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Dr Fauci on what it will take to end the HIV epidemic

December 14, 2019


I’m Anne Rancourt from the National Institutes
of Health, here at IAS 2019 in Mexico City. And I’m delighted to be joined by my colleague,
Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases. Thanks for being with me. Good to be with you. So Dr. Fauci, you gave two talks here today,
about ending the epidemic and one about HIV control. What does this mean, to end to the HIV epidemic? We have an exciting new initiative about that
topic. Tell us a little bit about what they means. Well, what it means is that we have the tools
now, with both treatment as well as prevention modalities, that over a period of literally
decades, we’ve reached the point today, in 2019, that we know that if we treat a person
who’s infected with HIV and bring down the virus to below detectable level, not only
do we save the life of that person, but we make it impossible for that person to transmit. We have no linked transmissions in over 150,000
incidences where there could have been transmission. So that’s one thing that we have. The other thing is pre-exposure prophylaxis,
which if you give a single pill, either on a daily basis or on demand, for someone who
is at risk, we decrease probably more than 97% the likelihood that they would in fact
acquire infection. So when you put those two things together,
you all of a sudden realize that now we have the tools. If we implement them properly, aggressively,
to the extent that we can, we can theoretically turn off the dynamics of the epidemic. And that leads to the second talk I gave,
which was HIV control. Of course, control means decrease incidence. So if you look at decrease incidence, control
of infection, and then end of the epidemic. So I think the bottom line that is emerging
from this meeting is that we’ve spent a lot of time and a lot of investments to get the
tools that we need to get control. Right now, the real aspirational goal is to
implement those tools. Now that sounds easy. You have the tools, implement them. But it’s not, because we’re dealing with human
nature. We’re dealing with people we don’t have access
to. We’re dealing with people who don’t like to
take a pill a day, every day. So we’ve got to get around that and that’s
where the new research comes, to give us ways of making it easier for people to get to those
scientific advances like long-acting antivirals, like passive transfer monoclonal antibodies,
like implantable ways to prevent infection. All of those things were discussed at this
meeting and that’s the reason why it’s such as exciting meeting, because it’s all coming
together. And so, tell us about the new initiative,
Ending the HIV Epidemic, that’s going on in the United States right now. Well, in the United States, about a year ago,
Bob Redfield, who’s the Director of the CDC, and I got together and looked at the data,
both demographically and geographically, about the incidence and prevalence in the United
States. And figured with the scientific advances that
we have, it probably could be feasible to put together a plan to end the epidemic as
we know it by decreasing infections by 75% in five years and by 90% in 10 years. We brought it to the Department, we spoke
to Admiral Giroir, who’s the Assistant Secretary. And importantly, we presented it to Alex Azar,
who’s the Secretary of HHS, who bought into it and thought it was a great idea, that
we had the tools. Gave it to the President, He announced it
as a State of the Union initiative. And now, what we’re doing, is that we’re focusing
both on the demographic hot spot as we call it. The most vulnerable, who are African American,
men who have sex with men, transgender, and individuals who are bisexual, who are generally
minority, almost all minority individuals, men who have sex with men, and young men who
have sex with men. And then you look at the geographic hotspot,
which is extraordinary because we have a big country in the United States. There’s 3,007 counties. More than 50% of all the infections are in
those areas of 48 counties plus the District of Columbia, plus San Juan. That’s almost amazing that with 3,007 counties,
it’s focused more than half in 50 locations together with rural areas where you have situations
in southern states where many of the infections are not in the big cities, but in the rural
areas. So if we focus our resources on that, we think
we can get the goal of getting down the infections by 90% in 10 years. You talked a little bit about treatment and
using it as prevention, or U=U as a lot people know the phenomenon. Is that one of the tools that you’ll be using,
rolling out? U=U is the hallmark of what we’re doing because
if you can get the infection level, the viral load, in any given individual to below detectable,
that person will not transmit infection. That means U=U. So if we accomplish U=U, if you think for
a moment, what does that mean? That means we don’t have anybody that’s transmitting
infection. So that’s what I mean when I say that concept
of U=U is the foundation of being able to end the epidemic. But you have to add to that pre-exposure prophylaxis
because we have four studies from Africa, which showed that even though you get great
benefits from treatment as prevention, you don’t decrease the incidence unless you add
something else. And that something else is pre-exposure prophylaxis. And we face a lot of challenges with implementing
both PrEP and treatment in terms of access and adherence to those. What do we need to do to overcome those challenges? We need to make it easier for people to adhere
to the regimens they have, number one. And we need to get to access the people who
are not on therapy. So the things that we’re doing to increase
it is that you ask people why they don’t take their pill everyday. One, there’s stigma. They don’t like to be
reminded that they’re infected every single day. A study that was very sobering was presented
here in Mexico City. It’s called HPTN O82. And what that study showed, that if you took
vulnerable women who are at risk in southern Africa and you have a program that directly
puts them on PrEP, but follows them carefully to see if they’re taking their PrEP. In the
first 3 months 85% were taking PrEP, which is really good. At the end of 12 months, 9%, only 9%. 91% stopped taking PrEP. So if you really want PrEP to be an important
part of the tools of ending the epidemic, we have to figure out a way, how to make PrEP
really easy, without stigma. One of the ways is long-acting injectables,
passive transfer of broadly neutralizing antibodies once every four to six or eight months. And a very exciting study that was presented,
which was an implantable… Tomorrow I believe actually, is that one… Exactly, tomorrow, yes. … is an implantable
that right now, even though it’s a small study, showed that you can get suppressive levels
for over a year. Great. Great. What about other agents that we might need
to help end the epidemic? Something disruptive as we heard it described
in one of the panels, like a vaccine or a cure? Well, that right now, vaccine. If we had
a vaccine right now, that would be the nail in the coffin of the epidemic. I speak a lot about having the tools, that
if we implement it properly, we could turn around the dynamics. That is true. But, given human nature, given the difficulty
in getting access to people, if you want a truly global, effective, durable end to the
epidemic, the only way you’re going to do that is with a safe and effective vaccine,
together with all of the other non-vaccine preventive modalities. Great. And Dr. Fauci, we’ve been living with HIV
as a reality in the United States for 38 years. There is a huge segment of the population,
young people, who have never known a world without HIV. Are you optimistic that with this new initiative
and where we’re going with the science, that we can truly end the epidemic and have a new
way of life for young people? You know, I am. I don’t think it’s going to be easy and I
don’t think it’s going to happen spontaneously. A lot of effort has to be put into it. But the one thing I’m absolutely certain of
is that it’s possible. So it’s up to us to make it happen. You know, if you had asked me 20 years ago
when we didn’t have all the tools, I’d say, “You know, I’m not even sure it’s possible,
much less whether we’re going to do it or not.” Right now, it is definitely possible, we just
need to do it. Wonderful. Dr. Fauci, thank you for joining me, taking
time. Thank you for joining us, for watching us. I hope you’ll tune in tomorrow, where I’ll
have more updates from IAS 2019. And for more information, please visit HIV.gov. Thank you.

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