It's not my place to speak on behalf of Andrew Sullivan or David Sanford. They're seasoned journalists who can respond to the critique of their articles. What do I tell my patients? The truth, as best as I understand it, the good news as well as the bad, and the areas where we remain ignorant. Forthrightly emphasizing important shades of uncertainty allows for real hope, and forms an intellectual bond between patient and physician. Decision-making becomes a joint enterprise, informed by intuition as well as knowledge.
False hope is a grave disservice. Having told many, many people with AIDS or cancer (my other specialty) over the past 20 years that there is no resolution to their problem--that death is the likely and imminent outcome--I can state that I have never held out false hope or obscured a painfully difficult situation. It is a betrayal of the responsibility and respect due to anyone with illness.
But there is real hope for people with HIV. I reiterate: We have witnessed the first true clinical remission of the disease. No, not for everyone. Yes, we do not know for how long. But life has been regained for many. It may last months, years, or decades. And the proof of principle--that the virus can be suppressed and the immune system restored (in part)--is the basis for such "real" hope. Hope, and the ability to imagine, is the engine that drives science. Do we not now have the right to hope, given how far we've come in the last two years? I contend it is an important step forward, having seen (and been a participant in) so much stumbling, listing, falling, and setback in the past.
Will the virus mutate and escape from the triple combinations? For sure. In some, this may occur quickly. In others, it may be a slow process. The second generation protease inhibitors from Agouron (expected soon in early 1997) and Vertex-Glaxo, have been tested clinically and appear to have non-overlapping profiles of resistance. So for some (not all), these drugs should be safety nets. Is this not reason to hope?
The debate about rational drug development is a good one for a Science article. I suspect there are differing opinions as to the proportion of the success that can be attributed to computer-based design. But I think it's interesting that with a single data set--the crystal structure of the HIV protease--not less than five distinct solutions (i.e., patentable chemicals which were formulated into drugs) were found. That's reason for hope when we attack integrase, Rev, or other protein targets. Look back at the summer coverage of the Vancouver conference. I was once told that when I teach, students may take away one or two points; the details are often lost in the wash. So with lay journalism. The cover of the sober Economist shows a jigsaw puzzle missing one piece; the title, "A Solution for AIDS." Time has an article with David Ho, sitting, smiling and cross-legged, on his lab bench; the caveats and question marks pale before lines about curing HIV with a triple punch. Look carefully at the context of the quotes taken from Sullivan's article, or Sanford musing about needing other drugs when his current regimen may flag. I fear the false hope that may be prevalent, and the current backlash, relates to our receiving information in "sound bites," pictures, and headlines. The devil is in the details, and he/she is to be found in the articles cited on careful reading. It may just be that the public prefers angelic pictures.
The vaccine dilemma--important, and currently overlooked. Why? I sense it is because the research has ground to a halt. Who has a fresh and innovative idea for an AIDS vaccine? It's back to the drawing boards, and until science can chart a new path, it's likely to be frustratingly quiet. News is not usually made by lack of progress. Perhaps a contribution would be to focus on the liability issues that deter companies from pursuing vaccines in general, and the terrible undercutting of the basic research enterprise in this country which is needed to open those new paths in immunology. The straight shot approach to an AIDS vaccine hasn't worked.
I have hope, real hope, tempered by all the uncertainties you've highlighted. It is not semantics to say if HIV can be controlled--for some in months, for others in years, for still others in decades--will that not be a realization of the authentic hopes of so many, to gain time that is precious?