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U.S. Department of State

Diplomacy in Action

Making Progress in the Fight Against HIV/AIDS

FPC Briefing
Dr. Anthony S. Fauci
Director, National Institute of Allergy and Infectious Diseases at the National Institutes of Health
Michele Moloney-Kitts, Assistant United States Global AIDS Coordinator in the Office of the U.S. Global AIDS Coordinator (OGAC)
Foreign Press Center
Washington, DC
November 24, 2009


Date: 11/24/2009 Location: Washington DC Description: Dr. Anthony S. Fauci (left), Director, National Institute of Allergy and Infectious Diseases at the National Institutes of Health and Michele Moloney-Kitts, Assistant United States Global AIDS Coordinator in the Office of the U.S. Global AIDS Coordinator (OGAC)brief on Making Progress in the Fight Against HIV/AIDS at the Washington Foreign Press Center on November 24, 2009.  © State Dept Image

Video

2:00 P.M. EST

MODERATOR: Good afternoon and welcome to the Washington Foreign Press Center. Today, we have with you Dr. Anthony Fauci, Director of the National Institutes of Allergy and Infectious Diseases at the National Institutes of Health; and Ms. Michele Moloney-Kitts, the Assistant Director of the Global AIDS Coordinator’s Office. Thank you. Without further ado, Dr. Fauci will begin, and then Ms. Moloney-Kitts will make her presentation and then we’ll open it up to question and answer.

Dr. Fauci.

DR. FAUCI: Okay. Thank you very much. It’s a real pleasure to be here with you this afternoon. I’m going to talk to you just for a few minutes about a quick update, as you see on this first slide, of the HIV/AIDS progress and priorities, just to give a bit of a summary of where we’ve been and where we are now and where we hope to be.

As many of you know, just today, the new numbers from UNAIDS were released, which, when you think in terms of the epidemiology and the numbers, they are really not significantly different – in fact, not different at all from what you’ve seen in the previous announcement from them last year, with 33 million people living with HIV, 2.7 million new infections in 2008, and 2 million deaths, which is essentially what we have seen over the past year.

Here in the United States, we still have an ongoing epidemic that tends, unfortunately, to slip off the radar screen because it has been relatively stable at a level that is not a very good level to stabilize with, which – over a half a million deaths and 1.1 million people living with HIV in the United States, about 20 percent of whom do not know that they are infected, which is a real problem with prevention, because about 65 percent of the new infections that are transmitted occur from an individual who does not know they’re infected to an uninfected individual. So that really is an important issue about more widespread testing to determine, in fact, who is infected, and if they are, to get them into therapy as well as to counsel them how to avoid infecting others, and if they’re not infected, to help them to understand how they may best prevent themselves from getting infected.

This really all fits into something that some of you may have heard of. Just this past summer, President Obama called for a comprehensive global health strategy, and at the forefront of that global health strategy was building on the strong efforts of previous administrations to carry forward the fight against not only HIV/AIDS, but also malaria and tuberculosis. You’re all aware of the highly successful PEPFAR program that you’ll hear more about, in which now, millions of people have gotten under therapy in the developing world that would not have otherwise had the opportunity to have therapy. And together with the Global Fund, another philanthropic organization, has really begun to transform a bit, at least into the developing world, the face of HIV.

This is a picture of President Obama visiting the NIH, and I show it to you – he came actually to give a talk a bit on ARRA funding, which is the American Recovery and Reinvestment Act. But he took the opportunity to express his strong support – and that’s him on the left-hand panel talking to me with my back to you and to Francis Collins, the new director of NIH – talking a bit about the AIDS research program at NIH, but more importantly, to talk about the things that we’re talking about here today, is the scope of the global AIDS problem and how we’ve been progressing over the years.

One other important issue that has arisen most recently, just literally a week or two ago, was the official lifting of the HIV travel ban, which has been a source of considerable embarrassment to us here in the United States, where individuals who were HIV-infected had almost a don’t ask, don’t tell type of a situation where there were restrictions on their travel. And because of that, the international AIDS meetings for the last – more than 15 years has not been held here in the United States because of that. So we’re through with that and we’re all very pleased that that’s the case.

With regard to what’s happened, and I titled my first slide “Progress and Priorities,” the investment in HIV research from a number of standpoints, particularly the National Institutes of Health, over the last 28 years since the beginning and understanding that we’re dealing with a new syndrome, the summer of 1981, has really been nothing short of remarkable with $42 billion having been spent on HIV research. And about 11 percent of the entire NIH’s annual budget is devoted to research on AIDS. When you consider all of the problems with cancer and heart disease and mental health and diabetes and obesity and things like that, to have 11 percent of the entire NIH research budget be spent on HIV/AIDS is, I think, remarkable.

The advances have been extraordinary. These are just some of the important advances that have been related to the extraordinary investment in HIV research, one of which, since we’re very limited on time, I just want to point out to you is in the arena of treatment. I think we can say without any exaggeration that with no other disease in history has the investment in therapy led to such striking advances in really transforming the lives of infected individuals.

There are more than 30 approved drugs approved by the U.S. Food and Drug Administration, including drugs in combination that have now gone from a situation where individuals who were infected with HIV – the first patients that I took care of at the NIH in the summer of 1981 – if a patient walked into my clinic with advanced disease, which was the only ones that walked into the clinic because we didn’t know it was HIV at the time – the median survival of those individuals was 26 weeks. Right now, if a person walks into the clinic and is a 20-year-old who is HIV-infected and I start them on therapy, mathematically modeling, you could predict that that person will live to at least 69 years old, which I think if you look in the annals of therapeutic advances and triumphs, that’s about as good as you could ever see anywhere.

This is a Lancet article that actually details that mathematical modeling showing what the life expectancy for HIV-infected individuals are at this time. With the association of major efforts on the part of the developed world to get drugs to people in the developing world, including PEPFAR, the Global Fund, and the philanthropic organizations, we now have about 4 million people in low- and middle-income countries on antiretroviral therapy. When I went to Africa – on my many trips, but the time I went in 2002, when President Bush sent me there to scope out what the framework of what would become the PEPFAR program was, there were about 50,000 people on therapy in Sub-Saharan Africa, all of whom could likely afford it, so they were the wealthy who were getting it – now, we have millions of people in that area of the world who are on therapy.

It is estimated now that there have been about 1.2 million lives saved over a three-year period from 2004 to 2007 with that program. That’s the good news. The sobering news is that only about 40 percent of individuals who could qualify to be on therapy by the current standards are actually receiving therapy. And you all know that for every person that we put on therapy, 2.5 people get infected, which means that if you do a numbers – simple arithmetic gain, we really are not going to be catching up with treating all the people who need to be treated, particularly with the new guidelines that will be coming out, or have come out, that the cutoff point for treating people now is not less than 350, but between 350 and 500, which means that if you go by standard Western guidelines, a lot more people should be on therapy, which is going to be a great challenge from a resource standpoint.

Finally, in prevention, there are a number of proven prevention strategies that we know work. They’re listed on that slide. Everything from counseling and media campaigns to distribution of condoms, needle exchange programs, circumcision, prevention of mother-to-child transmission. Again, that’s the good news. The sobering news is that globally, less than 20 percent of people who would benefit from prevention modalities actually have access to them. There are some strategies that are now in the testing stage. I’ve called them pipeline strategies – things like topical microbicides, things like pre-exposure prophylaxis, and a very bold approach which is being tested, which is really bold. It is going to be a very difficult situation to implement that, but if you can, it would be most extraordinary, and that’s the “Test and Treat.”

I know you’re all familiar with pre-exposure prophylaxis, namely treating high-risk people before they become infected. Conceptually, that sounds like something to do and it likely will work. It works for malaria; it works for trying to prevent people who are exposed to meningococcal meningitis. The problem is to treat people who are at risk at a time when you haven’t gotten to everybody who is actually infected, again is going to be a resource challenge.

Also, this “Test and Treat” concept that I’m sure you’re familiar with, WHO came out with a model that said that if you treated in a model country like Uganda – if you tested everyone or 95 percent of the people in the country once a year and treated everybody who was infected regardless of their CD4 count, that you could get the level of virus in the community low enough that you could actually have a downturn and even elimination of HIV. Personally, I don’t think that is going to be feasible for the elimination of HIV, but I do think that if it’s implemented well, that it could definitely decrease the incidence of HIV, and together, with even a modestly effective vaccine as well as topical microbicides and circumcision, that it would have a major impact.

We at the NIH are doing a number of research studies to test the feasibility, so I don’t want anybody to walk away and think that there will be a policy of “Test and Treat.” There won’t be. There will be feasibility studies to determine if a “Test and Treat” policy would be able to be implemented, and there’s a lot of confusion sometimes on that, and whether or not we’re going to implement it. You can’t implement it unless you have some scientific reason to think that it’s going to work.

And then finally on vaccines, it has been a very, very dry spell in HIV vaccines. The first glimmer of hope came just a – several months ago when a trial that was sponsored by the Department of Defense, the NIH, and the Government of Thailand announced the results of a 16,000-patient – person trial in Thailand, in which there was the earliest glimmer of some efficacy. It was very slight. It’s not a vaccine that’s ready for prime time. There was a 31 percent protection over the first couple of years. The interesting issue is it’s the first time we’ve ever, ever had a positive signal on any vaccine. So again, to avoid confusion, it’s not a vaccine that you would want to use, but it’s a vaccine that, in fact, shows for the first time that it’s at least feasible to protect people. So the job right now is to build on those data and to try and develop a better vaccine.

And the way forward following the Thai trial is to determine exactly what those immune mechanisms were that caused this good effect to devise methods to optimize it and to base it on the knowledge of that, how we can make better candidates for the future. So even if we do get a vaccine, it’s not going to be freestanding like a polio vaccine or a smallpox vaccine – and again, that’s what some people sometimes misinterpret – that if we get a vaccine that’s 50, 60, 70 percent effective, it’s still going to have to be implemented as part of a comprehensive HIV prevention strategy.

So I can say in summary, although we’ve accomplished an extraordinary amount over the last several years, and particularly even over the past year, if one really measures the challenges ahead, we can say that there is much, much more to do despite the fact that we’ve accomplished an awful lot. Thank you.

MS. MOLONEY-KITTS: Thank you very much. And basically, I have a presentation as well, and I believe you all have hard copies of it, and I’m going to go through it fairly rapidly. And I probably won’t go through each of the slides, but it’s there for your reference. And I think that Dr. Fauci did an excellent job of kind of setting the stage of what are the key issues that we’re dealing with in PEPFAR.

And of course, I think as most of you know, in 2003, the U.S. Government launched the President’s Emergency Plan for AIDS Relief that we know as PEPFAR, which was a five-year strategy intended to fight AIDS. And based on the success of the program, this program was hugely successful in 2008. It was reauthorized under the Tom Lantos and Henry Hyde United States Global Leadership Act Against HIV/AIDS, Tuberculosis, and Malaria. And so that has basically reauthorized PEPFAR for the next five years. And just so that you know, to date, the U.S. Government has provided about $25 billion in the fight against AIDS.

And annually, our investments every year do increase, although in the future – and they are probably going to increase more modestly than they have in the past – but last year, we were at about $6.6 billion, and this year, the President’s request is at 6.7. And it’s very important to note that the U.S. greatly exceeds any other donor by a long shot in the fight against AIDS, and that would be not only in terms of our bilateral programs, which are PEPFAR, but we’re also one of the first – and largest donor, by far – to the Global Fund for the fight against AIDS, TB and malaria.

So I think that certainly, the resource commitments show the commitment of the U.S. Government, and then, as Dr. Fauci noted, President Obama launched the Global Health Initiative in May of this year. It’s a $63 billion program over the next six years. And it maintains its focus on AIDS, TB and malaria, but also looks at other very critical issues that face the health of women and children around the world, in particular maternal mortality and child mortality, also something called neglected tropical diseases, and aims to hopefully eliminate those. This initiative also looks at better integration of programs. I think you may have heard some reference to PEPFAR as a very vertical approach to AIDS, and how do we integrate better on the ground and look for more sustainable approaches in terms of investments and partnerships with governments, as well in terms of looking at health systems and health systems strengthening.

I have a number of slides for you on PEPFAR results. I think that what you hear from UNAIDS today on the results to date, as well as other presentations and what has been mentioned previously kind of gets to that. I would suggest that you stay tuned for December 1st, when we’ll be releasing our most recent data, the data that we’ve provided for you today. It’s data that comes from last year.

So I would like to highlight in this presentation, however, a couple of the challenges that we face going forward. And as we look at the epidemic now and our investments now, what are some of the things that we think are really, really important, and under the Obama Administration, will really get some increased attention. And I think central to these is gender and women being at the center of a health agenda.

As I think you can know by the data, HIV is definitely a disease that disproportionately affects women, and the reasons why are because women have less power certainly in their sexual lives, often in family decision making, often in terms of political influence, legal protection. They certainly have more limited access to HIV/AIDS information and services. And when I spoke earlier about the linkages under the global health initiative with maternal health in family planning, those are all also barriers to care that women often seek. So they just basically have more limited ability to respond to the epidemic.

So PEPFAR has been working in gender for the last five years, but we’ll increase our focus going forward. We basically have five strategies that we’re interested in and that we focus on. The first is just increasing gender equity in HIV/AIDS activities and services. The second is looking at reducing violence and coercion. The third is addressing male norms and behaviors. Women are in a world of men, and so we have to influence men as we move forward. Increasing women’s legal rights and protections, and increasing women’s access to income and productive resources. So these are something that I think that you can look forward to in the future.

The other areas that we’re really wanting to focus more on in the next phase of PEPFAR relate to sustainability, and critical to sustainability for us is that countries and governments really own their epidemic and own the response – what do we need to do to help change things in the long term. So you will see that there’s more focus on systems – to help strengthen health systems. We know one of the key barriers to services and care in the developing world is the lack of human resources, doctors, nurses, community healthcare workers, midwives, laboratorians, pharmacists, professors at medical schools – one could go on and on. And so these are some of the things that we’ll be looking at, as well as looking at systems; systems to get commodities to the end of – a person who may be in a remote rural location, or systems to get information flowing back and forth.

So as we move forward, some of the challenges that we face: one is to make sure that we are able to ensure that services are sustained and remain available for the lifetime of our patients, because as you know, once you start HIV treatment, you need to do it for life. We need to make sure that the U.S. Government investments are making the biggest possible impact. And I was – the prevention slides I think that we saw earlier were really excellent, because clearly, prevention has to be a priority. We can’t continue to have more new infections than we’re able to put people on treatments.

We need to really collaborate with other donors, and in particular, the Global Fund, to make sure that we are really maximizing efficiencies across programs. We are strong believers in using national strategies against HIV/AIDS as a really good basis and starting point for coordinating efforts. We need to make sure that we maintain high quality of care. This is a very important service delivery program. And it’s very, very important that we have high quality adherence. ARV drugs is a good example of something that we need to make sure is continued.

So those are basically some of the key challenges that we face as we move forward. It’s – as I don’t think I could say it better than Dr. Fauci, we’ve accomplished a great deal. But obviously, we have a whole lot more to do. And we look forward to partnering with our country governments and NGOs and civil society as we move forward. So, thank you.

MODERATOR: Hi. We’ll open the floor now to questions. Please, before you ask your question, wait for the mike, make sure that you give us your name, the name of your organization, and to whom your question addresses to.

Yes, please.

QUESTION: Antoineta Cadiz from La Opinion newspaper, and – to Dr. Fauci, and I have two questions, actually. The first one is: Do you have any kind of program that target specifically Hispanics on AIDS here in the U.S.? And is there any kind of problem that you have faced with this group in particular in terms of the information they got about AIDS, the way they are treated, et cetera? And I have another question.

DR. FAUCI: Let me answer the first one, first --

QUESTION: Okay.

DR. FAUCI: -- so I – just so I won’t forget what you are saying.

The work that we do at the – I’ll talk beyond NIH and also CDC. So if you look at what the NIH does, we do research such as in clinical trials, and we have tried in our clinical trials to get an accrual of patients that represent the relative proportion of people in the community who are afflicted. For example, right now if you look at new infections, African Americans comprise more than 45 percent, even though they only comprise about 12 percent of the population. Hispanics in this country comprise about 13 percent of the population, but they account for about 19 percent of the infections. So we try to bring them in to see if there’s anything special about getting them on trials, et cetera, et cetera.

In the National Institute of Mental Health, they’re also trying to understand what some of the cultural and other barriers are in getting people to come forward to be tested, as well as to be counseled, because there are a number of cultural constraints that are in African Americans and Hispanics, particularly the idea about being gay, and men who have sex with men, which is a major problem in getting people to openly discuss that back and forth.

The CDC has similar programs in which they are trying to determine what some of the cultural barriers are into getting people on the treatment and prevention programs. We have not found anything different, except a much stronger stigma associated with certain behaviors such as homosexuality in the Hispanic and the African American population.

QUESTION: I will follow up my --

MODERATOR: (Inaudible.)

DR. FAUCI: Okay.

QUESTION: Okay. Yes. Hello, sir. My name is Paula Vilen and I’m with the Finnish Broadcasting Company. I have a question about a different virus, H1N1, if I may. Do you think, sir, has the epidemic already peaked here in the U.S.? And secondly, how worried you are about the mutations of that virus? Thank you, sir.

DR. FAUCI: Okay, so first of all, the – if you look at the pandemic in the United States, we estimate about 22 million people have been infected. If you follow the weekly numbers of projected cases, there’s – the last two weeks that has – there were 46 – 48 states that had widespread, then 46, and now there’s 43. So, one could make a guess that perhaps we have reached the peak and are coming down.

Having said that, we have to be extraordinarily careful when we make predictions with influenza, because influenza is notoriously unpredictable. So there are three possibilities that could happen. It could go up, start to come down, and then level off and have a lot more infections. It could go up, go down, and that’s it for the season, which would be the best possible scenario. I hope that’s the case, but I’m not sure. Or it could go up, down and then have a second wave as we get into the middle of the winter, namely December, January and February. So if you look at the numbers, strictly speaking, it looks like it might be, but we have to be careful about conclusions.

Second question: Am I worried about mutations? Well, that’s my job is to worry about mutations. So the one thing that’s good news is that this virus has been around at least since April. It’s traveled all around the world in every hemisphere, and we are now in the middle of our flu season with a pandemic raging, and there have been no significant mutations that would indicate that the virus is veering away from the vaccine. It’s still a perfect match. There is some drug resistance, but very, very little, and it doesn’t appear to be more virulent. So although anything can happen with influenza, thus far, it doesn’t indicate that there’s enough mutations to make you worry about it, even though you worry that it might happen.

QUESTION: Thank you. Marcel Calfat with the Canadian Broadcasting Corporation. How would you describe the HIV/AIDS situation in D.C., and how would you explain it?

DR. FAUCI: Well, this description has been well put out in a recent publication from the District of Columbia. It’s the worst location in the country. Three percent of the entire population is infected; 6.5 percent of African American males are infected. So if the District of Columbia were an African nation, it would have about 20 nations ahead of it in prevalence of infection, so it’s a very bad situation.

How you explain it, it relates to a number of things. This is a city of 600,000 people, 64 percent of whom are African American. In the African American community, we’re seeing, for a variety of reasons, related even somewhat to your question, that there’s a highly disproportionate number of infections among African Americans. If you look at men who are infected newly in the United States, there are – 45 percent of all the infections in men are among African Americans, and African Americans comprise 12 percent of the population. Astoundingly, of the infections in women in the United States, 60 percent of them are among African American women.

So when you have a predominantly African American population in which there is a reluctance particularly among gay men – people make the misinterpretation that this is all injection drug use. It’s not. The main risk group in the District are African American men who have sex with men. And culturally, it is much more difficult for them to be accepted in society, so they tend to more lead double lives, where they’re – in the weekdays, they’re heterosexual, and then on the weekends, they’ll go to various clubs where they have a lot of exposure, similar to the way it was in San Francisco and in New York with white, gay men in the early part of the epidemic. So we have a really serious problem that we have to address, and it’s a lot of cultural and other economic, poor access to healthcare and things like that.

QUESTION: A follow-up, if I may? Then are there special outreach programs specifically focused on African Americans in D.C.?

DR. FAUCI: Yeah. There have been few in the past. Right now, with the new leadership of the Department of Health in the District of Columbia, Dr. Shannon Hader, and others that are making a very strong attempt for outreach, we’re engaging in a collaborative effort with the NIH, the CDC and the District of Columbia Department of Health to outreach people to access them to get treated. And we’re aiming it at two specific populations. It’s called the Brothers program that goes after African American men, and then there’s a program that is also trying to access African American women to specifically try and outreach to them to get tested; if they’re infected, to put them on therapy; and if they’re not, to counsel them how to avoid it.

QUESTION: My name is James Butty, Voice of America, Daybreak Africa program. I know that Miss Moloney-Kitts had said that there will be new information coming out on December 1st, the latest statistics. But if you don’t mind, give us a little teaser in terms of what’s the progress with – what’s the progress for Africa in terms of infection and treatment? And the question I have is that I don’t know if – how you can clarify that. We hear that in some African countries, the risk of infection has been going down. And to what degree have these restrictions, PEPFAR restrictions that say that maybe countries that are receiving PEPFAR money cannot do abortion – to what degree – is that having any impact in terms of the progress that is being made by some countries in terms of reducing?

And the second thing – the question is: Is there a reconciliation between the Obama Administration plan and the Bush Administration plan, or are we going with the same program? I hope that the second question – is it clear?

MS. MOLONEY-KITTS: Yeah, it’s very clear.

QUESTION: Thank you.

MS. MOLONEY-KITTS: That was actually about three questions. So I –

QUESTION: Four.

MS. MOLONEY-KITTS: Four, four. I might drop one, so you can remind me if I forget.

So on the first question about a teaser, I can’t give you a teaser, but I can encourage you to look at the UNAIDS data that was released today and is on their website, because I think in fact – although overall, globally the numbers have not shown a great deal of progress – I think that there are places where we are seeing improvements. Certainly coverage relative to prevention to mother-to-child transmission, there were some increases between last year and this year, which I think shows some promise. And indeed, if you don’t look year to year, but you look at the long-term lens in terms of when the first trip to Africa was when there was less than 50,000 people on treatment, and today we think that there are many, many more. it’s hugely – so that’s very important. So one of the key messages I think that comes out of all of this is that we can do this. It’s totally possible. We just need kind of resource assistance and will.

The second question about prevention – first of all, I want to just be perfectly clear about something: The U.S. Government has never and will never fund abortions. It is not part of our prevention policy. It is not part of our Development Assistance Program. It’s not part of our family planning program. We just don’t do that. It’s against the law. And I cannot think of one example ever where we have.

So prevention efforts and what our success in prevention have to do with is, yes, indeed – and again, looking at the UNAIDS report, and I think if you look at certain countries that have national level surveys, we’re actually starting to see some promising signs in some countries. We also know that there are some effective interventions that are coming on-stream, a big one being male circumcision. The research was just released showing that as really having significant prevention benefits, so – but because it’s a major service delivery effort, it takes a while to get people trained and to get the services available. Certainly, that is now kind of going to scale in a couple of places. PMTCT is a big area of focus, and I think we’re looking at lot at what we’re calling combination prevention, where you actually look at – first of all, you have to understand your community. There are countries where – and there are even cities, just as we learned about in Washington, D.C., where you basically have sub-epidemics. So you have to figure out where are your new infections and then what are the best interventions to target them.

Then I think the last question is what is the change between the two presidents, but actually, it’s a little bit different than that because we had PEPFAR 1 which was authorized, and then we have reauthorization. And I tried to describe some of them. Certainly, the Obama Administration has demonstrated the same level of commitment to fighting the HIV/AIDS epidemic as was done under the Bush Administration. I think some of the things that you’re seeing that will be a little bit different is that we’re looking for a more integrated approach wherever possible. We’re looking for greater country ownership. We’re looking for more sustainable with some investments in health-system strengthening. And I would just add that I think this is not a question of presidents, but we are in an era of greater economic constraints, and that will figure into any of our foreign assistance or development programs, although certainly the Obama Administration has really emphasized repeatedly how committed they are to a robust foreign assistance program.

QUESTION: Thank you. My name is Andrei Sitov. I’m with Tass, the Russian news agency. Thank you for coming over and doing this, and thanks to the FPC for arranging the meeting. I wanted to ask about vaccines. We – I guess we’re all interested in the news from Thailand earlier this year. From what you just said, I gather that the news was scientifically valid, that the research they did was scientifically valid. Is that correct?

DR. FAUCI: Yes.

QUESTION: Then it probably wasn’t for you as an expert in this, it was somewhat expected for people on the outside like myself to have that sort of news to come out of a country that’s basically considered to be like a third world country. So if you were to look at the prospects for developing an AIDS vaccine, give us a guess – what’s the most likely source of a breakthrough?

DR. FAUCI: When you say source of a breakthrough, you mean what scientific --

QUESTION: Yes.

DR. FAUCI: Yeah. I don’t – I think pretty strongly as a scientist that we will not get an AIDS vaccine that has a substantial impact – and substantial is clearly more than 31 percent, which as I mentioned and repeated several times, it’s a start in the right direction, but it’s not the endgame. We need to be able to induce neutralizing antibody against a broad range of isolates that you see in the wild type. Right now, for reasons that we don’t understand, and it’s very frustrating, the HIV virus as it’s presented to the body doesn’t not induce broadly reacting neutralizing antibodies. And one of the tenets of vaccinology is if you can imitate natural infection with a vaccine, you will have a great vaccine. The one thing you don’t want to do with HIV is imitate natural infection, because the body does not make a very good immune response against HIV.

So what scientists are trying to do is to develop and identify various molecular configurations on the virus that we know rarely induce a neutralizing antibody, and present that in a form – and you do that by getting the crystallographic structure, putting it together with what we call scaffolding to show it to the body in a certain way – to induce an immune response that would preferentially make a neutralizing antibody. When that occurs, that’s going to be the breakthrough.

QUESTION: What are you – thank you, sir, for the scientific answer. I hope I can make use of it. But I meant it in much simpler terms. Where in the world would – the U.S. is probably one such place because you have mentioned that you have spent more than anybody else on research.

DR. FAUCI: Yeah.

QUESTION: What other potential partners do you see around the world for this sort of a breakthrough?

DR. FAUCI: Well, we see any partner that would like to partner with us. See, I believe that a vaccine – and I hate to make life complicated for you, but guess what, life is complicated. And the issue is that I think a vaccine is going to be variably effective or not, depending on the risk. I think low to modest risk heterosexual transmission has a much greater chance of getting a vaccine that could prevent that than a vaccine that could prevent injection drug use transmission or a vaccine that could prevent transmission among men who have sex with men. The Thai trial – interesting – was in low risk heterosexual individuals. So we’re going to have to do trials in countries in which the infection rate is low enough so that it isn’t going to overwhelm the vaccine, but high enough to give you a statistically significant figure.

The reason why we’re not able numerically or statistically right now – I wouldn’t say not able, but it would be difficult to do a trial in the United States – is that the transmissibility by heterosexual contact in the United States is so low that you would need tens of thousands of people to get a statistically valid trial. That’s the reason why we did it in Thailand, because we did it among heterosexuals, but the rate of infection was high enough to allow you to get a statistically valid answer.

QUESTION: Thank you. And then lastly, the Russians and their neighbors recently held a regional conference on AIDS and fighting AIDS. I was wondering if you took part in that, and if so, what was your opinion about the prospects for the region. Thank you.

DR. FAUCI: I think the prospects for the region are going to be good if we collaborate and cooperate. I was not there. I was, at the time, knee deep in H1N1, so I couldn’t go there.

QUESTION: (Off-mike.)

DR. FAUCI: Yeah. No – well, yeah, our people went there, and we do think that there are very good opportunities to collaborate with our Russian colleagues.

QUESTION: Thank you so much. Georgian Broadcasting, so – Georgian TV company Imedi. I want to continue the theme of H1N1. It’s good that it’s come down, as you predict, but is it enough vaccine in system? That’s my question, because it was some kind of panic about it. The question to both of you if you have any information.

DR. FAUCI: Well, there certainly is a gap between the supply and the demand in the United States. The gap was very large early in the fall in the end of September, the beginning of October. As the weeks go by, the gap is getting less and less. One of the problems with vaccines is that we still make influenza vaccine, through no choice or fault of anybody, in a very antiquated, time-honored, but nonetheless fragile way of growing it in eggs, harvesting it, and activating it and purifying it. Unfortunately, every once in a while, the virus doesn’t grow very well in eggs. That’s exactly what’s happening now, and that’s the reason why we have this gap between supply and demand. We had hoped that we would have many more doses of vaccine than we have now. That’s the bad news.

The good news is that as the weeks go by, that gap is getting smaller and smaller. For example, we had 11 million doses available in October. There are now over 50 million doses in the United States available. Still not at the level that we had hoped it would be, but it’s much better than it was.

QUESTION: Thank you. I’m Katherine – Katherine Carboo of the Embassy of Ghana, head of information, and I’m also reporting for the Ghana Official Portal. I just want to find out based on laboratory report – laboratory research that I did, it states that Ghana has – between the ages of 14 – sorry, 15 to 49, 3 to 4 percent with HIV/AIDS, meaning it has decreased from what it used to be. But unfortunately for us, right beyond our border on the eastern part of Ghana – that is, Togo – their prevalence is rising. I just want to know how closely you are working with the various countries who have already set up bodies that handle HIV/AIDS. I know Ghana AIDS Commission is doing a very good work, and the main problem presently is the influx, because they do trading, they do – I mean, across the board, that there is a whole lot of interaction and there is a likelihood that it will affect the prevalence in Ghana as well. That’s number one.

Number two, we know that genital herpes is also on the increase. I am wondering what your organization is doing to have that one (inaudible) as well. Thank you.

MS. MOLONEY-KITTS: I’ll start with the Ghana questions and some of the relationship, but maybe if you want to speak more on the herpes front.

So on Ghana, yes, we have a very robust collaboration with the Government of Ghana and many NGOs for the fight against AIDS there. And in particular, we’re working very closely on HIV prevention. And I don’t – I’m not that familiar specifically with Ghana, but I do know that prevention is quite central to our assistance and support, and it seems as though these prevention efforts are really making headway.

The issue of Togo – the U.S. Government does not directly support programs in Togo through our bilateral funds, but Togo recently received a global fund grant for HIV and AIDS, which will help them in their fight and help the financing of this.

But I think central to your question really is how do we work with high-risk groups and who are those high-risk groups in any one setting. And often, we find that people who move a lot, either across a border or have to move for their work or various reasons are often people who, for one reason or another, may be more vulnerable to HIV, who may transmit the epidemic. So it’s very important that we work with communities and associations. For example, in many countries we work with truck driver associations in order to help truckers with prevention. Often, we have a lot of programs right at borders so that we can help with the borders in terms of prevention.

One thing that we found actually quite interesting that was very successful was that if you can work with customs officials on a border to reduce the amount of time that it takes for people to cross a border, that actually can also be quite helpful in HIV prevention because they’re not spending all their time there waiting around with nothing to do, so they have a few drinks and they go to the local bar, and then before you know it. So there’s multiple strategies and approaches.

In PEPFAR – just quickly on the herpes front – we do support the identification, diagnosis, and treatment of sexually transmitted diseases, because we think it is important as a part of a prevention strategy overall, but – do you want to --

DR. FAUCI: Yeah. And we have research programs looking at the effect of treatment of underlying sexually transmitted diseases and its impact on the transmission. Any ulcerative genital disease, particularly herpes, is the major co-factor in transmission – major. So it’s probably the most important one of all of them.

MODERATOR: We have time for one last question.

QUESTION: This time around, I will keep count.

MODERATOR: One.

QUESTION: (Laughter.) Ms. – that’s what I said, I’ll keep count.

Ms. Moloney-Kitts, you mentioned that one of the new strategies for the Obama Administration more country – countries and governments should own what – their sustainability. Could you explain what that means?

MS. MOLONEY-KITTS: Yeah, I appreciate the question. It can be very jargony often in how we speak. But I think a very good example is – let’s just take financing, which is not the case in every country, but in some countries what we’re worried about is that if donors come in with a lot of financing, then maybe a government will end up shifting their resources to another area because, in fact, they won’t need to finance that part of their program because we’re financing it. What we would like to do is to work much more closely with governments, for example, to understand the overall financing situation to see if there are ways that they can look for financing in the future.

Another good example is in policy reform. Let’s take prevention to mother-to-child transmission. The U.S. Government and the Global Fund and all the donors can fund a lot of programs, but if the government doesn’t want to have a policy that requires in high-prevalence settings that women would need to opt out of HIV testing or that they would have rapid testing available with results on the same day, those are things that the government controls that as donors we can’t control.

So we really need this partnership moving forward to make sure that in some places five years from now, in some places ten years from now, in some places thirty years from now, in fact, countries and governments are well able to manage their own healthcare systems with their own resources and taking care of their own people. So that’s kind of the lens that we’re trying to look to the future.

MODERATOR: Thank you very much.

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