SUMMARY AND ACKNOWLEDGMENTS

Summary of Biomedical Research Issues

Max Essex

Harvard AIDS Institute and Harvard School of Public Health, Boston, USA

During this symposium, we've heard numerous presentations by Thai scientists and clinicians. All share a common theme: HIV-1 is rapidly infecting large numbers of people in Thailand. While the actual number of clinical AIDS cases is already high, it is only a tiny fraction of the AIDS cases that will be diagnosed in the next decade. Probably less than 5% of the people already infected have developed an AIDS-related disease. Most of the remainder will likely develop such a disease within the next five years, and many more new infections will occur. This raises the question of how to mobilize biomedical researchers within Thailand to address the epidemic. An inevitable dilemma is how to weig h the need to mobilize researchers and clinical specialists for AIDS against the heavy responsibilities these professionals had even before the AIDS epidemic.

One argument often voiced against putting more resources into AIDS research is that other infectious diseases, such as dengue and malaria, also threaten Thailand yet are unlikely to receive much attention in the West. However, HIV already kills many more Thai people than do dengue and malaria combined. Soon HIV will kill more each week than malari a and dengue together kill each year.

Another argument often used against a major mobilization of AIDS researchers in Thailand is that a great deal of AIDS research is already going on in the United States and Europe. How can Thai researchers with small budgets expect to make discoveries before their better endowed Western counterparts? Conversely, we might ask whether we can ensure t hat medical researchers in the West will seriously address AIDS-related questions that are of special interest to Thailand.

In the West, for example, heterosexual transmission is infrequent--it is not the major problem it is in Thailand. Infections in the West occur via different HIV-1 subtypes from those in Thailand and by different routes. Can we be confident that Western scientists will place a high priority on making a vaccine that will work best to block vaginal i nfections with HIV-1 subtype E, which predominates in Thailand? Can we be sure the diagnostic or blood-screening tests developed in the West for subtype B, which is acquired primarily by blood or homosexual contact, will work equally well for subtype E, which is acquired largely by heterosexual transmission?

At present in Thailand, research into diseases such as dengue and malaria has priority over AIDS research. This should probably be changed rapidly. For now, HIV-1 subtype E seems largely limited to Southeast Asia and sub-Saharan Africa. Of the countries affected, Thailand has the most advanced medical expertise. Unless an extensive research progra m is rapidly developed, the cost of later action may be prohibitive.

Summary of Clinical Research Issues

Donald S. Burke

Walter Reed Army Institute of Research, Rockville, USA

In this symposium, researchers have presented an impressive series of studies detailing the epidemiology and clinical manifestations of HIV-1 and AIDS in Thailand. Resources for clinical research in Thailand are limited, however. How can those limited resources best be used?

Worldwide, approximately US$2 billion will be invested into AIDS research in 1994. Only a small fraction of that amount will be readily available to Thai researchers. Clearly, it would be helpful if some guidelines were proposed to help prioritize research projects. Based on extensive discussions with my Thai and American colleagues, I suggest the following criteria:

1. Research on prevention should have a higher priority than research on treatments. In the long run, improvements in preventing HIV-1 infection will be more cost-effective and will have a greater impact on reducing the impact of the epidemic on Thai society than will improvements in treatment. Certainly every effort should be made to deliver high-quality medical care to all people infected with HIV-1, but precious research dollars should be focused where they are likely to have the greatest yield--on prevention. Research on vaccines is one clear example of important prevention research.
2. Applied research should have a higher priority than basic research. Other synonyms might also be used in place of "applied," such as "targeted," "goal-oriented," or "intervention-oriented." I have no doubt that Thai medical scientists, if provided with sufficient funding and a solid infrastructure, could conduct basic research of world-class q uality and importance. The reality, however, is that available funding is modest by international standards and the laboratory infrastructure still requires considerable strengthening. Thai government officials and international agencies can reasonably ask if money invested in basic research in Thailand is likely to have much impact in the interna tional arena. If not, then it would seem wiser to invest research funds into projects with clear, practical goals for the epidemic in Thailand. I hope this is not taken as my equating "basic" with "sophisticated" and "applied" with "simple." Nothing could be more incorrect: important applied research typically requires sophisticated integration of cellular and molecular techniques with clinical and epidemiologic observations.
3. Research on problems unique to Thailand should have a higher priority than research on topics common to all countries, including the wealthy, industrialized countries. Already we know that the HIV-1 epidemic in Thailand differs sharply from that in the United States and Europe in several respects. Most notable are the differences in viral stra ins (E genotype versus B genotype), the predominant mode of transmission (heterosexual versus homosexual or intravenous), and occurrence of unique opportunistic infections (such as penicilliosis). Thai researchers can make crucial contributions to the global research effort by focusing their efforts on these and other aspects of the epidemic that are unique to Thailand and Southeast Asia.
4. Research on more cost-effective, appropriate health care should have a high priority. The cost of the future epidemic looms as a crushing burden for Thailand. Every effort should be made to devise and evaluate new or adapted interventions that are cheaper and more cost-effective.
5. Research to verify and extend clinical research findings from industrialized countries should also be encouraged to a limited extent. For example, pharmacokinetic studies of new drugs should be done in populations of Thai patients to ensure that there are not major differences that might affect clinical use of the drug in Asians. As another ex ample, limited in vitro drug sensitivity studies might be done on the E genotype to ensure the new drugs' likely effectiveness in Thailand.
6. Research that maximizes Thailand's prospects for biomedical and pharmaceutical competitiveness and self-sufficiency should receive a high priority. Where possible, Thai university scientists should enter into collaborative studies with partners in Thai industry. Alternatively, Thai biomedical scientists might establish cooperative ventures wit h foreign industrial partners willing to license or otherwise share their expertise.

References

1. Commission on Health Research for Development. Health research: essential link to equity in development. New York: Oxford University Press, 1990.

International Organizing Committee

Dr. Natth Bhamarapravati
Center for Vaccine Development, Mahidol University

Dr. Donald S. Burke
Walter Reed Army Institute of Research

Dr. Monthree Chulasamaya
Faculty of Science, Mahidol University

Dr. Max Essex
Harvard AIDS Institute

Dr. Tun-Hou Lee
Harvard School of Public Health

Dr. Chirasak Khamboonruang
RIHES, Chiang Mai University

Dr. Prayura Kunasol
Department of Communicable Disease, Ministry of Public Health

Dr. Pornchai Matangkasombat
Faculty of Science, Mahidol University

Dr. Praphan Phanuphak
Faculty of Medicine, Chulalongkorn University

Dr. Vitura Sangsingkeo
Ministry of Public Health

Dr. Prasert Thongcharoen
Faculty of Medicine, Siriraj Hospital

Dr. Candace Lowe
Harvard AIDS Institute

Dr. Wiput Poolcharoen
Division of AIDS, Ministry of Public Health

National Organizing Committee

Dr. Natth Bhamarapravati
Center for Vaccine Development, Mahidol University

Dr. Thavitong Hongvivatana
Mahidol University

Dr. Yongyout Kachondham
Health System Research Institute, Ministry of Public Health

Dr. Dwip Kitayaporn
HIV/AIDS Collaboration

Dr. Wiwat Rojanapittayakorn
Department of Communicable Disease, Ministry of Public Health

Dr. Boonmee Sathapatayavongs
Faculty of Medicine, Ramathibodi Hospital

Dr. Werasit Sittitrai
Program on AIDS, Chulalongkorn University

Dr. Supattra Srivanichakorn
Division of Planning, Ministry of Public Health

Dr. Surapol Suwannakul
Faculty of Medicine, Siriraj Hospital

Dr. Usa Thisyakorn
Chulalongkorn Hospital

Dr. Chayan Vaddhanaphuti
Social Research Institute, Chiang Mai Hospital

Dr. Chantapong Wasi
Department of Microbiology, Siriraj Hospital

Dr. Wiput Poolcharoen
Division of AIDS, Ministry of Public Health

Dr. Chanpen Choprapawon
Thailand Health Research Institute