POSITIVELY AWARE MAY/JUNE 2011
ONE ON ONE
Interview by Jeff Berry
Any 30-year retrospective on the history of HIV and AIDS would be incomplete without the voice of Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases (NIAID) since 1984.
With an annual budget of nearly $5 billion, Dr. Fauci oversees research on the prevention, diagnosis, and treatment of HIV/AIDS and other sexually transmitted infections (STIs), influenza, tuberculosis, malaria, bioterrorism, transplantation, and immune-related illnesses. He is also a key advisor on global AIDS issues to the White House and the Department of Health and Human Services, and was awarded the Presidential Medal of Freedom in 2008.
In his first ever interview with POSITIVELY AWARE, Dr. Fauci talks about some of the many accomplishments we've made as well as the challenges we continue to face, while he also gives us a personal glimpse into his own life, and the things that are most important to him.
JB: As someone who's been a leader in the fight against HIV and AIDS since the beginning, what do you see as some of the most significant achievements we've made in the past 30 years?
AF: Well, there's a whole line of them—obviously the first major achievement was, a couple years into the epidemic, to identify the virus relatively rapidly. It was quite a mystery for a couple of years there, and that [identification] led to the development of a diagnostic test, which had a major impact on understanding the scope of the epidemic and practical considerations such as protecting the blood supply. I think that was the first gigantic leap forward which then led to virtually every other major advance over the last 30 years. Certainly, understanding the pathogenesis of the disease and understanding the molecular virology as a basic science tool was critical in everything else that followed, but if you were to ask me, say, 'you have 30 seconds to tell me the most profound advance that's occurred over the last 30 years,' I think, unquestionably, we have to say that was in the area of treatment. As you said, very correctly and appropriately, I've been involved as a clinician of basic science, a clinical researcher, and a science administrator in HIV literally from the first day that we recognized that this was a syndrome back in the summer of 1981 and when I first started seeing patients with HIV who would come into my ward. I refer to it when I write and speak as the dark years of my medical career where virtually everyone who came into the hospital would either die very soon or would go on for a relatively brief period of time in great pain, discomfort, and illness, and die. In fact, the median survival of people during the early '80s, before we had any drug to treat the virus itself, was 27 weeks or so, so it was just a matter of a few months because they didn't present to you until they were far advanced in their disease. Whereas, currently, given the spectacular, breathtaking, stunning—whatever superlative you want to use—advances in the development of an armamentarium of drugs, they have totally transformed the lives of HIV-infected individuals.
Unlike with some other infections, there will have to be a combination of prevention modalities that used together, two, three, or four at a time, will ultimately get us out of this difficult situation we're in.
Now, if a young person comes into my clinic—the same clinic or the same hospital ward I saw patients in 30 years ago—who's recently infected and I put them on an appropriate regimen of a combination of drugs that we have available to us today, you can do a mathematical modeling and project that, if that person takes the medications, they would live an additional 55 years. So when you stack that up against the major accomplishments in the translation of basic clinical and biomedical research to something that is extraordinarily critical for patient health, I think the development of the armamentarium of HIV drugs must rank up there among the very, very top, so that's the one thing that stands out.
That's not to diminish many of the other important findings—I think if you look at what's gone on over the last couple of years, particularly the last year and a half, there has been the realization that prevention will not be unidimensional with HIV, unlike with some other infections, that there will have to be a combination of prevention modalities that used together, two, three, or four at a time, will ultimately get us out of this difficult situation we're in with the explosive nature of the AIDS pandemic. Just in the last year, the success that has been demonstrated with circumcision; the modest but, nonetheless, very encouraging success with a vaccine for the first time in over two and a half decades; the very encouraging work on topical microbicides that came from Southern Africa; and most recently, the work on pre-exposure prophylaxis—I think all those things in the realm of combinations of preventions are also major advances and accomplishments. Not to mention all the other fundamental, basic science things that we've learned, but when you're dealing with a disease with a global impact such as HIV, the three major things you look at are diagnosis, prevention, and treatment.
As I told you, the first advance in diagnosis was way, way back in the first years, back in 1985 when the blood test was developed, the treatments began to trickle in, starting in the mid-'80s with AZT in 1986 and '87, up to and including the mid- to late '90s and into the 21st century with new drugs that began to transform the lives of people with HIV. And now we're in the era of rapid advances in prevention. So those are the three major things you think about when you're dealing with a pandemic. Two of them we've done very well with and right now, if you were to ask me for the last 30 years what's the major challenge, it is certainly in the arena of prevention, but also, the possibility, which is not going to be easy, of actually curing people with HIV, of really getting to the point where you can discontinue therapy in people without the virus bouncing back. That's going to be a particularly daunting challenge; not impossible, but daunting, but I think preventing infection will be much more practical than anything else.
JB: What do you see as some of the major pitfalls or stumbling blocks we've encountered along the way?
AF: I think one is a scientific one and many are implementation ones. I think the scientific thing is being unable, in a timely fashion the way we would have hoped, to be able to develop a safe and effective vaccine. I think that's because HIV is such a unique virus in that the body's immune response to HIV is not adequate or capable of ultimately suppressing or controlling the virus. If you look at all the historical maimers and killers among viral diseases—smallpox, measles, polio, hepatitis, and others—even though they cause a degree of morbidity and mortality, at the end of the day, the body is quite successful in ultimately suppressing and eradicating the virus and then giving the person who'd been infected lifelong immunity against re-infection. It's because of that that we've been able to develop successful vaccines against these viruses, because the body has already proven to us the concept that it's capable of developing an adequate immune response. We don't have such luck with HIV because, thus far, it's clear that the body has a real tough time in making an adequate immune response. So we have to do better than natural infection. We have to figure out a way to induce in the body a protective response with a vaccine that the actual infection itself is not capable of doing and that's a very, very daunting and challenging task. That's probably the prevalent, predominant, overriding scientific challenge that we face today.
With regard to implementation challenges, I think they're very, very clear. You still have 2.7 million people infected each year; we have 1.8 to 2 million deaths per year; and we still have not been able to get adequate treatments to any more than 30 or 40% of the people who need them worldwide, which means that 70% of the people who could benefit from therapy don't have it for a variety of reasons—access, resources, health care systems, etc. The other thing is that even though there are very effective prevention modalities, only a relatively small percentage of people who could benefit from availability of these prevention modalities actually have access to them. So I look upon it as two different types of challenges; one is the scientific challenge, as I mentioned, which is fundamentally around the vaccine; and the other is implementation challenges.
JB: You’ve been a major supporter of the involvement of the community in research, drug development, and helping to identify and establish priorities. Can you tell us why you feel community involvement is so important? Is there an issue that you feel needs more community involvement?
AF: I think we need to continue. You’re absolutely correct—back in the mid- to late ’80s, I got very involved in changing the paradigm of how we look at HIV research and implementation of programs because I was very impressed with the fact that this was such a unique, unusual situation early on when we had no treatments, that the people who were actually impacted by this virus really had good insight into what we in the scientific community and in the regulatory community could do to hasten the process of getting effective intervention to them. Clinical trials aren’t very good or beneficial if the people you’re doing the clinical trials on are not enthusiastic about getting involved and feel that they’re too stringent or not properly designed. The same thing holds true with policies that you need to implement. I’m a strong believer in that and I still think that we need to continue to involve the community and right now, we’re seeing a lot of that with the international community. The fact that we have therapies available in South Africa now is due, in large part, to the activist communities in South Africa demanding that the government abandon their totally unjustifiable and antiquated approach to HIV, which was really responsible for the deaths of a lot of people. The community was the one that triggered the outrage about that, so there’s still a big role for the community in pushing programs forward that are not getting the proper attention.
JB: Much of the HIV/AIDS advocacy movement was born in a time when activists were protesting by chaining themselves to the chairs of policy makers and staging die-ins. What issues do you think will motivate the advocates of the next generation and how will their actions be different?
AF: I think that what’s going to motivate them is to call attention to the fact that, even in times of stringent resources and constraints on resources, the global society has an obligation to treat people who are infected with HIV globally—most of the difficulty goes on in the developing world, but even in the United States, when you have programs, for example, that cut the availability of drugs through our ADAPs [AIDS Drug Assistance Programs], I think the activists are going to be the ones who have to call attention to the fact that for, relatively speaking, what’s not a lot of money, you’re talking about the real capability of saving lives. Activists are very good at bringing that to the attention of the authorities.
JB: What would you say to a health care provider or researcher just entering or thinking of entering the field of HIV/AIDS or infectious disease?
AF: Well, infectious disease is certainly a general area you could say this about, but more specifically, about HIV—if you want to have an impact, a real important impact, a field like HIV where so much can be done and so much still needs to be done, I couldn’t think of a better area to get involved in than infectious diseases in general, and specifically with HIV, because for the amount of effort you put in, the amount of benefit that you can accrue to people is extraordinary.
JB: What are some of the areas of research and study that you are the most excited about?
AF: I think I said that one is the cure; the other one is the combination of prevention, including the development of a safe and effective vaccine. I don’t think we’re going to get a vaccine that’s 95% protective the way some of our really effective vaccines are, like polio and measles and others, but I do think that a moderately effective vaccine in combination with other prevention modalities is going to go a really long way towards turning around this epidemic. So that’s what I’m really very excited about—new prevention modalities as well as trying, hopefully, to get a cure.
JB: Are there other areas that you feel we need to focus on in the years ahead that have been unfunded, underfunded, or not viewed as a priority in the past?
AF: I think we pretty much hit on the priorities. Obviously you always need new drugs in the pipeline, particularly if you’re thinking in terms of a cure. You need to get drugs that have mechanisms of action that actually get virus that’s not expressed but that’s hiding in the reservoirs, so that’s a big challenge—and we’re continuing to emphasize this whole issue of a cure.
JB: I’m sure you’re aware that recently there’ve been proposed budget cuts targeting research and science, so how would we prioritize what gets funded?
AF: Well, prioritization is always difficult, particularly when you have many worthy projects to be done. You just have to sit down and figure out, given the resources we have, what’s the best bang for the buck? That’s a difficult process—you have to go project by project and agenda by agenda.
JB: Do you view this as your life’s work, and if so, did you make a conscious choice that it would be?
AF: Yes, in fact I was really quite successful as a basic immunology/infectious disease researcher from 1972 to 1981, and when the first cases of HIV/AIDS started to trickle in, I made a conscious decision that I felt this was going to be a huge, huge global pandemic and I actually wrote about that in 1981 and ’82—that we were being somewhat naïve to think that this was going to stay constrained to a relatively restricted population of people. I turned around the direction of my career at that point and left an area that I was very successful in to start working on HIV, and I’ve been doing that literally for the last 30 years. And I think I’m going to keep doing that until we get to the point where I can feel comfortable that we really have turned around the pandemic. The answer to your question, the short answer, is yes, this is my life’s work.
JB: It’s easy to imagine that your work consumes much of your time. So may I ask what you do for fun?
AF: [Laughs.] Good question! My family asks me that too! I’m really a classic case
of a workaholic. My fun is modest things—
I run everyday, I get a lot of pleasure out of running; whatever time I have, which isn’t a lot, I spend with my family. I have three grown children now in college, and I like [doing] outdoor things, but I don’t get a chance to do them very much.
JB: Are any of your children going into research or medicine?
AF: No. I think because of me and my position and my notoriety, they tend to shy away from that the way some children do. They don’t like to essentially follow the footsteps of the parent, but they’re interested in public service, for sure, deeply interested in public service. Whether that is going to be in medicine or not, I think time will tell, because they’re still relatively young. I hope they do—I think it would be a good field for them.
JB: What would you most like to be remembered for?
AF: Ahhh, I think probably something that has indirectly to do with the science of HIV. It was my involvement in designing and being a principle architect of what ultimately turned out to be the President’s Emergency Plan For AIDS Relief [PEPFAR]. President [George W.] Bush sent me to Africa in 2002 to figure out if there was any way that we could have an impact on the epidemic in sub-Saharan Africa and the Caribbean. I spent about eight months of my life designing, fine-tuning, modeling, and finally coming up with a proposal for the PEPFAR program. It was to my great gratification that all that time I put in going back and forth to Africa, trying to model something that would be accepted and the fact that he did pledge and ultimately put more than $15 billion in that, if I were to pick out the one thing in my career, even though it wasn’t something that I did at the bench or with a patient, it was developing a program that the President was very enthusiastic about. I would consider that right up there in the top things I’ve done.
JB: Are you still seeing patients?
AF: Yes, I am! In fact, I made rounds on AIDS patients this morning at 9:30, actually. I see patients twice a week, every week, year round.
JB: How is it different now? Is it fulfilling whereas before, it was a dark time?
AF: Well, it was fulfilling before even though it was dark. It’s a little different now, because you see patients come in and you put them on therapy and they turn around within a few weeks from being close to death to being able to walk out of the hospital. I never forget the days and the years when I was in there day and night and they were dying no matter what I did for them. It’s interesting—some of the residents making rounds with us are 28, 29 years old. They weren’t even born when the first cases of HIV were around, so they don’t have a clue how bad it was back then, so it’s kind of an interesting experience to make rounds with them having seen both sides of that coin.