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The XVII International AIDS Conference (AIDS 2008)
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XVII International AIDS Conference Mexico City Notebook: Day Two

An Interview With Science Magazine Correspondent Jon Cohen

August 4, 2008

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Jackie Judd: Jon Cohen from Science magazine, welcome. First full day of the conference -- what stands out?

Jon Cohen: I think the thing that stands out more than anything else is that it is here, it is in Mexico City, and it is the first time the conference has been held in Latin America, so you see a much larger Latin American contingent here. It is easier for people to get to the conference here than to get to Bangkok, so there are thousands of Latin American researchers, clinicians, infected people and community people here at the meeting. And I think they are also addressing in a much more prominent way what the real drivers are of the epidemic in this region.

Jackie Judd: And some of the countries, Mexico included, are very conservative, in some cases Catholic. Is it difficult to address it head on when it is difficult to address what is fueling the epidemic?

Jon Cohen: That is a great point. It was made last night at the opening session by one of the co-organizers of the conference. In this region in many countries, though certainly not all, men who have sex with men are driving the epidemics in these countries. As you mentioned, the church is very strong in many of these countries and there is a tension there in providing prevention services to that community when you want to ignore the fact that that community exists. That is just happening all over the place in Latin America. I think that at this meeting they are saying loudly that they have to address this.

One of the interesting things at the opening conference last night is that they showed videos from Mexico that the government has made, TV ads attacking homophobia and urging people to not have stigma and discrimination. These ads were so strong that I thought that my own government in the United States would not have put together such ads.

Jackie Judd: And that campaign, as much as the AIDS policy in Mexico, is driven by the head of the program who is himself a gay man and HIV-positive.

Jon Cohen: Yes.

Jackie Judd: And so these kinds of conferences really do help kind of bring these issues forward and give them more prominence.

Jon Cohen: They do. Jorges Saavedra is his name and I think he is an example to all Latin countries of what you can do with leadership. As you mentioned, his own status and the fact that he is open about it has had a really powerful impact on this country.

Jackie Judd: Changing subjects now, Jon, something I have picked up and I know you have, too, is what one of the people I interviewed called AIDS backlash. What are you picking up on that?

Jon Cohen: Yes, I am hearing it all over the place. It is this notion that HIV/AIDS funding has displaced other funding in the public health arena and it is harming other things, or maybe it is draining doctors and nurses away from other places. It is a debate that has been roiling in the literature for the last year, and it has come out here again and again and again with a pretty unified voice saying that the argument is wrong.

Jackie Judd: Why do you think that it has surfaced as it has now? The people who are making those criticisms could have said the same thing three or four years ago, so why now?

Jon Cohen: Well, there is more money now than ever before. The money has gone up like this, so even three or four years ago, the money was not anywhere near what it is today. I mean, we are at $10 billion right now for help to middle- and low-income countries. It is really there that the concern is most focused. There have been papers in the literature where researchers have shown the displacement and have said, look what has happened to population control sort of services and research because of AIDS funding. That has incited a lot to riot that there are data there that say this is really happening. And I think there is a lot of competition in the public health world for money.

Jackie Judd: The other kind of idea that is out there is treatment, how much emphasis on treatment versus how much emphasis on prevention, but you are also hearing about treatment as prevention.

Jon Cohen: Yes, this is another one of these really hot-button topics that have been all over this meeting. It starts in January when the Swiss government comes out with a policy saying that if you are an infected person and your partner is not infected and the level of virus in your body because of the drugs has gone so low that it is undetectable for six months, than you do not have to use a condom because there is a very, very low risk of transmission. The idea is, on a population scale, that by treating loads of people with antiretroviral drugs you are going to lower the amount of virus circulating so much that you are going to have an impact on the epidemic itself, and that creates a prevention strategy. It is completely logical that treating people will lower the amount of virus in that [interposing].

Jackie Judd: I hear a "but" coming up.

Jon Cohen: There is a huge but coming. The huge but is whether it is really a prevention technique for a population. In the plenary this morning, Geoff Garnett from London made the point that I think was really an important point that cannot be overemphasized. It is that 80-percent of the people in the world who are HIV infected do not know their status. Furthermore, people do not taking antiretroviral drugs in most countries until their immune system has been pretty destroyed, so all the time before that they are not on the drugs. So what impact is this? How many people are we really talking about on the drugs? We know, for example, that in low- and middle-income countries there are 3 million people on treatment. How many people are infected in low- and middle-income countries? What do they represent?

Jackie Judd: So, how seriously is this notion being taken here at the conference?

Jon Cohen: It is being taken very seriously because you would expect logically for there to be an impact when you reduce the amount of virus in the population. But you would also -- the argument is that it is a really irresponsible message to tell people, if you are undetectable, do not worry about using condoms, because even if your virus in undetectable, it does not mean you cannot transmit it. The likelihood is lower, but you can still transmit, so a lot of people are really angry at the Swiss because they say it is irresponsible and is going to lead people to infect people with no reason for that happen when they knew better and they had to means not to.

Jackie Judd: There is something we are doing new this time. We are asking, as you know, webcast viewers to send in questions about the conference that you might be able to answer. We have a couple, so I will start with a woman from Washington who wrote in. She has been involved in research for quite a while and asked about vaccine research. What is being done by key leadership to demand transparency of lessons learned, consolidate critical scientific endeavors, and bring all the right people to the decision-making table, including developing country investigators who must carry this complex agenda to their ministries?

Jon Cohen: It is an interesting question about transparency because this September there was a failure of a vaccine made by Merck that the research community had more hope for, they had pinned more hope on that vaccine than any AIDS vaccine in the pipeline. When it failed, within 24 hours, they were public with it. They held meetings that were open to the public. They posted the information on the web. I covered the whole thing. It could not have been more transparent and, believe me, I am one to complain about a lack of transparency. I get very vocal about it. In the vaccine world, things have been fairly transparent. I think it has even been a model of transparency with this particular vaccine. Then the subsequent fallout from the vaccine bad news was that another trial that was set to become the next, next great thing was canceled. That process was terrifically transparent, too. So, I do not think transparency is the issue. I do think that the world is attempting to work together more than it ever has. There is this entity called the Global HIV Vaccine Enterprise and its head, Alan Bernstein, was here today with Tachi Yamada the head of the Gates Foundation, at the vaccine session with Seth Berkeley, the head of the International AIDS Vaccine Initiative. They were all on the same stage talking about all the issues. Indeed, one of the lead researchers from that failed Merck study was on the stage, too, so I think people are talking about it. The problem is that there is nothing that works, and there is really nothing on the horizon that looks all that promising. It is a terrifically depressing time.

Jackie Judd: Okay. Another question we had was about statistics, which are always very, very complex. It is an interesting question, particularly in the context of what we are learning about the true state of the epidemic in the United States. So, this is the question: People talk about stabilization in the epidemic. Is that because fewer infections are being reported, or is it because the number of people who are dying equals the number of new infections?

Jon Cohen: Stabilization is one of these really tricky questions and the whole statistics and the estimates -- there has been a lot of attention over the past few days to a report from the U.S. Centers for Disease Control and Prevention about how the U.S. underestimated the number of new infections per year. It went up from 40,000 to 56,000, a 40-percent increase. If you read the paper, they backtracked several years in the epidemic. It has been at that 56,000 level for many years. It has been stable. Now, it jumped from 40,000 to 56,000 over the last two days because of new research. But these are estimates and you make estimates with the best tools you have that day and you refine them when you have better tools. They have better ways to test for HIV in blood. They have better models to figure out how many people are infected. So, it is no surprise that these estimates are being revised. In India, they were radically revised last year, too. South Africa has revised them.

Jackie Judd: UNAIDS did [interposing].

Jon Cohen: UNAIDS did in a major, major way. None of that is any surprise to anyone who is in the business. They are estimates. You do the best you can and you refine it when you can. So, stabilization, if you look at UNAIDS figures from a few years ago, it went from 40 million infected people in the world down to 33 million. It is not because suddenly some great success story happened. It is because they got better tools.

Jackie Judd: The picture got clearer.

Jon Cohen: The picture got clearer. I say that all these data are so shaky that I do not look at -- I do see stabilization in many places. I do see the epidemic plateau. But take it all with a grain of salt because these are estimates.

Jackie Judd: Okay, thank you so much. We will see you tomorrow.

Jon Cohen: Sure, thank you so much, Jackie.

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