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Dr. Anthony Fauci Talks to VOA about the AIDS Pandemic and the Avian Flu Threat


This year marks the 25th anniversary of the deadly HIV/AIDS virus that initially took the lives of five homosexual men in 1981, in Los Angeles. Now, a quarter of a century later, some 25 million men, women and children have died, 40 million more are infected, and the disease is still expanding. Sub-Saharan Africa is home to more than two-thirds of the people with HIV/AIDS.

Dr. Anthony Fauci one of the leading experts on HIV/AIDS talks to VOA's Carol Castiel and David McAlary about the AIDS pandemic. In addition to that, Dr. Fauci, who is the U.S. Government's top infectious disease researcher, as Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, discusses a new health threat on the horizon -- avian flu and ways of preventing its spread..

The H5N1 strain of avian, or bird, flu has spread from Asia, across Europe, and into parts of Africa. It has killed countless millions of birds. And while it does not easily infect humans, it has sickened about 200 people and killed more than 100 since 2003. And while no human-to-human transmission has yet occurred, public health officials are bracing for the possibility of a global flu outbreak.

MS. CASTIEL:

Dr. Fauci, you are quite a pioneer in the research on HIV/AIDS. Those were the early days. Would you have ever imagined that the virus would have exploded into the pandemic it has today?

DR. FAUCI:

No, probably not. I knew instinctively in the early days that it would turn out to be much more serious than people were thinking when they were incorrectly thinking that it was confined to a restricted group of gay men, before we even knew that it was an HIV virus that was causing it. I never bought that from the beginning. It was looking very much like an infectious agent.

But even having said that, I think for anyone to say that they could have imagined that there would have been, 25 years later, over 60 million people having been infected, 25 million of which have died, I think that was probably beyond the imagination of virtually anybody at that time, in the summer of 1981. As the disease started to unfold, and it became clear that it was sexually transmitted, transmitted by blood and blood products, transmitted by injection drug use with contaminated needles, and particularly when it got into the developing world, where the predominant mode of transmissibility was heterosexual contact, at that point it became much clearer that the boundaries were unlimited; that there was no finite boundaries that you could say, well, this is going to stay confined to A, B and C.

But it took a while to get there. The summer of 1981, with those initial cluster of first five cases from L.A., and then many more from L.A., San Francisco and New York, during those few months, there was a lot of confusion about just what this was. But there was very, very little imagination that this could have been as bad as it has turned out to be.

MS. CASTIEL:

Now, we've made considerable progress in prevention and treatment, but why is this disease so hard to conquer? Can it ever be eradicated?

DR. FAUCI:

Well, it depends on what you mean by eradicated. Can it be eradicated from an individual person who is infected? Even with the best drugs that we have, the nature of the virus is to insert itself into the genome of one's cells. And even if you do very well on therapy, as so many people have done with the new antiviral therapies that we have, we have found, much to our dismay, that despite that, the virus never gets completely eradicated from the body. And we have experience where you treat people for several years, they do very well, their viral load is undetectable, their CD4 count is normal or even better than normal, and yet, when you interrupt the therapy, the virus bounces right back. So that's in the individual person.

If you're talking about eradicating HIV the way we have eradicated smallpox, it's unlikely that that will happen. And if it does, it won't be for a very, very long time, because of the pervasiveness of this. It's all around the world. It's sexually transmitted. People who are infected can go for a very long period of time not knowing they are infected, and hence can be at risk for infecting other people.

So you never say never in health and biology, but I would be really surprised if we ever got to the point where you could really essentially eradicate from the face of the earth HIV infection, after it has taken such a firm hold throughout the world right now.

MR. MCALARY:

Dr. Fauci, are we at the point with HIV that, given today's therapies and those on the horizon, it can be looked at perhaps as a chronic disease rather than what it was feared in the eighties, when it was relatively unknown?

DR. FAUCI:

I think you could say that. Because there are so many people, particularly in the developed world, and now more so in the developing world, who have the availability of good therapy; namely, the combinations of antiviral drugs, who, if treated appropriately and early enough, they can really have an immune system that remains reasonably intact, and they could live normal lives. We have so many people who now are going many, many years. We don't even know what the extent of that will be, because it's a moving target.

People ask me, well, what is the life expectancy now compared to a few years ago, or before we had therapy? You really can't say, because we haven't pushed it to its furthest limit yet. We have people that are doing well now for 20 years. We have some people who are really living virtually normal lives. And more than just a few. We have a lot of people that way.

So having said that, yes, in some respects, you can say that you can consider it not the way we originally thought, where it was essentially a death sentence, before the availability of therapy. But with appropriate therapy, the disease can be adequately controlled. So, hence, it has some resemblances to some of the chronic diseases that we deal with; that if proper treatment is maintained, individuals can lead reasonably healthy lives.

One of the problems with even saying, well, gee, we can look at it as a chronic disease, is the impression that people get, well, then it's okay, because it's not so serious to get HIV infected. In fact, that's probably responsible for the rebound blip that we're seeing in new infections because of the completely inaccurate impression that HIV just isn't so bad anymore because you have good drugs to treat it. And that's a very dangerous situation to get into, to assume that because you're dealing with something that can be relegated to the arena of chronic manageable diseases, that we can let down our guard regarding prevention of new infections. That's something you have to be very careful of.

MR. MCALARY:

It has been axiomatic for some time now that a vaccine is just 10 years away.

DR. FAUCI:

Yes.

MR. MCALARY:

Is that still the case? And where are we?

DR. FAUCI:

No, I don't think we can say that. The development of a vaccine, a safe and effective vaccine, for HIV is really quite problematic, for reasons that are very unique to HIV. Usually, almost always, when you have an infectious disease, even the deadly killers -- smallpox, measles, polio with its crippling effects, and others -- the human body, when they get exposed, even if they never get vaccinated, the vast majority of people, their immune system is capable of ultimately warding off the infection in question and then protecting the person from re-exposure or re-infection. So the best form of protection in vaccination is to have recovered from the natural infection.

Unfortunately, that's not the case with HIV, because the HIV is not handled very well by the immune system. And it is astounding that there isn't a single documented case of someone who has gotten infected, has got an established infection, and then their immune system has spontaneously cleared or eradicated the virus. Which tells us there is something very special about the way this virus interacts with the immune system that makes it very difficult for the immune system to handle it.

Having said that, it makes it even more difficult to develop a vaccine that could protect you against infection. So when you talk about, when will we have a vaccine, well, many of us are cautiously optimistic. But there are still some very important scientific barriers that need to be overcome before you can even put any kind of a prediction of when you will have a vaccine; one of the most important of which is we don't have any kind of a vaccine that can induce an immune response that would be protective against a broad array of viral isolates. We have that for so many other infectious diseases. But the vaccines that have been tried thus far have not elicited the kind of immune response that you would predict would be completely protective against HIV.

So no, we should not say that 10 years from now we'll have a vaccine, because we just don't know. Many of us feel that, within 10 years, we likely would have a partially protective vaccine. I don't know how protective that may be -- 20, 30, 40 percent at best. But very few of us feel that a very effective vaccine is literally within our grasp and around the corner. That just doesn't seem to be the case.

MS. CASTIEL:

Dr. Fauci, I would like to turn to Africa.

DR. FAUCI:

Yes.

MS. CASTIEL:

After all, at least two-thirds of those infected with AIDS worldwide do live in Africa. Talk about the progress made and the biggest challenges ahead for the continent in preventing and treating HIV/AIDS.

DR. FAUCI:

Some countries have done very well. And I think one of the challenges is to incorporate leadership from above, leadership within the country, political will, to face the problem, not deny it, and have the leaders of the country do what is necessary with regard to education and behavioral modification. Another important challenge that is very specific to developing nations, particularly in Sub-Saharan Africa, is the issue of the empowerment of women.

In Sub-Saharan Africa, as in other developing areas of the world, it's a virtually 50/50, man/woman, ratio of infection. So it is a disease of men and women. And in cultures in which women have very little empowerment to protect themselves from infection or to avoid those risk situations that would put them in danger of getting infected, you're never going to get a handle on HIV/AIDS' spread unless it is clear that women are empowered to take their own protection into their own hands. And that's the reason why you almost have to change some of the fundamentals of the culture, of how society looks upon women and their place in society.

That can only come from leadership. And that is the reason why we emphasize that you really need political leadership and political will to get a prevention method going and effective.

MS. CASTIEL:

That is very interesting. It is something that really money can't buy, or all of the financial assistance that is being provided to the continent.

DR. FAUCI:

Right.

MS. CASTIEL:

Now, in a related question, what about the unfortunate transmission from mother to child? This is an area where, it seems to me, prevention could make a big difference.

DR. FAUCI:

Right.

MS. CASTIEL:

To what extent is that occurring in Africa in particular, the prevention of this transition from mother to child?

DR. FAUCI:

Well, it has been a resounding success story in the developed nations. Here in the United States and other Western countries, we have had, early on, before therapy was available, about 25 percent of women who were infected with HIV, who gave birth, gave birth to an HIV-infected individual. With the treatments of the mother and, in some cases, the child after delivery, together with things like cesarean section, the infection rate now of transmissibility to infants born of infected mothers is 1 percent or less. So that is a resounding success.

With the availability of cheap regimens in the developing world, the 25 to 35 percent infections from mother to infant has dramatically gone down in certain regions where that is available. But we still have a long way to go. Because of the health care delivery system, women may not come to a health care facility until they are already in labor, or may not get there at all, may have a delivery at home. So if you don't know the person is infected and you don't get proper treatment to the mother and to the child in the first 48 or so hours after delivery, then you lose the opportunity of having a major preventive measure utilized.

So the answer to your question is that it is better than it was a few years ago, when therapies were not available, but we still have a long way to go. Because there are still many, many new infections per year, measured in the hundreds of thousands.

MS. CASTIEL:

Before we go to a break, quickly, to what extent are programs like the PEPFAR program, the President's initiative to eradicate, or rather to alleviate, AIDS, and the Global AIDS Fund from the United Nations, to what extent are they targeting this particular preventative measure?

DR. FAUCI:

Well, the President's Emergency Plan for AIDS Relief is fundamentally treating people who are HIV infected. The goal is to treat 2 million people, to prevent 7 million infections and to care for 10 million people, including AIDS orphans. It is a five-year program, $15 billion, an average of about $3 billion a year. It has had a major impact in the developing world, a group of Sub-Saharan African countries, Vietnam, and two Caribbean countries, Guyana and Haiti.

Prior to the President's Emergency Plan, or what we call the PEPFAR program, the President also initiated a $500 million prevention of mother-to-child transmission program, which antedated by about a year the PEPFAR program. So now they are kind of joined together in a comprehensive program. The same holds true for the Global Fund for HIV/AIDS, Malaria and Tuberculosis. There are also NGO's and bilateral agreements that are addressing the issue of mother-to-child transmission. But the first major program to do that was the President's Mother-to-Child Transmission Prevention program, which was about a year before the PEPFAR, to the tune of about $500 million.

MS. CASTIEL:

You're listening to Press Conference USA on VOA NewsNow. Our guest is Dr. Anthony Fauci, the U.S. Government's top infectious disease researcher, as Director of the National Institute of Allergy and Infectious Diseases. We're coming to you from his office at the National Institutes of Health just outside Washington. I'm Carol Castiel, along with VOA Senior Science Correspondent David McAlary.

MR. MCALARY:

Dr. Fauci, on this 25th anniversary of the first description of AIDS, there are some people who say that one of the under-recognized approaches that could mitigate the disease is male circumcision.

DR. FAUCI:

Right.

MR. MCALARY:

And there have been several dozen observational studies and now two randomized studies, blinded studies, going on in Africa to test this particular approach. It is said that in countries where most men are circumcised, that's where you have the lowest AIDS prevalence.

DR. FAUCI:

Right.

MR. MCALARY:

So there seems to be a strong correlation between male circumcision and low prevalence. What is your view on this as a potential approach to mitigating the disease?

DR. FAUCI:

I think it's a very important potential approach to decreasing the incidence of HIV infection. If you look at the data, they are very powerful. There are studies that go on now to even further confirm that. But in the data that I've looked at and some of my own colleagues and people that we support here at NIAID have looked at that, it is quite impressive, the effect of circumcision on decreasing the incidence of HIV infection.

MR. MCALARY:

Why has it gone relatively unnoticed compared to other approaches, such as behavior modification, mother-child transmission, even the microbicides? It doesn't seem to have been taken up by the world community.

DR. FAUCI:

Well, it hasn't because only recently have the data come out to indicate that this really is quite impressive in its effect. And I think you're going to start seeing more and more of that, particularly when some of the more recent studies come out and totally confirm the data. So although it was a little bit late in coming, I think the enthusiasm for it is mounting, to the point where it will assume its appropriate role as one of the major components of preventive measures, along with things like topical microbicides and mother-to-child transmission prevention, needle exchange, condom use, et cetera.

MS. CASTIEL:

Dr. Fauci, what countries or regions, in your view, show the greatest promise for diminishing HIV/AIDS? And which exhibit the worsening trends?

DR. FAUCI:

It's very difficult, because it's really a moving target. There are several countries in Sub-Saharan Africa that have done a very good job. The one we generally refer to is Uganda, where you have very strong leadership from the President of the country, President Museveni, who has really taken this very, very seriously. Senegal has done very well. In Southeast Asia, Thailand is another important success story.

Unfortunately, South Africa has lagged behind because of some difficulty in really fully appreciating the extent of the disease. But now, hopefully, we are going in the right direction there. It's very difficult to give a scorecard, because countries are getting better. Some of them are staying stable in their approach. But for the most part, in general, we seem to be going in the right direction, although there are some countries that really need to do much better than they are doing.

MS. CASTIEL:

How about China?

DR. FAUCI:

The problem with China is China is a difficult situation. Because, unfortunately, China has a history of not really facing the reality of what's going on. Or at least not letting the rest of the world know they're facing the reality. They had the very unfortunate situation of the contaminated blood supply, when people were selling blood. And before they realized that they really had a problem, they had a massive spread throughout the country. So China has a way to go. They really need greater transparency.

They have to take away the stigma of HIV infection. They have to investigate it thoroughly and they have to put some very aggressive preventive measures into play. Hopefully they have learned the lessons of the situation where they did not adequately address it, particularly with the first cases that were noticed that were related to contaminated blood.

MS. CASTIEL:

Before we turn to avian flu, Dr. Fauci, since HIV/AIDS was declared a national security threat akin to terrorism and war, how do you think the global public health infrastructure has improved or evolved commensurate with this threat?

DR. FAUCI:

It's tough to say that the infrastructure has improved or evolved. I think what they are using now, what is being utilized, is infrastructure as it exists at the same time as you try to improve it. I think one of the very good examples of a realization of how low-tech infrastructure was under-appreciated was within the situation in Sub-Saharan Africa, where there was an assumption that even if you could get the drugs cheaply, you would never be able to deliver drugs to people in Sub-Saharan Africa. And that proved to be incorrect. Because even with very low-tech community based health care delivery, we are seeing now that drugs are able to be gotten to people even in very rural areas.

This was proven very cogently a few years ago in Haiti by Dr. Paul Farmer, when he showed that you can go out into the bush and you could utilize locals to go out there and get direct observation of therapy, first, for tuberculosis and now for HIV/AIDS. We are seeing a lot of that in Sub-Saharan Africa now. So although infrastructure is being improved by some of the funding that is going into this, it is even more so a realization of the proper utilization of the infrastructure that already exists.

MS. CASTIEL:

David McAlary.

MR. MCALARY:

I've heard you say in a different forum that HIV is one of the most studied diseases in history by human researchers. Is there anything we've learned about it that helps inform another deadly feared virus that we have, avian flu, the H5N1 strain? Is there any overlap, anything that has made the research and the prevention of that disease easier because of our work on AIDS?

DR. FAUCI:

Very much so. Because a considerable amount of resources that go into the study of HIV go into fundamental basic research that can be extrapolated to any virus or any microbe. The study of the immune system and how the immune system handles HIV gives you great insight into how the immune system handles other microbes. So we look upon HIV as an emerging and reemerging infection. It emerged actually because it was a brand-new infection. The amount of money and the amount of resources, the amount of intellectual capital and talent and infrastructure that was built to study HIV, has a natural flow of benefit for the study of other diseases.

We see that with so many diseases. We see that with SARS, with West Nile virus. And we're seeing it right now in how we prepare for the possibility of a pandemic influenza.

MS. CASTIEL:

Dr. Fauci, I assume that the recent plan that President Bush unveiled, a preparedness plan in the case of a flu outbreak, is predicated upon the possibility of a human-to-human transmission.

DR. FAUCI:

Right.

MS. CASTIEL:

What is the likelihood that the bird virus could mutate and be transmitted from human to human, in your view?

DR. FAUCI:

You cannot put a number on that. Everybody asks that question. And I think when people put a number on that, they are not speaking out of any scientific basis for that. It is impossible to tell. It may not ever happen. H5N1 may be a dead-end, to the point where it continues to kill chickens, and then it ultimately fades away, and rarely, the way it is now, infects a human being. We have over 200 cases of infections in humans and over 100 deaths. That's a relatively, if not very, very, small, number, given the prevalence of it among chickens and the interactions between chickens and humans.

However, the possibility does exist, since influenza viruses tend to evolve, that it will evolve in a manner in which it will be able to effectively and efficiently go from human to human. We don't know what the chances of that are. But since it is a chance, then you have to prepare for the worst-case scenario. So that's the reason why you see pandemic preparedness plans, working under the premise that we will have to face the worst-case scenario. Even though the worst-case scenario might not ever occur, it would be irresponsible not to prepare yourself for the eventually of a worst-case scenario.

MS. CASTIEL:

Which countries or regions do you think pose the greatest challenge regarding the spread of avian flu?

DR. FAUCI:

When you have developing countries in which infection of birds like domesticated chickens are the likely vehicle of how it's going to jump and has jumped from chicken to human, and the more cases that go from chicken to human, the greater chance you give the virus to evolve to be able to go from human to human, so where you have a lot of human infections related to commingling of chickens with humans, then you're going to wind up with the greatest risk of that happening. That most likely happens in developing nations.

We've seen that in Southeast Asia, in Indonesia. We see it now in some countries in Africa. We have a situation in India where you now have infected birds. So wherever you have a relative lack of agricultural controls to separate the potential for infected chickens from exposure to humans, that's the greatest risk.

Europe is a great example. Europe had contaminated and infected migratory birds that landed in Europe, and there was some infection of some French chicken and turkey flocks. They handled it very well. They culled the turkeys. They culled the chickens. And there have not been cases of human infections, because there has been very little exposure of humans to infected domesticated fowl. So even though there were migratory birds that were identified in several of the Western European countries, there hasn't been the massive infection of chicken flocks, and therefore there hasn't been the human cases that we're seeing in Southeast Asia.

MS. CASTIEL:

Like with HIV, it seems like leadership, political will and preventative measures are the key to the spread.

DR. FAUCI:

Right.

MS. CASTIEL:

How would you assess the efforts in the developing world, whether it's in Asia or Africa, with respect to, at this early stage, preventing the spread of this avian flu because of the proximity between birds and humans in the agricultural sectors in those countries, which are dominant?

DR. FAUCI:

It's very difficult to generalize. It varies from country to country. And even those countries that have good intentions sometimes don't have the power or the capability of doing the kinds of things that need to be done. Let me give you an example.

One of the situations which we continue to be troubled with was the lack of transparency in China, who said they had no infected flocks. And then, all of a sudden you wound up getting people infected, which you knew had to come from infected chicken flocks. So you have to be open, honest and transparent. We don't always see that.

The other situation is it depends on the resources of the country. If you make it clear, if people report sick chickens, that when you cull them you will compensate the farmers for that, that would make it a better incentive for the farmers to come forward and say we have some sick chickens, let's address it. But when you have a situation where there is no compensation for the farmers, this is their livelihood, so they're not going to be enthusiastic about letting anybody know that they have sick chickens. So what might happen is that you have a fire burning and no one noticing it. And then, all of a sudden you have an explosion of infection among chickens and you have infected humans who are commingling with the chickens. That varies from country to country.

In Thailand, they're doing a very good job of it now, because the government has taken a major aggressive role. In other countries, even with good intentions from the country, it's very difficult to track what's going on. I mean, you talk about Indonesia, which has over 10,000 islands, with a population measured in the hundreds of millions of people, it's very, very difficult to track each of those islands and what's going on there. So it really does vary considerably from country to country.

MS. CASTIEL:

On this compensation effort, could the international community step in and play a role in that regard, some of the international health organizations?

DR. FAUCI:

Yes. Well, the World Bank perhaps even. There has been a lot of talk about what the developed world can do to get resources available to help the poor countries who don't have the capability of compensating people for reporting and ultimately culling chickens that are infected. So it's going to require some help from the developed world to the developing world.

MR. MCALARY:

Dr. Fauci, we've been talking about HIV/AIDS, H5N1 bird flu, but there are other infections milling about the world. We have been invaded by West Nile virus in the last few years. SARS was a scare a few years ago, and antidotes are still being worked up about that. Do you see anything on the horizon that worries you besides these particular diseases?

DR. FAUCI:

You really can't predict. So what worries me -- I wouldn't say it worries me, but it makes me alert. That's what we do. We address emerging and reemerging infectious diseases. That's our job. But there will always be emerging and reemerging infectious disease. So what you need is very good surveillance and you need the scientific and public health infrastructure to address it. So one of the things we need to learn lessons from HIV/AIDS, SARS, West Nile, and now avian flu, is that, inevitably, there will always be new emerging and reemerging diseases.

A new emerging disease is a brand-new disease, like HIV/AIDS or SARS. A reemerging infection is one that has been there a while but it's now in a different form or a different geographic location, like West Nile, like multiple drug resistant tuberculosis and malaria. So instead of reacting in a crisis mode as a society -- and we're getting better at this -- we need to realize and put resources into preparing for the eventuality of yet again another emerging and reemerging infection. Because if you look at history, it tells us that there will be emerging and reemerging new infections. Because we've seen it consistently over the decades and the centuries. So it's going to happen.

It may be the next pandemic flu or it may be another SARS. But microbes tend to evolve and the human species needs to be ready for it. And to be ready for it, you have to have a good infrastructure, you have to have a good scientific base, and you have to have good public health policies.

MR. MCALARY:

Has the world gotten better at detection and response in the last few years?

DR. FAUCI:

I think so. I think with the collaboration with the World Health Organization, we have a very, very fine system, with our own Centers for Disease Control and Prevention, who are very important in surveillance for the United States but also they play a major role globally; that in fact our capability of detecting the emergences of these new infections is clearly better than it was years ago.

MS. CASTIEL:

Dr. Anthony Fauci is the U.S. Government's top infectious disease researcher. He is Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. Dr. Fauci, thank you so much for sharing your insights with us.

DR. FAUCI:

You're welcome. It's good to be here.

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