August 15, 2006
Jackie Judd: Jon Cohen, welcome back.
Jon Cohen: Thanks, Jackie.
Jackie Judd: Today is Tuesday. Today at the Toronto conference we have seen a lot of president -- Former President Bill Clinton. What did he have to say, or was it just his mere presence that mattered?
Jon Cohen: Oh, I think it's mostly his presence. He's preaching to the choir here, but the choir loves him, and he is Mr. Charisma. He was here yesterday and on the podium with Bill Gates having a one-on-one conversation that the audience ate up as well. They can't get enough of him. They were packing into the rooms yesterday to hear him. They packed in today to hear him.
And he is providing a level of political leadership and a fluency of the language of HIV and AIDS that the audience really hasn't seen from a leader, a political leader of that stature, before. I think they just love hearing the preacher say what they believe.
Jackie Judd: It gets the agenda of Toronto in the papers, on television, and that's the point, isn't it?
Jon Cohen: I think you've put your finger on it. The media is all here, and they love celebrity, and they love big politicians like Clinton. He also articulates things very well, so he can take a message that a scientist says and the public has trouble understanding, and he just puts it into a -- "by gosh, that's just the way it is," and people get it.
Jackie Judd: You have seen him at an AIDS conference several years ago.
Jon Cohen: That's right.
Jackie Judd: Any differences between how he speaking about it? You say he is very fluent in the language now.
Jon Cohen: Oh, yes.
Jackie Judd: Also in how he's being received.
Jon Cohen: Yes, when he came to Barcelona in 2002, he was really just entering that stage of his life where he was making AIDS as issue that his foundation was going to address. And he was feeling his way around and just trying to say, "I've got this new foundation. It wants to make a difference. It wants to help lower the price of drugs for countries," and it was all -- here's what we are going to do. He wasn't standing up and giving talks about, this is what's going right, this is what's going wrong. He was saying, "Hey, I'm here. I want to help." Now he is saying, "I have helped. I want to do more and here is what I see is the major issues to address." One of them is what we talked about yesterday, is just getting more people tested. So he's going after that, and he's traveling a lot to Africa. He's really committing a lot of his time to the effort, I think.
Jackie Judd: Let's talk about prevention for a moment. We also talked earlier this week in a kind of preview about how the discussion, debate, dialogue about prevention is a much broader thing then it used to be. What evidence are you seeing of that as you wander the halls?
Jon Cohen: Well, there are a half-dozen different ideas in trials right now in humans that a few years ago didn't exist as ideas that were in human trials. Some of them are so basic that I think it would surprise people, like using a female diaphragm as a barrier to HIV. There's a trial studying that, and there will be results in a year or so.
One of the most provocative, controversial is the idea that people who do not have HIV, can take an HIV drug to prevent becoming infected by HIV. Now that's not proven, it's an idea. There are trials going on all over the world to test this idea. Three trials have completed and there will be a presentation here later about those trials. They didn't have enough infected people in the trials to determine whether it worked or didn't work, but they determined that it was safe. The people didn't get sick from taking a daily pill. If it works, and that's a big if, but if it works, I think it will radically change the way people look at prevention.
Jackie Judd: How so?
Jon Cohen: Well, in addition to having abstinence, be faithful and condoms, it's also going to include -- take this pill. And that might sound foreign to people, but when people go to places where there is malaria, they don't live there, they often take malaria drugs to not get malaria. There's also the risk that people who take a pill like that will take more risks, and they will overwhelm the benefit of the pill. That's something that is called behavioral dis-inhibition. A lot of people have wrung their hands over. I think the same thing occurred with the introduction of the birth control pill, and people worrying about people having more sex, or distributing condoms to high school students. It's the same issue. Are you just going to tell them to have sex by giving them condoms? But it's a real issue.
Jackie Judd: One of the researchers that was on the panel discussing these new prevention strategies said at the end of the news conference, "All well and good, but let's not forget about the effect that changes in behavior can happen," on prevention.
Jon Cohen: Well, right, and that's fine. What I think what Clinton and many other scientists have said, and Gates said is, "Well, we know the limits of changes in behavior, because we've seen. We're still seeing four million new infections a year, so, yes, of course, encourage behavior change." But that too, has limits. So let's get away from this idea of one thing fixes everything. It doesn't. People are complex. They have complex lives, and many people have no choice about the sex they have. Give them options.
Jackie Judd: Speaking of one thing fixing everything. You came back from a session you were very excited about involving the idea of monotherapy.
Jon Cohen: Yes, when the first AIDS drug came to market, there was only one drug available. It was AZT, and people took it and it was pretty lousy. That's called mono therapy, a single drug. For the first few years when new drugs came out, people would take one drug. Well, it's a bad idea. It's a bad idea because you become resistant to that drug pretty quickly. The great breakthrough in '95 was there were three drugs you could put together that delayed the emergence of resistance, so the drugs really worked, and they were strong, and they lasted. That's lasted 'til this day.
Well then here in 2006, to hear somebody get up and give a presentation about going backwards using a single pill, people are scratching their heads, why would you do such a thing? What they showed was that after 48 weeks, the 30 people who did single drugs did just as well as people who took combination drugs. So that's provocative.
Jackie Judd: Is 48 weeks long enough to know?
Jon Cohen: Forty-eight weeks certainly is a long time, but not long enough, and there were only 60 people in the study. And that's the real asterisk on this study. If it were in 1,000 people, then you would say with more certainty, "Wow, that really worked." But still, I think it's something that is getting at a deeper issue. This new drug they used called Kaletra is one of many new drugs that is pretty hard to develop resistance to. It's different from those first drugs. But the first drugs, if you have one genetic mutation in the virus, it could get around the drug. Now you need five, 10 mutations to get around the drug. So that's telling us something about how the drugs are working as well.
Jackie Judd: Is this something that we're going to be hearing more about in the coming years --
Jon Cohen: In the coming days, there are going to be more presentations at the meeting about it. Yes, I do, and I think it's going to be hotly debated. A lot of clinicians are going to say, "Why would you ever do such a thing? We have one pill now that combines three drugs. You can take it easily. Why would you do that?"
But the other perspective is well, we know that for most people who take anti-HIV drugs, they are at some point going to develop resistance, and you are going to have to go to other drugs, then. If you have 20 drugs where you can take, one, one, one, one, one, that gives you 19 options after you lose one. This is a different kind of strategy, and it also ties back to the idea of the drug that prevents people becoming infected. The pre-exposure prophylaxis is the horrible name that it's called, but a lot of researchers would like to see a separate drug just for that. So that if resistance develops to that, and resistance viruses circulate to that, it won't hurt everyone else who is infected and using that drug.
Jackie Judd: Okay Jon, thanks. More tomorrow.
Jon Cohen: Thank you, Jackie.
kaisernetwork.org makes every effort to ensure the accuracy of written transcripts, but due to the nature of transcribing recorded material and the deadlines involved, they may contain errors or incomplete content. We apologize for any inaccuracies.