NEWSWEEK: UNAIDS recently lowered its estimate of the number of people living with HIV. Is this reason for optimism? Dr. John Bartlett: We were so far away from our targets that this doesn’t affect much of anything. I’m frustrated by our spectacular inability to prevent this disease within the United States or Africa, or any place.
Why have we fallen so far short? We’ve never been good at preventing sexually transmitted diseases that require behavior modification, and there’s a total frustration with regard to vaccine development.
Merck recently announced not only that its potential vaccine failed to prevent HIV but also that the number of infections among trial volunteers who got the vaccine was higher than among those who got a placebo. How much of a setback is that? We’d pinned great hopes on Merck’s vaccine. We’re all disheartened.
The National Institute of Allergy and Infectious Diseases was about to launch a separate vaccine trial, which has reportedly been postponed indefinitely. Are there other promising candidates? The really bitter pill with Merck was not just that it was another vaccine failure but that this was one that people really thought would be successful. It was clear to people in the field that Merck was way ahead of the rest in terms of vaccine development. [But] people like me decided quite a while ago that, while the world needed to look hard for a vaccine, we had to move forward with the possibility that there would never be a vaccine.
So how are we faring in lowering HIV transmission rates? There are some promising studies that have been done or are being done now. The circumcision and the antiretroviral therapy for [HIV-positive] breastfeeding women [to prevent transmission to the baby] studies were a great success. Though, while circumcision might be very good at lowering the rates in places where not a lot of circumcisions are being done now, that’s not the case in the U.S. or in many other countries … There are [studies] that show if we treat people with HIV infection we prevent transmission to the other person in the couple by lowering the viral load … There are some microbicides on the horizon that look really good … Also, there are five ongoing studies of pre-exposure to an antiretroviral drug, Tenofovir.
You mean giving the drug to people who aren’t infected? Yes. Even though the studies will probably be effective, a lot of people will worry about millions of people who aren’t infected taking a drug that has potential side effects and potential for building resistance … and that has a fairly substantial cost. Another thing that could make a big difference is opt-out testing for AIDS. One reason the Centers for Disease Control revised its recommendation [and is now advocating voluntary testing] for everyone [in the United States] aged 13 to 64 is because they think it will be an important prevention strategy.
Why? If they know they’re infected, most people will take great precautions to make sure they don’t infect someone else. CDC calculations estimate that 250,000 people in the U.S. who are infected don’t know it, and, if they did, we might be able to reduce new infections by 50 percent. If that’s right, that’s substantial.
Is the U.S. government dedicating enough funds to fight the disease? President Bush has been a star for the PEPFAR program [the President’s Emergency Plan for AIDS Relief, established in 2003]. And now he wants to double the initial commitment to $30 billion. A lot of us say thank God for that, not only because it is an AIDS program but because it is helping to develop the infrastructure to bring vaccines, malaria control and several other kinds of health aid to these areas around the world that we should have brought it to years ago.
Do you expect the next president to provide a similar level of support? I hope so. I hope we get even more support. But we’ll see.
