Turning The Tide On HIV And AIDS

MS. DIANE REHM

11:06:54
Thanks for joining us. I'm Diane Rehm. When Dr. Anthony Fauci started his post at the National Institutes of Health nearly three decades ago, AIDS was a deadly virus. With few tools available to treat infected people, AIDS became a global epidemic.

MS. DIANE REHM

11:07:15
Today, HIV and AIDS remain a daunting public health challenge, but experts say new drugs have the potential to turn the tide. This is the goal as the International AIDS Conference is taking place here in Washington D.C. this week.

MS. DIANE REHM

11:07:35
Dr. Fauci is director of the National Institute of Allergy and Infectious Diseases. He joins me in the studio to talk about the challenges of overcoming AIDS. He has been with us many times to answer your questions. I hope you'll join us, 800-433-8850. Send us your email to drshow@wamu.org. Join us on Facebook or send us a tweet. Good morning to you, Dr. Fauci, it's good to see you.

DR. ANTHONY FAUCI

11:08:10
Good morning, Diane, it's good to be here.

REHM

11:08:12
You've been busy.

FAUCI

11:08:14
Indeed, we have, all of us. This has been an extraordinary week and we're just right in the middle of it.

REHM

11:08:20
How close are we to becoming what Secretary of State Hillary Clinton called for, that is an AIDs-free generation?

FAUCI

11:08:34
Diane, honestly, it's impossible to give a time for it because it's going to depend on certain things happening. The one thing we can say, which I emphasized during my talk yesterday at the conference, is that we now, after 30 years of incremental knowledge, have a science building block to give us interventions and treatment and prevention. And the implementation of that under optimal conditions such as in a clinical trial and then in the field, we've been able to show that we now have, even though we don't have a vaccine yet and we don't have a cure, we have the tools right now, the interventional tools to be able to significantly turn around the trajectory of the pandemic, if certain things happen.

FAUCI

11:09:23
We can do it. The scientific base tells us we can, but there are a lot of things that we have to implement aggressively together with other nations for this to happen. It's not going to happen spontaneously and that's the reason why, honestly, Diane, I can't answer your question about what the date is. It depends on what we do.

REHM

11:09:45
You got 22,000 people here in Washington all exchanging ideas, presenting information. What is the most exciting thing you've heard at this convention?

FAUCI

11:10:03
I think what it is, Diane, is exactly the question you led with, is that is it really true that we have the capability scientifically and clinically and the implementation of public and global health issues, can we do this? And people are taking different vantage point perspectives.

FAUCI

11:10:26
You could look at it broadly. You could look at it from the African-American community in the United States and from people in southern Africa. So there's a galvanization of discussion about the goal and the feasibility of actually sometime in the reasonable future to start to see a turning around of the trajectory of the pandemic. That's dominating the discussion.

REHM

11:10:48
How much money is called for, needed to do exactly that?

FAUCI

11:10:56
Well, already billions and billions of dollars are being spent and we need more input, more money, more donors. For example, what we're seeing that's really a good sign is major programs such as the President's Emergency Plan for AIDS Relief that was started by President Bush in 2003 and is being continued by President Obama, the Global Fund, philanthropic organizations like the Bill and Melinda Gates Foundation, and the Kennedy Foundation.

FAUCI

11:11:26
We're starting to see countries in the developing world starting to take more ownership of their own problem. So we need more countries who are not necessarily committing themselves to global fund money. We're the leading contributor, about a third.

FAUCI

11:11:43
We're seeing more countries come in, but we're seeing countries like South Africa and Rwanda and Botswana and others taking more ownership of their problem and devoting more of their resources to health as opposed to other aspects of their society.

REHM

11:11:55
Do we know going back, say, 22 years what the total population now of those with AIDS or HIV, do we know what that total population is?

FAUCI

11:12:15
We certainly do. There have been over 30 million people who have died from HIV AIDS. There are currently approximately 34 million people today living worldwide with HIV infection. In the United States, that number is about 1.1 million individuals...

REHM

11:12:34
1.1, in this country?

FAUCI

11:12:36
In the United States, right, exactly.

REHM

11:12:38
So worldwide the problem is much, much larger than it is here?

FAUCI

11:12:45
Yeah.

REHM

11:12:46
Is that because money has gone to the problem here in this country?

FAUCI

11:12:52
Ah, not entirely, Diane, about 90 percent of the infections are in the developing world, low and middle income countries and about 65-66 to 67 percent of them are in southern Africa. It has to do with so many factors, societal factors, health care, traditions, the way people live their lives, poverty, commercial sex work, how people view sexuality, women's rights and their difficulty in being able to protect themselves in certain societies.

FAUCI

11:13:26
All of those things in a combination have made a real disparate type of what we call epidemiology where you see so much of the infections in the low and middle income countries.

REHM

11:13:38
And what about the HIV drugs called the anti-retrovirals that are now central to prevention? What about treatment as prevention?

FAUCI

11:13:57
Well, that's a question that's also being very, very actively discussed at the meeting. We know now cumulatively over the years that if you have a combination of drugs -- now as I mentioned the last time on the show, you can get three drugs in one pill once a day that can actually, if taken regularly, drop the level of the virus in the body to below detectable levels so that people can actually essentially live a normal lifespan.

REHM

11:14:25
So it's now a chronic disease?

FAUCI

11:14:27
If you take your drug.

REHM

11:14:29
Right.

FAUCI

11:14:29
So now, what happened about a year and a half ago, is that a study was done to show that if you treat an HIV-infected individual earlier rather than later and that person is in a discordant sexual relationship with another person, so one person is infected, the other one isn't, you treat the infected person and you bring the level of their virus to below a detectable level, you decrease by 96 percent the likelihood that that person will sexually transmit the virus to their uninfected partner.

REHM

11:15:02
How much...

FAUCI

11:15:02
That's called a treatment as prevention.

REHM

11:15:06
How much does that cost, that individual and to what extent does insurance, as we know it now, pay for it?

FAUCI

11:15:17
Well, you know, it's interesting the terminology, treatment as prevention, is one that seems to not necessarily realize that that person is going to be treated anyway. The prevention is a freebie because if you're treating someone for their own infection, you obviously pay for it and in the developed world it's measured in thousands of dollars.

FAUCI

11:15:41
With generics in the developing world, it's measured sometimes as $100 or less per year for the drug. So if you identify a person who is infected and they need treatment and you have the health system to treat them, you're going to pay for that anyway. The extra added benefit of treatment as prevention is that you are also preventing the transmission of virus to an uninfected person.

REHM

11:16:08
But if you're using generics in other parts of the world, why aren't you using the same generics here?

FAUCI

11:16:15
Right, the recurrent question. The only way that you can get pharmaceutical companies to be able to put in the effort, the research and the production to make it, they have to get the profit so that they can go on and continue to make more drugs. So if everything is generic, I think they would probably go out of business.

FAUCI

11:16:35
That doesn't mean that we shouldn't be having lower prices for drugs and, in fact, the more good drugs we have, as in all business, competition drives the prices down.

REHM

11:16:47
You know, it's been a longstanding argument that you can't -- if you have a cold and it's caused by a virus, you can't treat that virus with antibiotics because it's not going to do anything. You have to have a bacterial infection. How does or do these drugs treat the HIV virus?

FAUCI

11:17:13
Well, your statement is not entirely correct. There are some...

REHM

11:17:17
That doesn't surprise me.

FAUCI

11:17:22
There are viruses to which we actually have treatments. For example, there's a treatment for influenza, a very common virus. The thing that's different with HIV is that if you treat a virus that is a non-deadly virus, for the most part influenza is not, though it can kill people, sooner or later the body is going to clear the virus anyway.

FAUCI

11:17:45
So you treat it and you may hasten the time or decrease the duration of your symptoms so that's treatment. But if you happen to not get therapy, generally the body's immune system is going to clear that anyway. So antivirals work by hitting certain vulnerable parts of viruses.

FAUCI

11:18:05
The HIV virus, as we've learned over decades of basic research and targeted drug development, has multiple vulnerable targets on it and when you get a combination of drugs, usually three, you can actually stop that virus from replicating.

REHM

11:18:23
Anthony Fauci, he's director of the National Institute of Allergy and Infectious Diseases. He is attending a huge conference looking at HIV and AIDS this week here in Washington.

REHM

11:20:04
And if you've just joined us, Anthony Fauci is my guest. He's been on this program many times talking about HIV and AIDS. He is here talking about the global AIDS conference going on here in Washington, D.C. this week with some 22,000 individuals from around the world attending. You're welcome to join us, 800-433-8850. Dr. Fauci, the FDA approved a new drug this week called Truvada. It's the first HIV prophylactic. How does it work and what is the promise?

FAUCI

11:20:59
Okay. So Truvada is one of those drugs that's a single pill, but actually contains two different anti-HIV drugs. For several years now, it has been used very successfully as part of a combination of drugs to treat people who are already infected. And because of some of the special characteristics of the drug in that it has -- it stays around the body long enough in the sense of when you administrate it.

FAUCI

11:21:28
There's a clinical trial that asks the question, if you give one pill a day -- and there were two major studies that showed this, one in men who have sex with men and one in heterosexuals -- that if you give someone who's at high risk of infection and you give them one pill a day and they take that pill, you can very effectively prevent them from acquiring HIV infection, which is really part of the question you asked me a moment ago about one of the multiple ways of treatment really being prevention. And that's exactly what it is only it's, as you mentioned correctly, prophylactic or pre-exposure of the infection.

REHM

11:22:10
So there have been some reports of kidney problems with Truvada?

FAUCI

11:22:17
Well, actually yes. There is no drug that you can give that doesn't have a toxic side effect. The issue is what is the balance of the risk, they're usually rare, versus the benefit? So the two drugs that are in Truvada, most of the time the toxicities are very mild, nausea, headache, abdominal discomfort, some diarrhea. But one of the drugs has an unusual, but definitely it occurs, kidney toxicities. So those are one of the things you have to watch out for, that it can give you some damage to the kidney and that has to be monitored.

REHM

11:22:56
Do you have any worries that if a drug like Truvada were made available to anybody who wanted it and could afford it -- 'cause it's not cheap -- are you worried that that might induce and encourage even risky behavior?

FAUCI

11:23:18
Well, two-part answer to your question. First of all we need to emphasize to your audience that pre-exposure prophylaxis with Truvada is not for everyone. And it shouldn't be a substitute for other prevention modalities. It's an additional part of what we call a comprehensive combination prevention strategy. It would be a mistake to think that you can then take this and you don't have to worry about condom use or being careful about multiple sexual partners. That's point number one.

FAUCI

11:23:50
Point number two, in the studies that have been done so far to try and ask the question during the clinical trial whether or not people actually who are in the trial increase their risk behavior, stop using condoms, had more sexual partners. And for the milieu of the clinical trial the answer is no, they have not.

FAUCI

11:24:12
But we have to make sure -- and the FDA actually makes this part of the condition of the approval -- that the company has to follow up and give additional data as the time goes by following the approval of the drug, as to what the answer to these questions are in addition to things like if people go on the drug without first being tested, that's really bad. Because you've got to prove that you're negative first if you're going to use the drug. Because if you happen to be infected and don't know it and start on the drug it's inadequate therapy for the treatment of already existing infection, even though it's very good to prevent the infection before it occurs.

REHM

11:24:58
How much does it cost?

FAUCI

11:25:01
You know, it varies. Probably now -- I'm not sure exactly what they're going to package it for just as a single drug, but it costs, you know, thousands.

REHM

11:25:12
Thousands.

FAUCI

11:25:12
Yeah, about $1200, I think, yeah.

REHM

11:25:14
NPR says $13,000 a year.

FAUCI

11:25:19
Right.

REHM

11:25:20
And it's not at all clear what insurers are going to pay for it. So they're not going to pay for prevention?

FAUCI

11:25:32
I'm sorry, your question is that...

REHM

11:25:33
I mean, why wouldn't insurers pay for something like that?

FAUCI

11:25:37
You know, I can't answer that, to be honest with you, Diane. I'd love to give you the answer to any questions. I'm not responsible for the thing, but it is expensive. It's measured in the thousands.

REHM

11:25:47
But now would areas hard hit like sub-Saharan Africa, would those drugs be available there?

FAUCI

11:25:55
Well, the company is working with the ministries of health and others in the developing world to try and get it to a price where in fact it would be affordable as part of a prevention modality. But remember that if you look at the prices now that are being implemented in these developing nations, the regular drugs that are very, very markedly reduced. And then, there's the generic drugs that are even more markedly reduced.

FAUCI

11:26:25
So I can't imagine implementing a program where it's going to cost you 12 to $14,000 a year for Truvada to prevent infection when you have so many people in the developing world who are infected who don't have therapy.

REHM

11:26:38
Who are already infected. Gotcha. Okay. And you wrote in Health Affairs that widespread male circumcision in Southern Africa and expanded services to prevent infections in infants represents good values in terms of both efficacy and cost effectiveness. Do -- have I heard correctly that Germany is banning male circumcision?

FAUCI

11:27:22
I can't answer that, Diane, because I really don't know. I can't say if you've heard correct. I have not heard that.

REHM

11:27:31
I would appreciate your checking on that.

FAUCI

11:27:33
Yeah, I'll try -- I can't imagine that a country is going to ban something that's a personal choice. They may be saying they're not going to pay for it as a medical prevention modality. I don't know, but I can't imagine the country banning something like that.

REHM

11:27:49
Okay. And, you know, it's one thing to have these drugs available, but how you get them to the people who need them, how simple or difficult is that?

FAUCI

11:28:07
It depends on what country you're in. One of the reasons why there's such enthusiasm, for example, for not only the Affordable Care Act but also for a program called the AIDS Drug Assistance Program that emanates out of the Ryan White bill, namely getting drugs to people in this country who are not insured, who can't afford drugs, who have no way of paying for the drugs.

FAUCI

11:28:31
When you get to the developing world, that was one of the interesting things that was a roadblock to people early on in the early 2000s saying that we should be doing a prevention care and treatment program in Africa. And when PEPFAR was established by President Bush and now continued by President Obama it's very, very clear that in fact it is not that difficult to get it to people if you go out and aggressively pursue them in the community. People thought, oh you'd never get drugs to Africans and that's absolutely incorrect. There are now in low and middle income countries 8 million people receiving any retroviral drugs. Eight million.

REHM

11:29:17
And how receptive are they to these antiretroviral drugs?

FAUCI

11:29:25
If you get the community involved in the seeking out, educating, getting people aware why it's important to be tested and to be put on drugs -- to the surprise of some but not all, and certainly not me because when I went to Africa and looked at that I felt this could be done and that's the reason why I recommended it to the president and to his administration to go ahead and do it -- is that they do accept it.

FAUCI

11:29:54
In fact the fact that there's drugs available for them, they look upon the United States as being their savior in that regard. It's an amazing situation to experience. When you got to Africa they love America for the program of PEPFAR and the global fund.

REHM

11:30:13
You know, I received a -- I'm trying to find it right now -- I received a flyer from a women's organization, women who have HIV and are being challenged when they talk about wanting to have a child.

FAUCI

11:30:39
Right.

REHM

11:30:40
What's going on there?

FAUCI

11:30:42
Well, I think the flyer you're referring to -- and this was discussed at part of the meeting, particularly in developing worlds and Southern Africa and other places, and it refers to women's human and reproductive rights. And this relates to how important it is -- maybe not fully understood by all -- for women in -- anywhere in the world certainly, to be able to have the control over their own human rights and their own reproductive rights. So women want to have children in a particular setting.

FAUCI

11:31:12
It's difficult if they're infected with HIV because in the worst settings, 35 percent of women who are infected would, in fact, transmit the virus to their child during the period of birth and the perinatal and even more percentage during breastfeeding. But if you treat women with antiviral drugs who are infected and you bring the level of virus to below detectable level, you dramatically decrease, practically getting to zero, the likelihood that they will transmit the virus to their child.

FAUCI

11:31:47
So when you talk about women wanting to procreate when they're infected, it is absolutely linked to the availability of them to have the treatment that would not only save their own lives but also would prevent the transmission of virus to their newborn child. So that's a very important issue.

REHM

11:32:06
Now -- very, very important. But is there resistance from some of those women to take that preventive or that treatment prior to having a child?

FAUCI

11:32:22
All the organizations and all the women who are -- and there are many, many community-based representatives at the meeting here in Washington, D.C., I don't see any reluctance of individuals who want to procreate or want to protect their children to taking drugs. I see women saying they want access to the drugs so that they can actually safely procreate.

REHM

11:32:48
Dr. Anthony Fauci and you're listening to "The Diane Rehm Show." One caller, Mark from Kalamazoo, Mich. asks, "What would happen if everyone in the world with the HIV/AIDS virus died? Would the virus be eradicated?"

FAUCI

11:33:17
Well, the initial jump of that virus from a nonhuman primate came in decades and decades ago likely and start in a pandemic before we realized it probably decades before we realized it. There's always the possibility that that was the case but I wonder why that question was asked? I mean, what -- the fact is what has that got to do with anything? We're dealing with a problem right now of we're trying to save people's lives. So...

REHM

11:33:50
I think it...

FAUCI

11:33:50
...the best way to end the pandemic is to get -- I thought the question was going to be, Diane, what would happen if we tested everyone and put everyone who is infected on therapy and brought down the virus to below detectable level. That's the way you would end the pandemic. You don't need everybody to die to do that. You can do it by getting people to lead normal healthy lives and not transmit the virus to others.

REHM

11:34:16
Quite right. At the same time I think I infer what's behind the question is, does the virus ever die?

FAUCI

11:34:28
Well, the virus that jumped species and adapted itself from a chimpanzee to a human is still out there in the nonhuman primate population. Will it ever be able to again jump species? Certainly that's a possibility. But if it happened, given the 30-year experience we've had with HIV, I think the world would recognize it enough to try to put the lid on it. But you can't guarantee that. But the direct answer to the question is, it's in many viruses. Seventy percent of new infections come from the animal reservoir, as it were. And certain it's conceivable that if you got -- completely got rid of the virus that because it comes from another species it might accidentally jump species again.

REHM

11:35:18
All right. To Fort Lauderdale, Fla. Good morning, Steven.

STEVEN

11:35:24
Good morning, Diane. Good morning, Dr. Fauci.

FAUCI

11:35:26
Morning.

STEVEN

11:35:27
My question comes back to the issue why AIDS drugs are so expensive in the United States and that we allow generics in developing countries. It seems to me that if an HIV positive person probably can't easily get private health insurance. And you talked about the Ryan White Act for low income people that pays for their AIDS medication.

STEVEN

11:35:53
So isn't -- you know, aren't the taxpayers, aren't the Americans paying that extra freight for the profits of the drug companies to pay for their research? Because private insurance companies probably aren't paying it. Maybe wealthy individuals with HIV are, but the vast majority are lower income disaffected populations who don't have the money for those expensive drugs.

FAUCI

11:36:19
The answer is obviously drugs are expensive but when you talk to the drug companies -- and I'm not -- I don't mean to put down the drug companies because this is the way they exist. They make a billion dollars average per drug investment before they actually start turning a profit when you think about the research and the development that goes into it. So in order for them to continue -- and I'm not defending or taking aside. I'm telling you what is the line and the discussion goes is that they need to have these prices high in order to be able to continue to make drugs. And they...

REHM

11:36:58
But isn't there some government money that's going to those drug companies?

FAUCI

11:37:04
There is, no doubt. Some of the basic research doesn't go directly to the drug companies, but the basic research that we do at NIH and that others do certainly is public general knowledge. And that public general knowledge that's in the literature is taken up by various companies to make products. And in fact, that's a good thing. That's what you want. You want to push the envelope of science so that you can have interventions that are developed by the private sector.

REHM

11:37:31
And we'll take a short break here. When we come back, more of your questions, comments. Stay with us.

REHM

11:40:02
I want to take the opportunity to clarify what I asked about Germany. There was a case in Germany involving a four-year-old Muslim boy who had complications after being circumcised. So a regional court in Germany ruled that circumcision, even with a parent's consent, amounted to criminal bodily harm. The ruling then prompted a firestorm of criticism from both Muslim and Jewish groups. Now Germany's government pledged last Friday to pass a law to protect the ritual circumcision of boys, seeking to calm a fractious debate over the religious rights of the country's Jews and Muslims that erupted after a German court ruled the practice amounted to illegal bodily harm.

REHM

11:41:13
So I asked you a question that I didn't know the answer to, Dr. Fauci. And I'm glad we do have clarification here. Let's go to Belleville, Ill. Good morning, Jay. You're on the air.

JAY

11:41:30
How are you, Diane?

REHM

11:41:31
Fine, thank you, sir. How are you?

JAY

11:41:32
I'm all right.

REHM

11:41:34
Good.

JAY

11:41:34
I've had HIV since '87. I've been on Truvada for the last three years. I've lived in Phoenix and Las Vegas. I've never lived in New York, but I've got lots of friends that do. And basically my question is they aren't talking anything about side effects of this pill, which are large. And they're not talking about the fact that -- oh, and they cut Ryan White in half this year. So that's another thing to think about. If they're not gonna pay for birth control or condoms, why on earth would they pay for Truvada as an insurance company?

REHM

11:42:13
Jay, let me ask you something. What kinds of side effects are you experiencing?

JAY

11:42:21
I don't have any trouble with it. I've been put on it and I've stayed on it because I don't have trouble with it. Other people -- it messes with your liver. I mean, you have to get your liver done every three months, a full blood screen on it. Plus, the virus mutates and Truvada will not continually work on it. I know three people that have had to be moved off of it because their virus mutated.

REHM

11:42:45
All right. Dr. Fauci?

FAUCI

11:42:47
Could I ask you a question?

JAY

11:42:48
Sure.

FAUCI

11:42:49
You're not on Truvada alone because…

JAY

11:42:51
No, no, no.

FAUCI

11:42:52
…if you're on Truvada alone, than you're in inadequate therapy. What else are you taking?

JAY

11:42:55
Ritonavir and…

FAUCI

11:42:58
Okay.

JAY

11:42:58
…Prezista.

FAUCI

11:43:00
All right. So I think we have to be careful of ascribing to Truvada toxicities and though, you're right, every drug has the potential, if not the reality, of toxicity. But we have to be careful about ascribing to one drug the side effects when you're on multiple drugs. It may be caused from that. That's fine. But generally from what we know that, as you know since you're on it, Truvada is made up of tenofovir and emtricitabine. Tenofovir is a drug that can lead to kidney toxicity. Emtricitabine in Truvada, you can also get some bone marrow suppression.

FAUCI

11:43:41
It's generally quite rare. And in the big picture of looking at the ability of this drug when given for prevention, to prevent infection, balanced against the rare event that you'd get kidney toxicity, a decision was made by the FDA in their approval that the potential benefit outweighs the toxicity.

REHM

11:44:02
I see.

FAUCI

11:44:03
But that doesn't eliminate the fact that with every time you have a drug there is a possibility…

REHM

11:44:10
Right.

FAUCI

11:44:10
…of there being toxicities.

REHM

11:44:12
Jay, thanks for your call. I hope you stay well. Dr. Fauci, talk about why the HIV rate is so much higher in the African-American community.

FAUCI

11:44:25
You know, Diane, it's a multi-faceted issue. And it has to do with a combination of things that range from lack of access, relatively speaking to other populations to healthcare, poverty, stigma is really big. When you look at -- I mean, the number are really very, very disturbing. Thirteen percent of the population in the United States is African-American and over 50 percent of the new infections in the United States are in African-Americans.

FAUCI

11:45:00
The majority of those -- more than that. I mean, a big majority is among men who have sex with men. And black men who have sex with men really have much more of an issue with stigma against them, even within their own community, than what we see generally with white men who have sex with men who have a community that's much more open, in general. I mean, you hate to give generalities, but this is what the reality is, in general, much more support among themselves, much more ability to openly talk about it and openly get counseling. That has to change.

FAUCI

11:45:35
And that's one of the things that's being discussed in great detail at the meeting, that we've gotta get into the community, get people tested, get them linked to care, kept in care if in fact they're infected, to be on therapy and to adhere to the therapy. But that needs community mobilization and that's what's finally being done, is community mobilization. There was a paper presented at the meeting that showed that among men who have sex with men the rate of new infection is much, much higher than white men who have sex with men. Yeah, I mean, there's…

REHM

11:46:10
Wow.

FAUCI

11:46:11
And it has to do with any of a number of things, including stigma, including poverty, including other sexually transmitted diseases, incarceration, things like that.

REHM

11:46:20
And, of course, then the ability of those men to infect female partners.

FAUCI

11:46:28
Exactly. And that is exactly -- if you look at the situation with black women, it's even more disturbing because they are even more vulnerable than anyone in the population because if you look at women, new infection, 60-plus percent of the new infections among women -- up to 70 percent are among black women. And this idea that black women are having more sexual partners than white women is absolutely nonsense. So it has to do an awful lot with where you are in an environment in which the virus is highly prevalent.

REHM

11:47:07
So what do you say to African-American women to try to help themselves to remain protected?

FAUCI

11:47:19
Yeah, I think what we need is that, first of all, you speak to the African-American women to assume a real proactive, community-supported demand for your rights, you know, as a woman, being able to protect yourself. And getting to the community, counseling and educating about what you can do to avoid infection. And it has to be done at the grassroots community level. It can't be top down for people who don't understand the community. There needs to be a lot of input from the religious leaders in the African-American community.

FAUCI

11:47:54
For a long time they haven't stepped up to the plate. Now they're doing much, much better, but there has been a time there where the stigma essentially immobilized them.

REHM

11:48:01
They just didn't wanna talk about it.

FAUCI

11:48:04
Exactly. And that's the worst thing.

REHM

11:48:06
All right. To Dallas, Texas. Good morning, Carol.

CAROL

11:48:10
Good morning.

REHM

11:48:12
Go right ahead, please.

CAROL

11:48:15
Yes. My call is concerning the questions that you were just discussing because I happened to see a show recently that was talking about poor people in the Deep South and how many problems they're having with not having enough doctors, not having any state support to speak of, compared to New York, Chicago, L.A. And I was just wondering what's being done to try to even that out.

FAUCI

11:48:43
Well, you're asking a very complicated, systemic problem of the disparity and the uneven distribution of availability of healthcare in various parts of our country. That's a problem that's difficult to solve, that needs to be addressed and there needs to be incentives for physicians. You know, you could have something resembling a domestic Peace Corp type thing where you get people to -- and there are groups that are actually doing that. It's not that it's a vacuum. There are groups that are doing that, but you obviously need to have incentives to get people to provide care in those rural settings.

REHM

11:49:23
You know, it's so interesting that the numbers of individuals going to medical school don't wanna be in general practice anymore. They don't want to go for a simple internist practice, but rather a specialty because that's going to help them pay their medical school debts. We've got to fix that system as well.

FAUCI

11:49:53
Right, right. Exactly.

REHM

11:49:54
So let's go now to Cleveland, Ohio. Good morning, Greg.

GREG

11:50:01
Good morning. How are you both doing?

REHM

11:50:03
Fine, thank you, sir.

FAUCI

11:50:04
Very well.

GREG

11:50:05
I had a question. It's somewhat off topic, but it had to do with -- I wanted to ask your specialist there what he feels about Leonard Horowitz's work and his book, "Emerging Viruses, AIDS and Ebola." He talks about that AIDS was a manmade disease that was a project between the CDC and the DOD back in the '60s, trying to -- they were making an immune-suppressing drug that they wanted to spread to other countries. And he details it with quite a bit of literature in that book. And I was wondering what the expert has to say about that.

FAUCI

11:50:51
Well, I haven't read the book, but I can tell you that if there's a claim that HIV is a manmade disease with a nefarious collaboration between the CDC and the DOD that's absolute utter nonsense. And I don't even wanna discuss that anymore.

REHM

11:51:08
All right. To Fenwick Island, Del. Hi there, Jerry.

JERRY

11:51:13
Hello. Thanks for taking my call.

REHM

11:51:15
Surely.

JERRY

11:51:17
My question relates to the vast amount of research effort and money that's gone into AIDS research and HIV research over the last 20 to 30 years. What has been significant collateral benefits, in terms of the understanding and treatment of other infectious diseases, allergic and immunological problems over the course of time? (unintelligible) arthritis or herpes problems, shingles, things of that nature. Has anything evolved or emerged from the research in HIV issues that might be promising for these other disorders?

FAUCI

11:51:55
That's really a great question. And the answer is a lot of spin-offs. And we spend time articulating this. I can give you a real rapid summary. We understand the human immune system because of this experiment of nature, as it were, of HIV and its devastating effect on the human immune system that has allowed us to really accrue some very difficult to accumulate, but now that you have a virus that destroys the body immune system, you learn and get much more insight into the intricate workings of the immune system.

FAUCI

11:52:30
And that's helpful to many of the diseases that you mentioned, immune-mediated diseases, the arthritis and a variety of other diseases. Also the effort that has gone into targeted drug development for anti-HIV drugs has been extremely helpful in the whole process of targeted drug development and drug design based on the structure of various vulnerable parts of the virus. So it's been good for infectious diseases in general and good for immune-mediated diseases.

REHM

11:53:01
And you're listening to "The Diane Rehm Show." Dr. Fauci, a great deal of money, time and effort has gone into trying to learn about study and deal with the HIV/AIDS infection. There is another looming crisis coming and that is Alzheimer's. With the aging population, with so many people affected by Alzheimer's and more to come is there going to be that kind of war on Alzheimer's that we have seen with the infectious disease of AIDS?

FAUCI

11:53:52
I think there should be certainly more resources in a time of constricted resources. This is a major problem. The difficulty right now with Alzheimer's is that although we're making progress it's still very much at the discovery phase of exactly what is going on there. So research works in predictable and unpredictable ways. If you make an observation and make a scientific breakthrough that could open up the doors to absolutely pouring a lot of money in, but…

REHM

11:54:30
But if we don't do it now, we're gonna be behind the ball.

FAUCI

11:54:32
I agree. Right. Diane, I am not at all and I would never presume to argue with you or disagree with you, that we absolutely need to do more with a disease as devastating and increasing right now in its incidence as Alzheimer's disease is.

REHM

11:54:53
And yet, what's happened is that you've had individual members of Congress getting behind the AIDS effort.

FAUCI

11:55:02
Right.

REHM

11:55:04
But no one has gotten behind the Alzheimer's effort.

FAUCI

11:55:07
That's not so. Actually there are congressional initiatives now that are percolating through the system.

REHM

11:55:12
Percolating?

FAUCI

11:55:12
Yeah, yeah, no. They're coming through the system and they are actually getting to the point of being incorporated into the budget of the NIH.

REHM

11:55:21
Is there any thought in your mind that Alzheimer's is in any way connected to a virus known or unknown?

FAUCI

11:55:35
There is no evidence to indicate that that's the case, but in science, you keep an absolutely open mind. And you don't rule anything out until you can absolutely prove the positive or find out something that rules out that this is the case. So it's still in the area of great discovery. You know, getting back to that issue with Congress, you know, there has been a bill passed that has been mandating that certain amount of money be spent on Alzheimer's, but more, in addition…

REHM

11:56:07
But it's a very small amount.

FAUCI

11:56:09
Right. Right. It's measured in tens of millions of dollars.

REHM

11:56:12
Right. Right.

FAUCI

11:56:13
Right.

REHM

11:56:13
And what's going to be needed? How much has been spent on AIDS? Can you estimate?

FAUCI

11:56:21
Yeah, I can tell you the number. Over 30 years it's been tens of billions of dollars. It's been about $50 billion since 1982. We spend about $3 billion a year on AIDS research at the NIH.

REHM

11:56:35
Well, let's hope that at some future time you and I can sit here and you will say, Diane, we found a way to cure AIDS and now we're going to move on and do some other things.

FAUCI

11:56:58
Indeed.

REHM

11:56:58
Fingers crossed.

FAUCI

11:56:59
Fingers crossed, Diane.

REHM

11:57:01
Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease. Thank you all for listening. I’m Diane Rehm.

ANNOUNCER

11:57:14
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