July 13, 2004
Jackie Judd: Jon Cohen of Science Magazine, welcome back.
Jon Cohen: Thanks for having me.
Jackie Judd: Um. Today at the conference, Jim Kim from the World Health Organization, WHO, said that the world's efforts to get access for all has been what he called a miserable failure. What was interesting about that was that he was reflecting back on himself because he had WHO's three by five program. Why would he be so candid?
Jon Cohen: It is surprising that a general would say that an enemy is advancing and we're losing the war so bluntly because officials like that you know they usually try to cover up or downplay their failures. At Barcelona two years ago there was great hope that drugs would get into people's bodies quickly all over the world. And it just hasn't happened quickly. And it kind of reminds me, I was thinking about it today that it's kind of like a kid gets into a good college where it's really, really hard to get into that college and then doesn't do the work once they arrive. Here we are, you are in college. There is money now. There are cheap drugs now. There's momentum now and it's just people kind of well, we're getting there. And I think he's frustrated. I think he's saying that my own program is in danger of collapsing. This needs more people who feel a sense of urgency right now to solve problems. I mean, people are dying from HIV at 14,000 a day every day. We're seeing this travesty that's racing and not waiting for anyone.
Jackie Judd: A lot of the frustration that's felt here about what you've just described is directed directly at the United States. Why is that?
Jon Cohen: It's curious because the U.S. spends more on HIV and AIDS than any country in the world. And it's also understandable why the anger exists, I think. Most of the leaders here, public health leaders, political leaders have pointed out that the Global Fund to Treat AIDS, Tuberculosis, and Malaria is the vehicle to deliver drugs and prevention to countries. Why? Why is it the vehicle? It's a new thing, why put faith in that?
It's because of its organization. It's a ground up grass roots structure that says the countries have to come with a proposal with all the stakeholders and say what they're gonna do and how much money they want. And, it actually is a very clever way to distribute public health money to get something done. And they have to be accountable as well. The anger is because the U.S. government has contributed to the global fund but it has committed fifteen times as much money to its own bilateral program which means money that it's going to decide where it goes and how it goes there and negotiate with the government as it sees fit.
Jackie Judd: That's PEPFAR. President Bush's program.
Jon Cohen: That's PEPFAR. That's right and that's $15 billion over five years as compared to commitment to the global fund from the U.S. of $200 million for five years. So it's fifteen times more for PEPFAR which serves fifteen countries as opposed to the global fund which takes on the world. And that's where the anger stems from and there's a political component that angers and scares people as well.
Jackie Judd: What's that?
Jon Cohen: Well, when bilateral donation goes on that's kind of code for I'm gonna slip in my political agenda here. If I don't like condoms as the message, you're not getting my money. The U.S. for example doesn't like needle exchange. The administration doesn't. Well, they're giving money to Vietnam as one of those fifteen countries. Sixty percent of the people who are infected in Vietnam are injecting drug users. That's the very group where you need needle exchange, but with the U.S. money that can't happen. So, there is an illogic that is clashing with the rhetoric.
Jackie Judd: You mentioned there's a political reason. And you and I have been talking politics basically yesterday and again today. There is also science going on here right?
Jon Cohen: Believe it or not there is. This is a bizarre scientific meeting because often the science takes a back seat to the politics. And once again that's happened. And today's it's really crystallized where the politics has gone front and center. But I just came out of a session that was terrific basic research. And when people run this meeting into the ground and say there is no good research there and it's all politics and circusy stuff, I just scratch my head and say well you're not there because what I saw was good.
Jackie Judd: What did you spot?
Jon Cohen: Well there is this session about something called superinfection. It was thought for a long time that once you became infected with the HIV you couldn't become infected with another strain because you'd develop an immune response that would basically kick out any new virus that showed up. Well, it's been realized over the past couple of years that humans, indeed, can become infected with a second strain. And the implications for vaccines are pretty sobering. What if you had a vaccine that only worked against one strain? It wouldn't be anywhere near as useful a vaccine. But it also has implications for treatment and it has implications for sexual behavior. And those came out today.
Jackie Judd: In what ways?
Jon Cohen: If you are HIV infected and you are a gay man, let's say. You may well want to have sex without a condom and if you have sex without a condom with another man who is HIV infected, neither of you are really putting each other at risk of infecting the other one. Well, we know now that you may well be putting yourself at risk, even in that situation because when that second virus comes in it speeds up the decline of your immune system and boosts your virus back up. So that's a scary message.
Jackie Judd: And there was also talk today about how closely intertwined TB is to HIV. Tuberculosis.
Jon Cohen: Yeah, I think it's something [pause] We're confused often in this world of HIV and AIDS because of the way the epidemic unfolds so differently in different places. In the wealth countries of the world Tuberculosis just isn't a big problem. It is a growing problem but it doesn't compare to the poorer countries of the world. In the poorer regions of the world, TB is the number one killer of HIV infected people. That's what they're dying from. You know, you don't die from HIV per se. You die from these other diseases that run wild in you. And there's now some clarity that the way that TB and HIV interact has to be understood in order to best design treatment for people.
Jackie Judd: How so?
Jon Cohen: Well in two ways. One thing that TB does is that it speeds up HIV's ability to destroy things. Just having TB in there charges things up and let's HIV run wild. If you can treat someone's TB, HIV is still grinding. It's still moving faster even though you're treating the TB. National programs like the one unveiled in India make cutoffs for who gets access to treatment first. Right now they have a cutoff of people who have CD4 cells of 200. A normal person has 600-1200. Two hundred, you're getting low and you're really vulnerable to lots of infections. Lots of people get TB at 400 who are HIV infected. They've got TB at 400 CD4's. They're not eligible for the AIDS drugs, but they're the ones who most need it because they'll die from it. Their HIV will speed up even though they're getting TB treatment. Their HIV is going to race forward. If you don't give them HIV drugs, they are the most vulnerable people of dying from HIV infection. So it really impacts national programs that rolling out drug delivery as best they can and have to make tough decisions about who gets it and who doesn't.
Jackie Judd: Some of what you just described about tuberculosis, it was talked about at the plenary session this morning. There was probably a crowd in the arena of about maybe five or six hundred people. So what happens to the information they hear in that arena? Do they go home and begin to institute different kinds of policies? What happens with the information heard here?
Jon Cohen: It's really tricky calculus. Part of what happens is the smart people in the country go to the policy makers and say listen we have evidence of what we're doing isn't the best thing. Policy makers in every country I've ever observed are slow to make decisions. Clinicians make decisions quickly, so there will be a tension and a clash and arguments about this.
There's a second thing that I didn't mention about TB and HIV in that the drugs that you use to treat HIV and TB can clash with each other. So that adds complexity to it too. These countries are coming out with national plans that will have to be rewritten or amended to incorporate the new information. And that's not an easy thing to do. These wheels turn slowly and that's what Dr. Kim was complaining about. If the wheels turn so slowly then anytime you introduce new scientific insights, it's hard to incorporate them quickly.
Jackie Judd: A lag time of years in some cases.
Jon Cohen: It can be, if ever. You know, once you convince the government of China to roll out a treatment program, that is an unbelievable shift in policy from what they were doing the year before. They are not anxious to keep adjusting it and adjusting it and adjusting it. We took care of AIDS. You want us to do more? You want us to change what we just decided?
Jackie Judd: You have new ideas?
Jon Cohen: You have new ideas? You told us this. Now you're telling us that. Science is a very hard meal to digest, you know, because it keeps rolling around. It's what science does. It's always provisional. It's always what do we know right now. And what we know right now. You know the superinfection story, one other thing that came out today is a study in Africa in three countries found that 28% of these people studied in this group had two viruses in them. Two strains. That's an astonishingly high rate. What the means is that we see HIV strains combining, recombining into brand new strains. What's happening inside of people's bodies, we have to re-conceptualize how we even treat people.
When you come into the United States for treatment, what happens? You say you've got insurance, you've got good coverage and your doctor is smart. Doctor takes your blood, checks your HIV and checks the genes of your HIV and says which strain, what's in here that's already resistant to drugs. They put that in your file. You don't start drugs for three, four years, five years. Five years down the road your immune system is declining. The doctor says lets put you on drugs. They don't go back and re-test your genes again. They go back to what was there. Now if you got super infected, you've got different genes in there. And that's what came out today. That can be drug resistant. So they start you on treatment and it doesn't work. That's ... how do you incorporate that into policy let alone into the individual clinician who is also overwhelmed by all this?
Jackie Judd: Thank you so much. More tomorrow.
Jon Cohen: More tomorrow.
Jackie Judd: Jon Cohen of Science Magazine.
Jon Cohen: Thanks a lot.
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