Science, medicine, and the future: The search for an HIV vaccine

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Abstract
Will an appropriate HIV vaccine ever be developed? The answer to this depends on a complex interplay of politics, science, institutions and their organisation, and public-private partnerships. Politics Many political realities will need to be accepted if the global health community is to develop an HIV vaccine: Vaccines are a public good and should be supported worldwide Rich countries have the expertise and experience to develop and test HIV vaccines but do not have sufficient numbers of patients to conduct clinical trials of efficacy Most poor countries have poor infrastructure and inadequate resources to conduct major trials of an HIV vaccine but are fertile ground for such trials. Thus, rich and poor nations are obliged to cooperate in the successful development of an HIV vaccine Any trial of an HIV vaccine must take into account the history of exploitation and abuse of vulnerable people in clinical trials. All research has the potential to introduce unequal power relations between the researchers and the trial participants, particularly when the researchers are from a rich nation and the participants are from a poor nation Rich countries want to do research in poor countries. Poor countries often have weak research infrastructure and regulatory institutions, allowing rich countries to exert more control over the research and over intellectual property rights (Credit: GIACOMO PIROZZI/PANOS) Most countries lack the political will and commitment—reflected in inadequate investment—to develop an HIV vaccine. Science The current impressive knowledge of the genotypic, phenotypic, pathological, and clinical aspects of HIV/AIDS reflects the substantial scientific discourse that has occurred around the world over the past two decades. However, the current knowledge base remains inadequate, in that it has failed to elucidate the most critical item on the HIV vaccinologist's wish list: the correlates of protection against HIV. Until these are defined with accuracy, as has been the case with other infectious agents, such as hepatitis B, the required “height of the high jump bar” will remain speculative. Another problem is that animal models for investigating candidate vaccines are inadequate. Results from studies of candidate vaccines in small animal models are invaluable, but their applicability to the development of an HIV vaccine in humans may be tenuous. Products that have an acceptable safety record in animal studies should be used as rapidly as possible in human studies, because human studies will give critical insights into the potential success or failure of a vaccine that far outweigh those from any animal data. Institutions Science has traditionally moved relatively slowly and cautiously in the transition from laboratory development of new agents to commercialisation. Yet in the case of HIV vaccines the scientific community is, for humanitarian reasons, under pressure to move with urgency. The scientific and corporate communities are being asked to “think out of the box” and to break down traditional modes of operations, while still maintaining the highest values of science and ethics, in developing an HIV vaccine. For almost a decade after the discovery of HIV a concerted and coordinated international effort to produce a vaccine was slow to develop. But a number of initiatives have helped to create a scientific framework for rapidly testing hypotheses and products. The International AIDS Vaccine Initiative (IAVI), whose mission is the development of and worldwide access to an HIV vaccine, has helped to keep the need for a vaccine high on the agendas of many governments. Following from IAVI's advocacy, changes in the scientific priorities of traditional institutions, such as the National Institutes of Health, the WHO, and the European Union's HIV vaccine platform, have also helped, as has the establishment of regional vaccine development programmes in poor countries, such as the South African AIDS Vaccine Initiative. This new framework gives the public and private sectors the chance to become partners in getting important academic, financial, and logistic support. Effective coordination, maintenance, and expansion of these structures are essential. Equally important is the need for cooperation among these international bodies, to ensure that the efforts are not inhibited by organisational pride, traditions, or the desire to be first. Levels of political will to support global initiatives to develop an HIV vaccine will largely determine the rate of their progress and success. Such political support will need to come from the highest levels of government and from global bodies such as the United Nations. Vaccines are but a part of the message of prevention that all governments should be endorsing, along with progressive policies on sex education, condom distribution, needle exchange programmes, and appropriate treatment. State and private sector funding of national and international vaccine programmes should be given the highest priority. Political support for these programmes needs to be independent of other international crises. For example, our response to the events of 11 September should not deflect attention from the urgent need to develop a vaccine against the greatest threat ever to humanity from an infectious disease. Yet compare the rapid and committed response by the US government to the threat of anthrax with many governments' lack of support for development of an HIV vaccine over the past two decades. Public-private partnerships Political processes should seek to maximise the synergies between government and the private sector through public-private partnerships. Over decades the private sector has been the mainstay of vaccine production and distribution, and thus the private sector's expertise needs to be harnessed to produce and distribute an appropriate HIV vaccine. Vaccines have never been as commercially successful as other...