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AIDS: The tipping point

A Q&A with Anthony Fauci about the past, present and future of global AIDS.

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National Institute of Allergy and Infectious Diseases (NIAID) Director Anthony Fauci speaks during an event for World AIDS day. (Alex Wong/Getty Images)

Anthony S. Fauci, MD, has been on the frontlines of the scientific fight against HIV/AIDS since the disease was first identified three decades ago. He is arguably the U.S. government’s best-known scientist, testifying before Congress on more than 200 occasions and interacting with every U.S. president since Ronald Reagan. He was appointed Director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health (NIH) in 1984, and oversees an extensive research portfolio of basic and applied research to prevent, diagnose, and treat infectious diseases such as HIV/AIDS and other sexually transmitted infections, influenza, tuberculosis, malaria and illness from potential agents of bioterrorism.

John Donnelly interviewed Dr. Fauci on his perspective of the fight against AIDS at this moment, and how discoveries by scientists can now be best used.

What are the biggest opportunities from research on HIV/AIDS that are could be better utilized? What should be happening that isn’t?

I think that can be best explained with what has gone over in the last year and a half regarding the scientific validation of the efficacy of certain interventions in the realm of prevention. These studies have really redefined the concept of scientifically based combination prevention modalities.

There is a realization that there is not one size that fits all, nor is it that one modality in and of itself is going to have a major impact in terms of preventing the spread of HIV. One that has captured the attention and the excitement of people most recently is the issue of treatment as not only good for the individual in a life saving manner, but also treatment as assuming a role in the prevention tool kit. A recent study in a clinical trial found that you could remarkably decrease the likelihood that an individual will transmit the infection to their uninfected sexual partner. 

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A second study, following up observations made in studies years ago, that stands out very boldly among others is the benefits of medically supervised adult male circumcision, which in three randomized studies showed there was a 50-plus percent protection against acquisition of HIV in men who underwent an adult male circumcision. The good news that becomes better news about that is the results get even better over time. In one of the settings, in the Rikai District of Uganda, the effectiveness in the community now is over 60 percent for approximately four years. 

Then you have the conceptual breakthrough that with topical microbicides, particularly if used consistently, you can also have a major impact on prevention. Those results will likely get better as we get better adherence. There’s the issue of pre exposure prophylaxis both in gay men and in heterosexuals. 

Put together, what is the impact from all these developments?

All of a sudden we have a convergence of prevention approaches, which includes treatment as prevention, and that really validates the concept of combination prevention. There is now an enthusiasm and an excitement if we can implement some of these scientific advances, we can have a major impact in turning around the trajectory of the epidemic. The bottom line is we are pushing these advances in implementation so that we see the light at the end of the tunnel. 

When we can get the incidence of HIV down enough to turn the trajectory of the pandemic, it will assume a momentum of its own in diminishing HIV. That’s because the fewer people who are transmitting infection and the more people who are trying to protect themselves from infection – those are the two arms of the problem – that diminishes the pool of people capable of infecting the other people. 

What kind of operational research – the real-life testing that follows clinical studies – are you following closely now?

There are some studies in the U.S. to find out is it really feasible in a high-risk population to go out to test people, link them to care, get them on treatment, and have them continue to take their medications. 

One of these studies is in Washington, D.C.?

Yes, Washington and the South Bronx are among a handful of cities that are being looked at as to what tools you’ll need to access high-risk populations. Clearly, in this country, African-American