sexta-feira, janeiro 20, 2006

As igrejas de Dublim

The Church of Viral Suppression
By Bob Huff

There is something Old World about the biannual European AIDS Conference. The
two I have attended were held in cold, northern towns where fuels like peat and
coal are still used to heat rooms. This year's meeting, in Dublin, Ireland, was
sponsored by the European AIDS Clinical Society (EACS) and offered two full
days of scientific talks and poster presentations to doctors and researchers
from around the continent. But unlike the Annual Retrovirus Conference in the
US, which primarily attracts scientists and physicians with a strong interest
in research, the European conference is also attended by a substantial number
of everyday, working clinicians who come to get a refresher course in
state-of-the-art HIV care.

As at most medical conferences, outside of the hushed meeting rooms more festive
attractions await, including a forest of posters and a colorful exhibition hall
where pharmaceutical companies set up tents to woo doctors who wander into
camp. This is the village marketplace, a swirling festival of lights and video
screens where the throng mingles beneath giant logos amid laughter and the hiss
of espresso makers.

At EACS, though, more than any conference I've been to, it is the pharmaceutical
company-sponsored satellite session that seems to be the central attraction. Not
exactly an official part of the scientific program, satellite sessions are
granted to the drug makers in return for significant financial support of the
conference. Not surprisingly the companies use these events to feature their
latest products and to promote recent data that has appeared in proper science
sessions. In Dublin, nine companies held satellite sessions over a three day
span, beginning at 7:30 in the morning and ending well after dark.

These sessions began to feel a bit like church services, packed with pilgrims
come to witness eminent doctors uphold enduring truths and argue the nuances of
contending theologies. In honor of the tenth anniversary of the advent of truly
effective HIV treatment, almost every company's satellite presentation began
with a ritual recitation of the miracle of HAART. In Dublin we gathered to hear
the ancient faith affirmed: "The goal of antiretroviral therapy is to achieve
maximum virologic suppression."

They Love to Tell the Story
The Concert Hall of the Royal Dublin Society has a reverential air to it, made a
bit musty by shelves of thick Gaelic books that line the hall. At nearly every
session a hushed congregation fills the great room, rising to the rafters and
spilling into the nave aisles. Onstage, sponsors' crusade banners flank a large
central screen that displays an endless procession of PowerPoint slides. The
high priests of European AIDS medicine preside over these sessions and bid for
the hearts of the multitude with impeccably reasoned logic that leads from
point-to-point and slide-to-slide, arriving at a version of truth the sponsors
hope will prove undeniable. Their presentations are as finely honed as a
Jesuit's tract. Often they are scripted by third-party medical communications
firms, and the presenters are well compensated for their aura and expertise.
The arguments are crafted to lead - not push - the learned audience to the
desired epiphany. But free will is respected and the audience is never bullied
and rarely cajoled, although sometimes in the hands of a less skilled presenter
the pitch becomes too obvious and clangs like a cracked bell.

The topics of these sessions are like parables that reveal the patron's
underlying message. If the theme is lipoatrophy and how to avoid it, you know
you are in the church of Gilead to learn about the demons of thymidine analog
NRTIs. The sermon is subtle and you may hear the virtues of Viread invoked only
once or twice during the hour; yet to those with eyes that can see, the path is
clear: Truvada will set you free. If the devil is lurking in the lipids, then
this morality play is about the evil Kaletra, and rescue by good King Reyataz
or Sir Viramune is certain. But if you are called to worship time and tradition
by the old sage Abbott, then it's mighty Kaletra reciting the ancient mystery of
virologic failure without PI resistance.

In a kind of communion ritual, attendees sometimes receive small devices that
allow them to register their opinions on formal questions posed by the
presenters. Within seconds the collective responses are displayed on the big
screen for all to behold and wonder at. In these moments the secret heart of
the congregation is revealed. Often responses seem preordained, such as when a
question points to an obvious choice that reinforces the sponsor's message.
This is a pedagogic exercise and seems very effective. But the beliefs of the
mob can be frightening too. In a catechism sponsored by the makers of efavirenz
(Sustiva, Stocrin), the limits and dangers of nevirapine were drilled
unmercifully, yet a sizeable minority of respondents never quite seemed to
grasp that they risked a case of liver failure by prescribing nevirapine to a
woman with more than 250 T cells (over 400 for men).

These errant answers are a sobering reminder of why satellite sessions are so
useful. Despite how complex treating HIV can be in day-to-day practice, the dos
and don'ts must be made sufficiently simple so that garden variety doctors - the
parish priests of medicine - can keep the message straight and tend their flocks
without losing any sheep to the wolves of toxicity, resistance, or
lipodystrophy. When the guidelines are made clear, adherence to the faith is
more likely.

There were no apostates or freethinkers in the big hall. No heretics hailing
hydroxyurea, immune modulation, or other theories that stray from the central
doctrine of everlasting viral suppression. Although Merck allowed a peak behind
the veil to suggest a coming paradise of therapeutic vaccines and integrase
inhibitors, most companies offered redemption here on earth, available now (or
soon) at your local pharmacy. The sponsors' prize for mounting this pageant is
a buttressed position in the minds of Europe's doctors - and a possible up-tick
in market share. The doctors get a renewed awareness of the complexities of
treating HIV and some measure of comfort knowing they are in touch with the

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