AIDS: The tipping point

Anthony S. Fauci, MD, has been on the frontlines of the scientific fight against HIV/AIDS since the disease was first identified three decades ago. He is arguably the U.S. government’s best-known scientist, testifying before Congress on more than 200 occasions and interacting with every U.S. president since Ronald Reagan. He was appointed Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (NIH) in 1984, and oversees an extensive research portfolio of basic and applied research to prevent, diagnose, and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism.

John Donnelly interviewed Dr. Fauci on his perspective of the fight against AIDS at this moment, and how discoveries by scientists can now be best used.

What are the biggest opportunities from research on HIV/AIDS that are could be better utilized? What should be happening that isn’t?

I think that can be best explained with what has gone over in the last year and a half regarding the scientific validation of the efficacy of certain interventions in the realm of prevention. These studies have really redefined the concept of scientifically based combination prevention modalities.

There is a realization that there is not one size that fits all, nor is it that one modality in and of itself is going to have a major impact in terms of preventing the spread of HIV. One that has captured the attention and the excitement of people most recently is the issue of treatment as not only good for the individual in a life saving manner, but also treatment as assuming a role in the prevention tool kit. A recent study in a clinical trial found that you could remarkably decrease the likelihood that an individual will transmit the infection to their uninfected sexual partner. 

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A second study, following up observations made in studies years ago, that stands out very boldly among others is the benefits of medically supervised adult male circumcision, which in three randomized studies showed there was a 50-plus percent protection against acquisition of HIV in men who underwent an adult male circumcision. The good news that becomes better news about that is the results get even better over time. In one of the settings, in the Rikai District of Uganda, the effectiveness in the community now is over 60 percent for approximately four years. 

Then you have the conceptual breakthrough that with topical microbicides, particularly if used consistently, you can also have a major impact on prevention. Those results will likely get better as we get better adherence. There’s the issue of pre exposure prophylaxis both in gay men and in heterosexuals. 

Put together, what is the impact from all these developments?

All of a sudden we have a convergence of prevention approaches, which includes treatment as prevention, and that really validates the concept of combination prevention. There is now an enthusiasm and an excitement if we can implement some of these scientific advances, we can have a major impact in turning around the trajectory of the epidemic. The bottom line is we are pushing these advances in implementation so that we see the light at the end of the tunnel. 

When we can get the incidence of HIV down enough to turn the trajectory of the pandemic, it will assume a momentum of its own in diminishing HIV. That’s because the fewer people who are transmitting infection and the more people who are trying to protect themselves from infection – those are the two arms of the problem – that diminishes the pool of people capable of infecting the other people. 

What kind of operational research – the real-life testing that follows clinical studies – are you following closely now?

There are some studies in the U.S. to find out is it really feasible in a high-risk population to go out to test people, link them to care, get them on treatment, and have them continue to take their medications. 

One of these studies is in Washington, D.C.?

Yes, Washington and the South Bronx are among a handful of cities that are being looked at as to what tools you’ll need to access high-risk populations. Clearly, in this country, African-American men who have sex with men are way up there as a high-risk group. Another one is African-American women who have sex with men, as well as those who are injection drug users. There is a growing number of people who practice high-risk heterosexual sex within those cohorts. So right now there are studies that are going on in a number of cities and we’re looking at what are the mechanisms and feasibility of seeking out, voluntarily testing, linking to care, and treating.

Could some of the same prevention approaches that you would use in Africa or Asia be put to use in Washington, D.C.?

It depends. It’s very difficult to make generalized statements. There are certain demographic groups within the Washington, D.C., population that because of a variety of reasons – stigma associated with men who have sex with men – that make it quite problematic to access those people. Sometimes we do very, very well, but sometimes some of our inner cities approximate what you see in developing countries in terms of AIDS incidence. It really varies. What we are trying to do is figure out what the right formula is and what is the best way to test people voluntarily.

We need to overcome the suspicion of medical programs in our cities, particularly those sponsored by the federal government in a population of people who have suspicion understandably about that. Those are all challenges. So far it looks like we are making some headway.

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Can some of the studies done in Africa, such as door to door testing, inform what you could be doing in the United States? Are we learning from Africa?

We are learning back and forth. You have got to get community involved. That’s one thing we’ve learned from Africa, the use of community workers. In Africa, it’s a little different. Given the fact that the demands and the challenges far outstrip the resources, there are things that are done at the community level by workers that otherwise might be done by medical personnel in the United States. But those people at the community level are actually being quite effective.

And the greater use of community health workers can be done in both places, the U.S. and Africa?

Absolutely.

What are the best strategies in getting people tested for HIV in the United States?

We are trying to figure that out. We aren’t assuming that in one place something is working so it will work somewhere else. In Africa, you constantly go back and ask yourself the question, ‘we have put a certain amount of money in this, is it working?’ Every once in a while, you ask, ’By the way, did we make a difference?’

And if you didn’t, you ask what are you doing wrong, and how do you correct it. If we did make a difference, now we probably should be putting more resources in it because we know it works.

Let’s talk about cost effectiveness. How do you make the case now that it is cost effective to spend more money on treatment? 

You’ve got to look at data that you have, what we are learning now from studies. At least in the United States, in a resource-rich country, it seems the early you treat, the better off you are not only for the health of the patient and for the transmission inhibition, but also when you look at health care costs. You look at the cost of starting people on treatment relatively earlier than you would vs. starting someone on treatment after they have had advanced disease. What you find is that clearly the cost savings is to treat the person earlier. Even though you are starting to pay the piper earlier, the total cost of the piper at the end of the day, or the end of the life, is clearly much, much greater if you wait until you treat someone who gets very sick. There is no doubt about that. 

So to get people early enough, you have to figure out the best way to access them through testing, which gets back to the question of the studies going on in the Bronx and Washington, D.C. What is the best way to get to the people before you can even get testing to link them to voluntary care and treatment?

Once you get them there, the data indicate cost effectiveness, disease burden, the ultimate amount you have to fork out, it is clearly better if you are on the early end of the spectrum rather than the late end of the spectrum.

Is there ethically any difference in starting treatment early for someone in Johannesburg versus someone in Washington, D.C.?

No there isn’t. But you have to talk about the resources that you have. In a perfect world, you would want to put a full court press every place. But you have a situation where you don’t have resources and even infrastructure and the health systems are not built up well enough to access even 30 to 40 percent who absolutely need it for life-saving therapy. So before you even get to the point of looking at a cost-benefit ratio of preventing infections (by putting people infected with HIV immediately on treatment), you have got to get to the people you need the drugs to begin, who are already very sick. 

But by starting people early on treatment in Washington and not in Johannesburg, aren’t we entering a situation that is parallel to one we had a decade ago in which antiretroviral medicines were widely available to people in rich countries but not in poor ones? If countries give treatment as prevention …

You don’t give treatment just as prevention. People get confused about that. Treatment is now going to assume a role as part of a combination prevention toolkit. Think of treatment as a two-fer: saving the life of an individual and potentially blocking that person’s probability of infecting another.

To answer your question, sure, when you talk about the best of all possible worlds, it would be very nice if we had the resources where we could treat all 15 million people who fit the guidelines of needing to be treated in the developing world.

Could you talk about the importance of Secretary of State Hillary Clinton’s speech (in which she called for an “AIDS-free generation”)? 

The speech was a step in the direction of the administration making an attempt to utilize the recent scientific findings to improve greatly how we approach the global HIV pandemic. This was done in a way that may see us turning the corner and turning around the trajectory toward the pathway of ultimately having an HIV-free generation. So it’s going to be a multi-step process. It isn’t like the beginning of this effort. But in the last year or so, we have enough scientific advances so that we can start to see some significant turnarounds in the trajectory of the pandemic. But it’s not going to happen alone. We’re going to need a lot more host-country involvement, we’re going to need other donors, we’re going to need to be more efficient in what we do with the resources that we have. Now is a critical time in the history of the AIDS pandemic, and to have Secretary Clinton speak out, with her credibility and passion, is very important for the world to hear her.

But you still have the problem of funding.

Yes, there is always that problem.