World AIDS Day: Q&A
On World AIDS Day 2011, we speak with Dr Martin S. Hirsch, MD, FIDSA to find out the latest news on the global fight against AIDS. Dr. Hirsch is editor-in-chief of The Journal of Infectious Diseases, professor of medicine at Harvard Medical School, professor of infectious diseases and immunology at the Harvard School of Public Health, and a physician at Massachusetts General Hospital. – Nicola
Q: Thirty years after the first reports of AIDS, why is HIV/AIDS research still important?
A: Although we have made enormous progress in developing effective combination antiretroviral therapies to control HIV infection, we have been far less successful in preventing infection. Thus, in the US, as well as in the rest of the world, there are more people living with HIV infection today than ever before; worldwide, this number is over 30 million. Many individuals who are infected do not know that they are and, thus, they continue to spread virus to contacts by sexual contact, needle sharing, or mother-to-child transmission. We are not near having an effective preventative HIV vaccine, nor is a cure for those already infected on the immediate horizon. The risk of emerging drug-resistant viruses is also always with us. For all these reasons and more, it is essential that research efforts continue until we can say that HIV has been eradicated or is no longer a public health problem in the world.
Q: What notable important discoveries or research findings have there been in the field recently?
A: In my view, the most notable research advances in the field recently have been in efforts to prevent new HIV infections by using treatment as prevention and pre-exposure prophylaxis. Studies published this year by Myron Cohen and colleagues have shown in placebo-controlled studies that by treating HIV-infected members of discordant couples (one infected, one not), new infections can be reduced by up to 96 percent. This emphasizes the need for early recognition of infections and early treatment. It has also been established that pre-exposure prophylaxis with antiretroviral drugs can reduce transmission in high-risk populations, whether they be heterosexual or men who have sex with men. Pre-exposure prophylactic regimens have taken the form of oral therapy or topical administration of vaginal microbicides. The challenge now is to find ways to implement these strategies worldwide to prevent new infections in cost-effective ways.
Q: What should the public take away from these findings?
A: The public should be aware that only by early recognition of infection can we reduce the scourge of continued HIV transmission and disease. The US Centers for Disease Control and Prevention and other organizations have indicated the need for more routine testing of all populations who enter medical care in the US, and gradually our states and other public health authorities are implementing these suggestions. Nevertheless, there are still thousands of individuals in the US and millions in the world who do not know they are infected and who continue to spread virus. The public should insist on more HIV testing with appropriate measures to protect confidentiality among those tested. It is also critical that efforts to make effective therapies available to those in need not be curtailed in these times of budget stringency. Cuts at this time would reap bitter harvests in years to come.
Q: What do you see as the priority areas for future HIV/AIDS research? Where will the next great advances be?
A: There are several priority areas for HIV research in the years ahead. These include:
- Continued efforts to develop safe and effective prophylactic vaccines. Despite lack of progress in this area to date, an effective vaccine against HIV is a real possibility, and would be the best way to eradicate this virus as a major health problem.
- Advancing research to identify viral reservoirs within the body and novel approaches to eradicate viruses within these reservoirs. Only one patient has been “cured” of this virus to date, but several novel approaches are being studied in an attempt to make a cure for others a reality in the years ahead.
- Many strategies for better control of HIV transmission have now been validated. The challenge is to effectively implement these strategies. Implementation research is needed, using experimental programs in different locales to see how we can implement preventive strategies in cost-effective ways among varied populations worldwide.
Q: During a recent speech at the National Institutes of Health, US Secretary of State Hillary Clinton called for the US and the world to make achieving an “AIDS-free generation” a goal, noting the scientific advances in treatment and prevention that have been made, including just this year. As we observe another World AIDS Day, can we now envision such a goal?
A: The goal of an “AIDS-free generation”, as suggested by Secretary Clinton, is a realistic goal if world leaders devote the funds and mobilize the strategies to make it happen. We have learned the importance of early recognition of infection, early therapy to prevent disease progression and HIV transmission, and the potential value of pre-exposure prophylaxis in high-risk populations. Research into potential cures and effective vaccines continues. With the proper will among our populations and leaders, we can turn this modern day scourge into a disease of historical interest, as we have done with other scourges such as smallpox in the past.