One glaring reality, made even more apparent during this meeting, is the two-tiered treatment and research that exists between the global south and the rest of the world. Here in sub-Saharan Africa the standard first line treatment is a once-a-day combination pill that contains Stavudine, a drug with such toxic side effects that no doctor in the U.S. would ever consider prescribing it. But, it's cheap. In the U.S. a patient diagnosed with HIV is counseled about starting antiretrovirals as soon as possible and given the option to start immediately. However in the developing world the WHO treatment guidelines recommend starting treatment at CD4 counts of 200 and below (already very immunocompromised). One thing that is clear from the data amassing from years of cohorts on treatment in both the developed and developing world is that when it comes to treatment, the earlier the better. The virus is worse than the treatment and there is a large body of evidence that the inflammatory effects of the virus replicating in the body even at high CD4 counts has negative effects on all of the body's systems, particularly the liver, kidneys, and cardiovascular system.
What does all this mean in sub-Saharan Africa where the median CD4 count at initiation is between 100-140? When to start isn't the relevant question right now, the issue is getting people on treatment!
I was disappointed by the lack of presentations from African presenters. It felt like the conference was dominated by white South Africans, Americans, and Europeans presenting data on Africans. UNC project had two oral presentations, and both were given by Malawian co-investigators, but we were certainly the exception. A white South African woman gave an excellent plenary lecture on gender and sexuality and the need to change normative behavior among males. She is exactly right, but exactly the wrong person to deliver the message. Much more powerful and appropriate would be a black African woman.
Cape Town is stunningly beautiful and is a developed city with infrastructure that feels more European than African. Something felt a bit off to me though. I've never in my life been more conscious of my skin color. I felt a pronounced undercurrent of racism; I felt judged before I even opened my mouth by what color my skin was. Anyway, I'm still sorting through my feelings and experiences and will try to post a more coherent analysis later. Even though the infrastructure challenges are greater, the food isn't as good, I am so happy that I live and work in Malawi and am so happy to be back.
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