When you speak about distance form a starting point you can express it trough space or trough time of the path covered. “It was really an extraordinary journey that we have all taken over the last thirty years from the very beginning of the understanding that we were dealing with a new disease” said to me Anthony Fauci, director of NIAID: the scientist that since the beginning drove the US answer to the HIV epidemic, remaining to the forefront in the fighting against AIDS trough five different US President –Regan, Bush, Clinton, Bush (the second one) and Obama. It was a long period, full of difficulties but also rich of success.
During the International Aids Society Pathogenesis and Treatment and Prevention Conference in Rome you gave talk about the story in which you have been involved since the beginning: thirty years of AIDS and fifteen year after HAART…
Yes, It was hard at the beginning, I remember the very difficult early years before we knew that HIV was the cause of the virus and then the sequential advances in science, from the discovery of the virus to the blood test that cleared the blood supply, to understanding pathogenesis. Those were important scientific advances, but it wasn’t until AZT, the first drug, was approved for anti-HIV in 1987, when we had the beginning of a hope that we might be able to do something about this disease. But after that, very quickly it became clear that the virus developed resistance to AZT, because it was only a single drug therapy. From 1987 to 1996 we had a progressive increase in the number of drugs that were effective until the era of triple combination, what we call HAART, that in 1996 completely transformed the lives of HIV-infected individuals. It was very clear that this was lifesaving therapy, and that was THE good news. The sobering news is that people were still starting to get infected: every single year there were millions of people getting infected, so we had to concentrate much more on prevention. What we have seen over the last few years is some striking advances in prevention, even over the last six months : I’m referring to circumcision, the first vaccine trial that showed a modest efficacy, topical microbiocides in women, pre-exposure prophylaxis first in gay men and then in heterosexuals and a very, very important the HPTN 052 study that showed treatment as prevention. The evidence of this last study means that if you treat HIV-infected individuals who are in a discordant relationship with a partner who is not infected, not only it is good for the person who is infected, but you can decrease by 96% the likelihood that you would transmit the infection to the non-infected partner. So, these are all major advances that have occurred over the last several years, but also spanning all thirty years, that’s the good news of the extraordinary story in thirty years.
Which are the challenges we are now facing?
In my opinion the two major challenges are the need to develop a vaccine because, even though we have very good tools for prevention, the really important next goal would be a vaccine and finally a cure: this is going to be difficult to do but there has been some indication that it would at least be feasible. As I said in my talk during the conference in Rome, with these scientific advances we need to now implement it, which means that we have all of the scientific information we need to have a major impact on the global pandemic. It is up to us globally to have the commitment, the political will and the resources to use enough money, enough resources to be able to translate the scientific advances to the people who could benefit from that. I think it’s an extraordinary opportunity and we should not let that opportunity pass.
Science was able to set up the scene, now we need money but we need also a cultural change. Do you think that sociology and/or social science behaviour are the crucial next step?
There are many important things we need to do. First of all, we obviously need more resources. We have about six million people in low- and middle-income countries who are receiving antiretroviral therapy, there are nine million people who could benefit from therapy who are not getting therapy, so we need to implement, but with the implementation there needs to be behavioral and sociological changes. For example, we know that certain prevention modalities work, but when you look at the studies, even in a trial in which the modality works, many people do not adhere to it. A typical example was the pre-exposure prophylaxis study among men who have sex with men, overall in the study it was 44% effective. However in people that really took their medication –that were truly adherent- the efficacy went up to 70-plus percent. Even further, if you drew blood and only counted the people who had blood levels of the drug, the drug was 90-plus percent effective, which tells us something very, very important: not only do you need a biological modality of prevention, but people have to adhere to it and that’s a major challenge that we are facing.
In your last editorial in Science you said now we are for the first time in the history of HIV/AIDS in the condition to consider feasible to switch off the epidemic…
Yes, I said in the editorial that we have had gradual advances in science over thirty years but now we have reached the point, even without a vaccine and even without a cure, that we have the tools in our toolkit to turn around the epidemic, to decrease the trajectory so that it starts to go down. We should not wait any longer, we need full implementation. First of all, money invested now will save a lot more money years from now and in the meanwhile will be saving many, many lives. I hope that the world takes note that now is the time to act. We are all aware that there are difficult financial and economic constraints throughout the world, but I think if you look at the big picture you’ll see if you invest money now, you’ll save a lot more money later.
Articolo presente in – HAART and correlated pathologies n. 12 –