Conference maketh a ready man

Just back from the 12th Bangkok International Symposium on HIV Medicine, organised by HIV-NAT - the HIV Netherlands Australia Thailand Research Collaboration. This year was the fourth consecutive year that I have attended this Symposium, and each year I have found it - for me - the most useful meeting. It is practical, offering information that is immediately of use, presented by internationally respected experts in their field.

It is of course very medical, and I'd guess the vast majority of participants are doctors or other healthcare professionals. This year, I was accompanied by Caroline from Spiritia and Rika from the Medan-Aceh Partnership, and I'd guess we were among the only members of the 'community' attending. A pity: all such meetings benefit from involvement of the affected community - as was demonstrated very early in the epidemic by the gate-crashers at the first AIDS conference in 1983, which resulted in the Denver Principles - principles which are still relevant today - reread them!

Equally there appeared to be extremely low attendance from Indonesia; including us, I less than a dozen. A pity, because as I say, the symposium is very practical and relevant in our setting. And the price is right: it cost us well under US$1000 per person all in. One would think that many doctors could afford this amount from their own pockets - without having to take kickbacks from pharma companies.

Among the plenary sessions was a Great Debate: "Should ART be started earlier in an asymptomatic patient?" Prior to the debate, the audience was polled (with electronic voting), and significant majority supported an earlier start. Two speakers then spoke in support of an earlier start (with CD4 count above 250) while two others supported the current guidelines, and members of the audience were also provided an opportunity to add input, Re-polling following the one-hour debate showed the pro-late starter had won my a significant majority. The main argument against an earlier start was the cost, but it was clear that many were also swayed by the argument that, even with guidelines recommending starting ART as soon as the CD4 count drops below 200, the average CD4 count at start is under 100. Thus mandating an earlier start was felt to be irrelevant - and perhaps a distraction.

Bernard Hirschel was one of the speakers supporting an early start. Besides being one of those issuing the famous (or notorious) 'Swiss Statement', he is also a strong supporter of the concept of 'treating our way out of the epidemic' (more on this later). All developed world guidelines now support an earlier start, with CD4 count below 350. We've heard the argument "yes, but the developing world is different" before, and if we'd accepted that in 2003, we'd still be talking about starting antiretroviral therapy in Africa.

I assume the WHO must be working on revised guidelines for resource-limited settings as we speak - the current ones are almost three years old, a lifetime for HIV treatment. It'll be interesting to see how they jump.

Back to the debate: several participants wondered why this format is not more used in international AIDS meetings - there was a debate on the Swiss Statement in The ASHM meeting last year, but this allowed much less audience participation and voting. The electronic voting offered by the Queen Sirikit Centre made this easier, as perhaps did the rather smaller number of attendees than in some other conferences.

We in Spiritia have organised debates in several of our national meetings, with topics including whether universal access to ART free-of-charge is appropriate and whether positive prevention violates human rights. I wonder if there will be a debate at the ICAAP in Bali next August. Perhaps we could debate whether the provision of a special lounge for participants with HIV at AIDS conferences is still appropriate...

Babé