found all over the world. Roche 
told us that its test already accurately measures the 
subtypes commonly found in the U.S., and that its second-
generation test will include others as well.)

Comment

Exactly what indications viral load testing would be approved 
for -- important for reimbursement, and perhaps even more so 
for improving the prevailing standard of HIV care -- has been 
controversial. Everyone agrees that the three major kinds of 
viral load testing (PCR, branched-DNA, and NASBA) do measure 
what they claim to measure. Everyone agrees that viral load 
provides important information about prognosis, that persons 
with a high viral load are likely to do worse. The Roche test 
was easily approved for these purposes.

A month ago it looked like this was all the approval this 
viral load test would get -- which would have given insurance 
companies, HMOs, and other payers an excuse to reimburse for 
only two viral load tests (for the baseline) in a patient's 
lifetime, depriving many patients' doctors of the tools to 
get the most benefit from protease inhibitors and other new 
therapies. This almost happened because, for historical 
reasons, the test was reviewed by the FDA's Blood Products 
Advisory Committee, and by the Biologics division of the FDA, 
which are relatively unfamiliar with HIV -- and because Roche 
did a poor job of presenting its case for approval to that 
committee.

The controversial issue was whether to also recommend the 
test for monitoring patients, especially for determining 
whether an antiviral drug or regimen is having the intended 
antiviral effect in a particular patient. Everything now 
known about HIV and antivirals strongly supports this use. 
But the final evidence -- a body count proving that patients 
who are randomly assigned to have their physician not use 
viral load do worse than those randomly assigned to have 
their physician use it -- is not yet available (such trials 
are under way now). Activist pressure may have helped in 
getting the FDA to include a statement on clinical use, 
although hedged:

"The test has also been used as an aid in assessing viral 
response to antiretroviral treatment as measured by changes 
in plasma HIV-1 RNA levels. The clinical significance of 
changes in HIV RNA measurements has not been fully 
established although several large studies that will more 
fully determine the role of comparative HIV RNA measurements 
in patient management are now in progress. HIV-1 RNA levels 
as measured by PCR were used as one of the surrogate markers 
in the accelerated approval process for the protease 
inhibitor drugs Invirase(TM), Crixivan(R), and Norvir(R), and 
for the reverse transcriptase inhibitor drug Epivir(TM). The 
utility of plasma HIV-1 RNA in surrogate endpoint 
determinations has not been fully established."

THE NEW YORK TIMES covered the approval accurately on June 4, 
but most other media reporting has been superficial. The 
reason is clear; much of the background on this story was not 
conveyed in the FDA and Roche press releases. Even the TIMES 
noted the concern that Roche and other companies had not 
applied for approval much earlier than they did -- without 
mentioning that a major reason for this was the lack of 
clarity at the FDA (and in the professional community) about 
what evidence would be required for approval.

What You Can Do Now

We believe that everyone with HIV should get the two tests to 
establish a baseline; and for 60 days only (starting June 
17), persons in the U.S. can get them free. (This is not 
charity from Roche; probably most physicians who have used 
viral load have used the Chiron test, and Roche clearly hopes 
that the free offer will get many of them to switch to its 
product. Roche is donating the test kits, and certain 
laboratories are donating their services, also clearly in the 
hope of future business. Patients or their HMOs, etc. will 
probably need to pay for the physician's office time and the 
blood draws.) For more information about this free test 
offer, call the Roche Amplicor(R) Access Program toll-free 
hotline, 888/TEST-PCR, between 8:30 a.m. and 5:00 p.m. 
Eastern time; patients can request an enrollment packet to be 
sent to their physician.

The same hotline will also help patients obtain reimbursement 
for the test after the 60-day free program.

Even if one does not plan to get further viral load testing, 
establishing a baseline is important because it helps with 
decisions about how aggressive to be with therapy, and it 
leaves open the option of getting tested later to see if 
one's viral load has changed.


***** Viral Load: New Recommendations for Clinical Practice

by John S. James

A panel of leading HIV clinicians and researchers has 
published interim recommendations for how to use viral load 
testing, based on currently available knowledge.(1) The 
recommendations, which appear in the June 1996 issue of 
NATURE MEDICINE, answer common questions of physicians and 
patients about when to use the test and what the numbers 
mean. The information is current; while the recommendations 
represent months of work by the authors, NATURE MEDICINE 
published them very rapidly, about one month after receiving 
the manuscript.

The article summarizes the recommendations in a table:

"* Plasma HIV RNA level that suggests initiation of 
treatment: More than 5,000-10,000 copies/ml and a CD4+ 
count/clinical status suggestive of progression; [or] 
>30,000-50,000 regardless of laboratory/clinical status.

* Target level of HIV RNA after initiation of treatment: 
Undetectable; <5,000 copies/ml is an acceptable target.

* Minimal decrease in HIV RNA indicative of antiviral 
activity: >0.5 log decrease.

* Change in HIV RNA that suggests drug treatment failure: 
Return to (or within 0.3 to 0.5 log of) pretreatment value.

* Suggested frequency of HIV RNA measurements: At baseline, 2 
measurements, 2-4 weeks apart.  Every 3 to 4 months or in 
conjunction with CD4+ counts.  Shorter intervals as critical 
decision points are neared.  3-4 weeks after 
initiating/changing therapy."

(For those not familiar with logarithms, a 1.0 log change 
means a 10-fold change; a 0.5 log change is about 3-fold; and 
a 0.3-log change is 2-fold. So the third of the five points 
quoted above means that an antiviral treatment should 
decrease viral load to less than a third of its starting 
value, for the physician to be confident that the treatment 
is working. Less of a decrease might have been due to testing 
errors, or to normal daily fluctuations in viral load.)

The NATURE MEDICINE paper also reviewed the major published 
research on the relationship of viral load to HIV disease 
progression.

The team which prepared the recommendations was convened by 
the International AIDS Society U.S.A.

References

1. Saag MS, Holodniy M, Kuritzkes DR, O'Brien WA, Coombs R, 
Poscher ME, Jacobsen DM, Shaw GM, Richman DD, and Volberding 
PA. HIV viral load markers in clinical practice. NATURE 
MEDICINE; June 1996. Volume 2, number 6, pages 625-629.


***** Viral Load: New Proof of Importance for
Disease Staging and Prognosis

by John S. James

Research findings published May 24(1,2) have extended earlier 
work showing the importance of viral load in predicting HIV 
disease outcome. Measurement of plasma HIV RNA (indicating 
the concentration of virus in the blood) was found to be a 
much more accurate predictor of later illness than CD4 (T-
helper) count, strongly suggesting that patients and 
physicians should consider viral load when making HIV 
treatment decisions. This data provides longer followup than 
for any previous study of viral load.

The research team, mostly from the University of Pittsburgh 
but including two members from Chiron Corporation, looked at 
disease outcomes in a cohort of 180 HIV-positive gay or 
bisexual men who were enrolled between April 1984 and March 
1985 in the Pittsburgh site of the MACS study (Multicenter 
AIDS Cohort Study). The 180 include all who were HIV-positive 
when they enrolled at the Pittsburgh site, and for whom 
frozen plasma samples were available for testing. It is not 
known how long the men were infected before they enrolled.

Only 41% of the 180 volunteers received antiretroviral 
treatment at any time during the study. [It is important to 
note that the average survival times today will almost 
certainly be longer than those reported below, which indicate 
survival starting ten years ago when much less treatment was 
available.] [Note: Brackets are used to indicate our comments 
about the article -- JSJ.]

The data were looked at in several different ways:

* First, the researchers used viral load at entry into the 
study to divide the 180 volunteers into quartiles (four equal 
groups, of 45 each, with the highest, second-highest, second-
lowest, and lowest viral load). They measured the viral load 
with a "second generation" bDNA test from Chiron Corporation; 
this test, not yet available commercially but only for 
research, can measure down to a cutoff of about 500 copies of 
HIV RNA per milliliter of plasma. (The bDNA test which has 
been available to practicing physicians until now has a 
cutoff of 10,000 copies, 20 times higher than the second-
generation test.)

Of those in the lowest viral quartile, which was 4530 copies 
per ml. or less, only 8% progressed to AIDS within five 
years. In the next quartile, 4531-13,020 copies, 26% 
progressed. In the second-highest quartile, 13,021 - 36,270 
copies, the proportion was 49%; and in the highest quartile, 
above 36,270, 62% developed AIDS in five years -- almost 
eight times the progression rate of the lowest quartile. 
[These particular viral-load levels might be lower than those 
measured today, since these samples were processed 10 years 
ago with procedures not optimized to preserve them for viral 
load testing; it is likely that damage to the RNA led to 
lower counts being recorded, meaning that the numbers above 
are too pessimistic. One of the researchers told us that the 
samples in this study are likely to have suffered a 1.6-fold 
to 2-fold decrease in viral load counts due to how they were 
preserved -- meaning that the counts above may actually have 
been 1.6 to 2 times higher than the numbers given above.]

Looking at survival, in the lowest quartile of viral load, 5% 
of the volunteers died within 5 years. For the next quartile 
it was 10%, the second-highest quartile 25%, and in the 
highest quartile, 49% died within 5 years.

The increased risk of progression to AIDS, and risk of death, 
was still evident even ten years after this single viral load 
measurement.

* Viral load was even more predictive when the average of the 
first two measurements was used, instead of a single viral 
load test (The MACS study drew blood samples every six 
months). And the predictive ability was further improved by 
eliminating the 29 patients (out of 172 for whom two tests 
were available) who had an 80% or more drop in number of 
copies between their first and second test. (This drop 
probably meant that those people were still recovering from 
their primary HIV infection, meaning that their viral-load 
tests may not have properly measured the "set point," or 
long-lasting, relatively stable viral level which remains 
after primary infection and seems to control the speed of 
disease progression.) Once these adjustments were made, those 
in the highest quartile (average viral load greater than 
28,720, in this group) had a median survival time of only 2.5 
years, with only about 5% surviving for ten years. The 
authors interpret this as "evidence that a persistently high 
viral load is almost always associated with more rapid 
disease progression."

On the average, after statistical adjustments including both 
HIV RNA (viral load) and CD4 counts, the relative risk of 
death was 1.57 (a 57% increase) for each threefold increase 
in viral load. 

* CD4 counts were much less predictive of AIDS progression 
and survival. When the same volunteers were divided into 
quartiles by CD4 count (less than 322, 322-527, 528-787, and 
greater than 787) the three higher quartiles showed no 
difference in survival, nor in progression to AIDS. Only the 
lowest quartile showed a worse outcome. When the 29 
volunteers with an 80% or more drop in viral load were 
excluded, the predictive ability of the CD4 test did not 
improve.

In another look at CD4 count, the researchers found that 50% 
of those with CD4 over 500 [ten years ago], if they also had 
a viral load greater than 10,900, died within six years -- 
compared with only 5% of those with the same CD4 counts but a 
viral load of less than 10,900. They suggested re-evaluating 
the practice of using CD4 level as a trigger to begin 
antiretroviral therapy. [This does not affect the use of CD4 
counts for starting prophylaxis for pneumocystis or other 
opportunistic conditions; in this situation, the CD4 level 
does show who is at risk.]

Comment

This long-term followup study shows the predictive value of 
modern viral load testing. But in order to have the long-term 
progression and survival information available, the 
researchers necessarily had to use frozen samples collected 
years ago. Therefore, the particular numbers reported above 
should not be blindly applied today. But the conclusion that 
viral load testing is important for patient management -- 
probably considerably more important than CD4 testing for 
guiding antiviral therapy -- seems hard to dispute.

Even before these results were published, there was clear 
consensus among experts that viral load testing is valid for 
prognosis (predicting whether an individual is likely to do 
well or poorly in the future). But there has been controversy 
about its use for patient management, with some saying that 
the data to support such use is not yet available. The 
problem is that to get conclusive proof of the value of viral 
load testing for management requires randomly assigning some 
patients to have their physicians use viral load testing as 
part of their care, and randomly assigning others to not use 
viral load, and then looking for a statistically significant 
difference in the number of deaths or AIDS complications in 
the two groups. Such trials are now being done, but they will 
take time, since existing frozen samples cannot be used (as 
there is no way to know what a physician in the past would 
have done with the additional information, or how a patient 
would have responded to the resulting change in treatment).

We have argued elsewhere that there are fundamental problems 
with this kind of trial to prove the value of viral load 
testing. Aside from the ethical concerns, it will be hard to 
reach statistical proof, since antiviral therapies are still 
limited, and many patients in the trials will not have good 
access even to what does exist (as these trials do not 
provide or pay for treatment); if physicians cannot make 
effective use of the viral load information, how much 
difference could it make? A negative result would not show 
that viral load is not useful, but only that it was not 
useful within the limitations of the particular (and largely 
undefined) guidelines and therapeutic options existing at the 
time of the trial. How helpful is this information, when the 
therapies and guidelines surely will have changed 
considerably by the time the trial results are available? And 
we do not see how these trials will have the statistical 
power to add much to our knowledge about HOW to use viral 
load, when they are designed primarily to answer the go/no-go 
decision of whether viral load should be used in individual 
patient care.

There is already so much information consistently supporting 
the importance of viral load, that it is inconceivable that 
this test could be found to have no use in clinical care. 
Viral load testing has already become a de facto standard for 
those who can afford it. The problem today is to get better 
care out to everyone else. This is especially important now 
that many more treatment choices are available. Viral load 
will be essential for making these choices intelligently -- 
for example, to find out when an antiviral regimen is failing 
to work for a particular patient, so that different 
treatments can be tried instead.

References

1. Mellors JW, Rinaldo CR, Gupta P, White RM, Todd JA, and 
Kingsley LA. Prognosis in HIV-1 infection predicted by the 
quantity of virus in plasma. SCIENCE May 24, 1996; volume 
272, pages 1167-1190.

2. Ho, DD. Viral counts count in HIV infection. SCIENCE May 
24, 1996; volume 272, pages 1124-1125.


***** Op Ed: Viral Load FDA Approval Delays

by David Scondras

[David Scondras served on the Boston City Council for ten 
years, from 1983 through 1993. He is co-founder of Search for 
a Cure, a Boston organization with a mission of cutting red 
tape, both government and corporate, which interferes with 
development of or access to effective treatment for HIV.]

We have good news and bad news; as this is going to press, 
the FDA has just approved the Roche viral load test for use 
by clinicians for HIV prognosis, and for monitoring the 
activity of antiviral therapies. The bad news is that it took 
much too long and were it not for the intervention of many 
treatment activists, the FDA's "Biologics Division" (Center 
for Biologics Evaluation and Research, CBER) very well might 
have made a bad decision. Delays in approvals harm those HIV 
positive individuals who have insurance, including Medicaid, 
that may not reimburse without FDA approval. And 
unfortunately there is a tendency for the Biologics Division 
to delay until they receive significant pressure from the 
activist community.

These problems are a direct result of the lack of experience 
of CBER in evaluating treatments for HIV illness, compared 
with the experience of the "Drugs Division", (Center for Drug 
Evaluation and Research, CDER). The speed with which CDER 
moved on protease inhibitors stands in stark contrast to the 
delays and need for extensive advocacy campaigns at CBER.

Another example of CBER's erratic, slow and inconsistent 
behavior surrounds the effort to get a "Treatment IND" for 
access to the Salk therapeutic vaccine. After nearly a year 
of delay, CBER gave the green light for a phase III trial for 
this vaccine. Many people signed up since it might help, 
apparently has no side effects, is cost free to HIV infected 
people, and has very few restrictions on the use of any other 
therapies. However, many people who cannot get into the trial 
want access, so activists met with the FDA; at that meeting 
CBER staff made a commitment to allow an expanded access 
program, including Treatment IND status (the simplest legal 
method for getting new treatments to persons with HIV who 
otherwise cannot get them) for people with a CD4 count 
greater than 300. But when the decision arrived, it was for 
an open-label protocol [collecting research data] which the 
company specifically had said it cannot afford to undertake 
along with the $60 million phase III trial. We are now faced 
with the task of trying to get CBER staff to keep their word. 
This struggle continues.

The time has come to call for an HIV-positive, community-
chosen ombudsman who would have the power to appeal any 
decision made by the FDA divisions to Commissioner David 
Kessler, with the requirement that any such appeal result in 
a written decision by Dr. Kessler within a stated and 
reasonable time.

Meanwhile, as a practical matter, it is time to move 
decisions on HIV therapies and diagnostic tests from CBER to 
CDER, because at least the drug division has had ample 
experience with the intricacies and unique problems and needs 
of the HIV positive community, which is clearly lacking in 
the biologics division.


***** PMPA: New Information

by John S. James

PMPA, an antiviral being developed by Gilead Sciences but not 
yet tested in humans, came to widespread attention last 
November, when a study published in SCIENCE (November 17, 
1995) showed that it could block SIV (simian immunodeficiency 
virus) infection in macaque monkeys even when given 24 hours 
after exposure; PMPA protected 100% of the monkeys tested, 
while AZT protected none (there were 10 monkeys in each 
group). Now another study, presented at the Ninth 
International Conference on Antiviral Research in Fukushima, 
Japan, found that PMPA reduced SIV in chronically infected 
macaques by more than two logs (99%), or past the limits of 
detection; the virus reappeared when the drug was stopped.(1) 
Also, a 10% PMPA jell protected all four monkeys from vaginal 
transmission, while both of two monkeys treated with the 
control jell without PMPA were infected,(2) suggesting the 
possibility of a means of preventing sexual transmission 
which could be controlled by women -- which would have great 
public-health importance. (SIV is similar to HIV; the virus 
is so close to HIV-2 that many believe that humans acquired 
HIV-2 by SIV infection from monkeys. No animal ancestor to 
HIV-1 is known.)

For both studies, the researchers are from Gilead, the 
University of Washington Regional Primate Research Center, 
and the National Institutes of Health. Chiron Corporation 
also participated in the treatment study.

Gilead Sciences plans to start human testing of PMPA in 1996.

References

1. Bischofberger N, Tsai CC, Follis KE, and others. Antiviral 
efficacy of PMPA in macaques chronically infected with SIV. 
Ninth International Conference on Antiviral Research, 
Fukushima, May 19-24, 1996.

2. Miller C, Rosenberg Z, and Bischofberger N. Use of topical 
PMPA to prevent vaginal transmission of SIV. Ninth 
International Conference on Antiviral Research, Fukushima, 
May 19-24, 1996.


***** 3TC: Glaxo Wellcome Broadens Patient Assistance

On May 20 Glaxo Wellcome Inc. broadened its Patient 
Assistance Program for Epivir(TM) (3TC, lamivudine), to no 
longer deny the drug to patients who qualify for their state 
ADAP (AIDS Drug Assistance Program) in states which have not 
included the drug in their program. A large majority of 
states already cover the drug, but several still do not. 
(California included 3TC in its program on April 25). 3TC was 
approved for combination use with AZT in November 1995.

Almost all major pharmaceutical companies have patient 
assistance programs for at least some of their drugs, 
although these vary greatly from company to company. The 
programs cost the companies little, since patients who 
receive a drug would otherwise not be customers but would go 
without, as they have no way otherwise to buy or obtain it. 
And the companies benefit by avoiding the public relations 
fallout that would occur from many people being denied 
expensive but life-critical drugs, due to their economic 
circumstances.

Recently there has been a problem of some companies excluding 
any patient whose public or private health insurance or 
managed care plan has rejected coverage for their drug (and 
sometimes also those patients whose health coverage has not 
yet made a decision). The pharmaceutical companies want to be 
sure that they are not used as the provider of last resort, 
allowing other institutions to refuse to pay for drugs they 
would otherwise have to cover. The problem is that patients 
then become pawns in the battles between large organizations. 
(This was not a major problem until recently, because 
traditionally it was taken for granted that if the FDA 
approved a treatment, it would be covered by health plans.) 
The problem around ADAP has been particularly acute, because 
of the current funding crisis for that program, and also 
because it ostensibly covers everyone in the state within 
certain income limits who needs HIV treatment, resulting in 
more widespread exclusion than private insurance or managed 
care programs, which only cover their enrolled members.

Glaxo Wellcome noted in a May 15 letter that its program "was 
never intended or designed to serve as an alternative funding 
resource for inadequately funded state ADAP programs. 
Obviously this is a stop-gap approach to the immediate 
problem, and the need for a viable long-term solution grows 
in significance every day... This kind of solution is only 
going to take place as a result of collaborative efforts 
between government, community and industry."

Merck still has a similar policy of disqualifying patients 
from its patient assistance program for Crixivan(R) if they 
qualify for other programs which have rejected Crixivan 
coverage, although they will cover people up until the time a 
state formally rejects coverage. The Glaxo Wellcome policy 
was even more restrictive, excluding people until the state 
took a positive action allowing coverage.

Comment

 While Glaxo Wellcome clearly deserves credit for this change 
in policy, people should know that Project Inform was a key 
community group that undertook the difficult negotiations 
without which the change would not have happened. Other 
groups, including ACT UP/Golden Gate, had earlier pressured 
the company to extend its expanded access program in some 
states, but the extension had run out and Glaxo Wellcome had 
still refused to change its basic policy of excluding people 
in states which failed to put 3TC in their ADAP formulary.

"This issue represents a growing economic tug of war between 
industry and government over who should be paying the bill 
for uninsured patients and others not adequately served by 
Medicaid," said Martin Delaney of Project Inform. "The total 
cost of HIV drugs is dramatically rising with the routine use 
of combination therapy, the approval of protease inhibitors, 
and the fact that some patients who had previously rejected 
the available drugs are now coming in for treatment."

With the new policy on 3TC, many people have access to 
treatment recommended by their physicians, when they did not 
before. But now community groups will need to work with 
industry to lobby state governments, and the Federal 
government, at least as effectively as they have lobbied 
companies.


***** Prison: California Conference on HIV and Prison Issues, Oakland,
June 27

A statewide conference on AIDS in prison will be held all day June
27, in downtown Oakland. Five workshop tracks will focus on:
 * Education and prevention;
 * Transitional case management;
 * Vocational training & employment;
 * Advocacy & change;
 * Legal issues.

The conference is sponsored by many organizations, including AIDS 
Legal Referral Panel, HIV/AIDS in Prison Project of Catholic Charities 
East Bay, Marin AIDS Project, Service Employees International Union 
Local 970, Women's AIDS Network, and WORLD. It will take place 
8:30 a.m. to 5:00 p.m. June 27 at Preservation Park, 13th Street and 
Martin Luther King Jr. Way, in downtown Oakland; cost is $40, 
scholarships are available. For registration and other information call 
510/834-5657 ext. 3150, or 415/255-7036, ext. 313.


***** AIDS TREATMENT NEWS New Index Available

AIDS TREATMENT NEWS has completely rewritten its index to 
recent issues, covering January 1994 through May 1996. 
(Earlier articles were already thoroughly indexed in our 
three published volumes of back issues.)

This new index, 24 pages in length, represents our current 
judgment about which articles today still contain important 
information on each topic. It uses an expanded format which 
includes part of the article title with each entry, so that 
readers can see if they might be interested before looking up 
the article. We are using the index in house, almost always 
preferring it to a computer search to find the articles we 
are looking for.

Following our subscriber benefits policy, we have already 
sent the new index to everyone who began a full-rate 
subscription ($100 per year individual rate or greater) since 
January 1995. Others can buy a copy for $10. Contact AIDS 
TREATMENT NEWS, 800/TREAT-1-2 or 415/255-0588, or by fax at 
415/255-4659.


***** Activist Communications, Activities at 
Vancouver Conference

AIDS activist organizations are planning demonstrations and 
other communication at the XI International Conference on 
AIDS, July 7-12 in Vancouver. There will be a nightly world 
activist meetings beginning July 6 (planned for 8 p.m. at The 
Robson Square Conference Center, underground below the Old 
Courthouse, Hornby & Robson Streets), possibly an informal 
meeting on July 5, and a march to the conference site on 
opening day, July 7. ACT UP chapters, including Golden Gate, 
New York, Paris, and Philadelphia, are sending people to the 
Conference; ACT UP/Golden Gate and ACT UP/Paris will have 
booths on site. There will also be an ACT UP press room, and 
probably a larger meeting room in addition. At least one 
activist phone number in Vancouver will have current 
information at all times.

For more information, contact Paul Davis, pdavis@critpath.org 
or Jennifer Depiero, jel@dolphin.upenn.edu, or call, fax, or 
mail either of them at ACT UP/Philadelphia, 215/731-1844, fax 
215/731-1845, mail P.O. Box 15919, Middle City Station, 
Philadelphia PA 19103-0919.

Activists "want to be inclusive in our planning process of 
the diversity of issues across the planet; therefore we are 
asking individuals and groups to help us decide what kinds of 
actions should be focused on during the Vancouver 
conference." Likely issues already being discussed include 
drug pricing, forced HIV testing, failed government 
leadership, and finding international funding (including 
access to treatment) for people in developing countries.

AIDS activists and organizers in developing countries are 
particularly invited to submit information and ideas to: Kate 
Krauss, ACT UP Golden Gate, kate_krauss@out.org, 415/252-
9200, fax 415/252-9277; or Jennifer Depiero (addresses 
above).


***** "Access for All": Communication Strategy Proposal for 
Activists at International Conference

by John S. James

AIDS activists' communication to the public can be difficult. 
Because of the great diversity of issues people are working 
on, and because of the shallowness of most news media 
reporting, it is often hard for TV viewers and newspaper 
readers to understand where protesters are coming from, what 
our issues are. We need a theme or sound bite to communicate 
one central idea immediately, to the media and to other 
conference delegates as well, letting people know right away 
that we are on their side.

One possible theme is "Access for All" -- meaning access to 
medical care for HIV and AIDS (and other medical care as 
well), to information, to prevention programs, and to other 
services, for all the world's people. Almost everything we 
are now planning could fit gracefully under an Access banner:

* High prices of protease inhibitors and other HIV/AIDS 
drugs. Exorbitant drug prices cause different problems in 
different countries (depending on whether there is national 
health care, for example), but are destructive everywhere. 
All price issues ultimately affect people's access to medical 
care.

* Treatment access in developing countries. In past 
International Conferences, people from developing countries 
often sensed that U.S. activism pursued issues less important 
to them, while neglecting emergencies in their countries. 
"Access for All" means that we are going to address the 
problem of most of the world's people having no access to 
scientifically tested HIV treatments, being completely left 
out of all the fruits of biomedical research. One part of 
this problem, the lack of money for treatment in developing 
countries, is obvious.

Another root of this problem is the excessive focus of almost 
all mainstream clinical research toward high-priced, often 
inappropriate treatments. Is it possible that non-proprietary 
possibilities are not tested -- even with government or 
foundation money -- because proven treatments available at 
developing-country prices would also be used in rich 
countries, threatening key markets for high-priced drugs?  
Could activists help prevent genocide by raising this issue 
at Vancouver?

* Research for a CURE. This issue cuts across economic lines, 
since no amount of money can buy a treatment that has not 
been discovered and developed. "All" includes those with 
money, as well as those without.

* Funding issues. "Access for All" includes money issues such 
as protecting Medicaid and increasing ADAP funding (U.S.), 
finding more money for research, and funding treatment for 
developing countries.

* Protecting medical research. "Access for All" includes 
making sure that necessary medical research is not stopped by 
animal-rights activists, who are now targeting AIDS in 
particular in order to get publicity. (This issue also cuts 
across economic lines, as there is no way to buy your way out 
of the consequences of damage to research.)

* Prevention. "Access for All" can include prevention, 
including vaccines, the need for vaginal microbicides or 
other prevention methods under the control of women, 
professionally designed and targeted AIDS education unimpeded 
by politics, and needle exchange.

* Information access. "Access for All" includes computer work 
(since computer communication is by far the most efficient 
and least expensive worldwide two-way information system). In 
addition, "Access for All" can challenge the widespread 
misbehavior of medical/technical journals, which often 
require that important work be kept secret in order to be 
effectively distributed. The registration fee of the 
International Conference could also be addressed -- the 
choice of such an expensive format  -- and the refusal of the 
Conference to release abstracts in advance (as many other 
conferences do, greatly improving peoples' use of scarce time 
at the meetings). Also included with information access is 
misbehavior by the media, which has often run amuck at the 
International Conference by latching onto a catchy theme 
(such as the "deep kiss," or non-HIV AIDS, or excessive gloom 
and doom, from certain previous Conferences). Still another 
information issue is the need for translation of AIDS 
materials into different languages.

"Access for All" provides a unified public message to which 
many different issues and projects can relate. The above list 
is not complete, of course, but illustrates how we can take 
the diversity of AIDS activism and communicate it coherently 
to media audiences, and to Conference delegates. A major 
advantage of having a common theme is to help change the 
impression of disunity among AIDS activists. We can be 
working on many different problems and projects, but at the 
same time we are all working together.

Implementation: The first step is to agree on a common theme; 
"Access for All" is just one possibility. ("Access" may be 
too vague to communicate well. Other possibilities: 
"Treatment for All"; "Medical Care for All People"; ...) The 
agreed theme can be used in banners, signs, stickers, etc. 
Also, longer documents including fliers and press statements 
can relate this theme to the specific issues, problems, or 
opportunities being targeted. And when people speak to the 
media or address the Conference, they can relate their 
message to the common theme when appropriate.

We should choose a theme which will translate well, and 
prepare signs in many different languages, so that people 
will recognize their own language, and international 
reporters can find activists and other individuals from their 
country to interview. A march which includes the same sign in 
many languages sends a message of world activist unity, and 
is accessible to video and print media of many countries.

Ideally, the theme chosen should get final approval at the 
activist meeting the day before the conference (and perhaps 
also at the Community Forum). However, much of the material 
(signs, fliers for advance distribution, etc.) will have to 
be prepared in advance. The best approach might be to reach 
agreement soon, among those who can be contacted now. Then, 
in the unlikely event that the activist meeting in Vancouver 
decides on something different, it would be OK to have more 
than one theme at the Conference.

A powerful first step would be to seek agreement not only on 
a theme, but also on a consensus document suggesting examples 
of how that theme could be used. This article could serve as 
an early draft; feel free to circulate it to others who 
should be involved. Or we might decide on a different 
approach.

To facilitate preparation of signs and other materials, the 
consensus document should include translations of "Access for 
All" (or other theme we select) into many languages.


***** AIDS TREATMENT NEWS
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ISSN # 1052-4207 

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