Q&A: 30th anniversary of World AIDS Day

Richard Marlink, MD
Richard Marlink

Today marks the 30th anniversary of World AIDS Day, which is observed every Dec. 1 to show support for people living with HIV/AIDS, spread awareness and commemorate the more than 35 million people who have died since the start of the global epidemic.

At the end of 2017, WHO estimated that 36.9 million people were living with HIV/AIDS, including 1.8 million who were infected in 2017. But there has been immense progress. Between 2000 and 2017, global HIV-related deaths fell by 38% and 11.4 million lives were saved thanks to antiretroviral therapy, according to WHO.

To mark the date, Infectious Disease News spoke with Richard Marlink, MD, director of the Rutgers Global Health Institute. As an oncologist, Marlink treated some of the first HIV/AIDS patients at the former St. Vincent’s Hospital in New York and helped establish the first HIV/AIDS clinic in Boston. - by Erin Michael

Where should HIV research focus right now a cure or a vaccine?

We’ve been trying to do both for a long time, and both have proven to be elusive goals. I don’t think it’s necessary to choose, in that the solutions actually may be very much related. That is, to be able to cure a retroviral infection would be such a breakthrough that it probably would lead to also knowing how to create an effective vaccine and vice versa. If we found significantly effective vaccines — they don’t have to be 100% effective — if we found one that is significantly effective, we’d probably have information on a better pathway toward perhaps curing the retroviral infection. A retrovirus is an RNA virus that converts RNA into DNA and incorporates that DNA into our DNA, and then its life cycle continues on as DNA to RNA to proteins. That reverse step, and then the incorporation into our own DNA, is where we have been able to attack the virus with reverse transcriptase inhibitors. Also, once it is incorporated into our DNA, we do not know how to get it out. That would require a level of genetic manipulation of which we are not yet capable, although I’m sure we will be someday soon. There are other manipulations that have allowed us to move toward a cure. Rarely, people have a genetic resistance to HIV infection. Using that knowledge, one patient has actually been cured by undergoing the very dramatic intervention of two bone marrow transplants with donor stem cells known to have the genetic resistance to HIV infection. This man, who came to be known as the “Berlin Patient,” actually needed the transplants to treat his underlying leukemia, and he wound up being cured of his HIV infection. That aside, we really haven’t learned in any practical way how to get this virus out of our DNA.

Will we see an HIV cure or vaccine in our lifetime?

Yes, in our lifetime. The reason for that is there have been some promising vaccine results in the last few years. They’re not promising enough, however, to be able to put an exact timeline on when an effective vaccine would be discovered, let alone distributed and accessed by those who need it. The big dilemma now is that it’s much harder to test an AIDS vaccine in that we know how to prevent HIV infection with antiretroviral drugs. Obviously, there is an ethical responsibility to give people the knowledge and opportunity to avoid HIV infection in any situation. So how can a vaccine be tested when a daily drug is making infection highly unlikely? You’d have to enroll a lot more people in your trial to know if you have an effective vaccine compared with placebo. At the same time, a vaccine is a much better scenario than having to remember to take the same drug every day for the rest of your life — partly because that depends on compliance and supply, and especially because missed doses can lead to drug-resistant strains of HIV, which put us in danger of developing an entirely new epidemic.

Late last year, President Donald J. Trump disbanded the Presidential Advisory Council on HIV/AIDS after several of its members publicly resigned in a letter that said the president “simply does not care” about the subject of HIV/AIDS. Is the administration taking the epidemic seriously? And what are the public health implications if the country’s top experts are no longer advising the president on HIV/AIDS policy in the United States?

Part of President Trump’s disbanding the presidential advisory council on HIV/AIDS is probably related to his thin skin when being criticized, but probably also related to the fact that AIDS is not on his administration’s priority list at all. I think both reasons are why it happened. What are the public health implications of this happening? Again, the harder to reach groups that are at greater risk for HIV are going to be even harder to reach, because they won’t have the benefit of our public health funding and efforts. Now our efforts to reach those in need and those at risk for getting infected will receive less funding, and those who are living with HIV and dependent on assistance for this lifelong treatment will have it much harder. The AIDS epidemic is still very much with us and it needs to be on our government’s priority list, not removed from the list of priorities, which is what is happening now.

Research has shown that many high-risk patients are not getting tested for HIV (examples here , here and here ). What are the most effective interventions for improving HIV testing rates among the patients who need it most?

Well, many people who are at high risk for HIV infection are in hard-to-reach populations, or populations that are disenfranchised and not part of the health care system. Those could be people who already face stigma or discrimination, regardless of their HIV status, or people who are engaging in risky behaviors such as using IV drugs. All will require special attention and special outreach to improve HIV testing rates. When the risk factors for HIV infection are discussed one-on-one with patients in a respectful way, taking their social and cultural settings into account, resistance to testing is very rare. However, that effort requires time, outreach and specialized programs to reach populations that are already stigmatized, are not coming for routine care, or are not part of the health care system.

Nearly 50% of people with HIV/AIDS are over the age of 50 years. What advice do you have for physicians who are treating aging HIV/AIDS patients?

My advice to physicians and nurses in general is that all age groups are susceptible to HIV infection. Discussion of HIV risk, HIV status and sexual histories should be a part of routine patient care, so that the health care provider knows whether a patient has been tested or is already HIV positive. The patient may know, and the provider may not know. For those who are taking care of patients over the age of 50, we need to remember that HIV seems to increase the risk for many other conditions that are associated with increased age. That is, risks for cardiovascular disease, bone loss, and certain cancers are independently increased with both age and HIV infection. We also need to remember that older patients with HIV may have comorbid conditions. Treatment for other conditions, such as hypertension or diabetes, may necessitate consideration of medication interactions for those taking HIV drugs. And, lastly, the stigma that’s still associated with HIV infection is compounded in older patients in that they may already face issues of isolation or other age-related psychosocial challenges.

The U.S. Preventive Services Task Force, or USPSTF, recently recommended that clinicians offer pre-exposure prophylaxis, or PrEP, to patients at high risk for HIV infection. However, PrEP has been approved for HIV prevention in the U.S. since 2012, and guidelines for its use have been in place since 2014. What is the importance of the USPSTF’s recommendation?

The importance of the recommendation is that it moves PrEP more toward the mainstream practice. Primary care and all clinicians need to determine whether their patients are at risk for HIV infection, because it’s the recommended primary care intervention to take PrEP if they are. This will hopefully help regular primary care practitioners to follow the now established guidelines, talk to their patients about the potential benefit of PrEP and feel comfortable prescribing it. It’s not as difficult as people think. It doesn’t require a specialist to prescribe PrEP and to follow that patient on PrEP.

What is the take-home message for ID clinicians on World AIDS Day?

World AIDS Day is a day set aside by the World Health Organization for all of us to not only remember those who have succumbed to the epidemic, but also to raise awareness about what we can do end the epidemic. For the ID clinician, that would mean that we still have to be advocates for a broad, public health response to the epidemic involving all parts of society. We need to acknowledge that the epidemic is far from over, with 15 million infected people in the world still without access to lifesaving antiretroviral drugs. Advocacy still is job number one for ID clinicians and, in fact, for all clinicians and public health practitioners. Also, I think that for World AIDS Day, the message for the infectious disease community is that we have the drugs that can both bring infected people back from illness and help prevent people from getting infected in the first place. We need to spread the word to the non-ID clinicians and practitioners of all types that the drugs work, and they need to be used for both treatment and prevention.

References:

WHO. HIV/AIDS. http://www.who.int/news-room/fact-sheets/detail/hiv-aids. Accessed November 29, 2018.

World AIDS Day. About World AIDS Day. https://www.worldaidsday.org/about/. Accessed November 29, 2018.

Disclosure: Marlink reports no relevant financial disclosures.

Richard Marlink, MD
Richard Marlink

Today marks the 30th anniversary of World AIDS Day, which is observed every Dec. 1 to show support for people living with HIV/AIDS, spread awareness and commemorate the more than 35 million people who have died since the start of the global epidemic.

At the end of 2017, WHO estimated that 36.9 million people were living with HIV/AIDS, including 1.8 million who were infected in 2017. But there has been immense progress. Between 2000 and 2017, global HIV-related deaths fell by 38% and 11.4 million lives were saved thanks to antiretroviral therapy, according to WHO.

To mark the date, Infectious Disease News spoke with Richard Marlink, MD, director of the Rutgers Global Health Institute. As an oncologist, Marlink treated some of the first HIV/AIDS patients at the former St. Vincent’s Hospital in New York and helped establish the first HIV/AIDS clinic in Boston. - by Erin Michael

Where should HIV research focus right now a cure or a vaccine?

We’ve been trying to do both for a long time, and both have proven to be elusive goals. I don’t think it’s necessary to choose, in that the solutions actually may be very much related. That is, to be able to cure a retroviral infection would be such a breakthrough that it probably would lead to also knowing how to create an effective vaccine and vice versa. If we found significantly effective vaccines — they don’t have to be 100% effective — if we found one that is significantly effective, we’d probably have information on a better pathway toward perhaps curing the retroviral infection. A retrovirus is an RNA virus that converts RNA into DNA and incorporates that DNA into our DNA, and then its life cycle continues on as DNA to RNA to proteins. That reverse step, and then the incorporation into our own DNA, is where we have been able to attack the virus with reverse transcriptase inhibitors. Also, once it is incorporated into our DNA, we do not know how to get it out. That would require a level of genetic manipulation of which we are not yet capable, although I’m sure we will be someday soon. There are other manipulations that have allowed us to move toward a cure. Rarely, people have a genetic resistance to HIV infection. Using that knowledge, one patient has actually been cured by undergoing the very dramatic intervention of two bone marrow transplants with donor stem cells known to have the genetic resistance to HIV infection. This man, who came to be known as the “Berlin Patient,” actually needed the transplants to treat his underlying leukemia, and he wound up being cured of his HIV infection. That aside, we really haven’t learned in any practical way how to get this virus out of our DNA.

PAGE BREAK

Will we see an HIV cure or vaccine in our lifetime?

Yes, in our lifetime. The reason for that is there have been some promising vaccine results in the last few years. They’re not promising enough, however, to be able to put an exact timeline on when an effective vaccine would be discovered, let alone distributed and accessed by those who need it. The big dilemma now is that it’s much harder to test an AIDS vaccine in that we know how to prevent HIV infection with antiretroviral drugs. Obviously, there is an ethical responsibility to give people the knowledge and opportunity to avoid HIV infection in any situation. So how can a vaccine be tested when a daily drug is making infection highly unlikely? You’d have to enroll a lot more people in your trial to know if you have an effective vaccine compared with placebo. At the same time, a vaccine is a much better scenario than having to remember to take the same drug every day for the rest of your life — partly because that depends on compliance and supply, and especially because missed doses can lead to drug-resistant strains of HIV, which put us in danger of developing an entirely new epidemic.

Late last year, President Donald J. Trump disbanded the Presidential Advisory Council on HIV/AIDS after several of its members publicly resigned in a letter that said the president “simply does not care” about the subject of HIV/AIDS. Is the administration taking the epidemic seriously? And what are the public health implications if the country’s top experts are no longer advising the president on HIV/AIDS policy in the United States?

Part of President Trump’s disbanding the presidential advisory council on HIV/AIDS is probably related to his thin skin when being criticized, but probably also related to the fact that AIDS is not on his administration’s priority list at all. I think both reasons are why it happened. What are the public health implications of this happening? Again, the harder to reach groups that are at greater risk for HIV are going to be even harder to reach, because they won’t have the benefit of our public health funding and efforts. Now our efforts to reach those in need and those at risk for getting infected will receive less funding, and those who are living with HIV and dependent on assistance for this lifelong treatment will have it much harder. The AIDS epidemic is still very much with us and it needs to be on our government’s priority list, not removed from the list of priorities, which is what is happening now.

Research has shown that many high-risk patients are not getting tested for HIV (examples here , here and here ). What are the most effective interventions for improving HIV testing rates among the patients who need it most?

Well, many people who are at high risk for HIV infection are in hard-to-reach populations, or populations that are disenfranchised and not part of the health care system. Those could be people who already face stigma or discrimination, regardless of their HIV status, or people who are engaging in risky behaviors such as using IV drugs. All will require special attention and special outreach to improve HIV testing rates. When the risk factors for HIV infection are discussed one-on-one with patients in a respectful way, taking their social and cultural settings into account, resistance to testing is very rare. However, that effort requires time, outreach and specialized programs to reach populations that are already stigmatized, are not coming for routine care, or are not part of the health care system.

Nearly 50% of people with HIV/AIDS are over the age of 50 years. What advice do you have for physicians who are treating aging HIV/AIDS patients?

My advice to physicians and nurses in general is that all age groups are susceptible to HIV infection. Discussion of HIV risk, HIV status and sexual histories should be a part of routine patient care, so that the health care provider knows whether a patient has been tested or is already HIV positive. The patient may know, and the provider may not know. For those who are taking care of patients over the age of 50, we need to remember that HIV seems to increase the risk for many other conditions that are associated with increased age. That is, risks for cardiovascular disease, bone loss, and certain cancers are independently increased with both age and HIV infection. We also need to remember that older patients with HIV may have comorbid conditions. Treatment for other conditions, such as hypertension or diabetes, may necessitate consideration of medication interactions for those taking HIV drugs. And, lastly, the stigma that’s still associated with HIV infection is compounded in older patients in that they may already face issues of isolation or other age-related psychosocial challenges.

PAGE BREAK

The U.S. Preventive Services Task Force, or USPSTF, recently recommended that clinicians offer pre-exposure prophylaxis, or PrEP, to patients at high risk for HIV infection. However, PrEP has been approved for HIV prevention in the U.S. since 2012, and guidelines for its use have been in place since 2014. What is the importance of the USPSTF’s recommendation?

The importance of the recommendation is that it moves PrEP more toward the mainstream practice. Primary care and all clinicians need to determine whether their patients are at risk for HIV infection, because it’s the recommended primary care intervention to take PrEP if they are. This will hopefully help regular primary care practitioners to follow the now established guidelines, talk to their patients about the potential benefit of PrEP and feel comfortable prescribing it. It’s not as difficult as people think. It doesn’t require a specialist to prescribe PrEP and to follow that patient on PrEP.

What is the take-home message for ID clinicians on World AIDS Day?

World AIDS Day is a day set aside by the World Health Organization for all of us to not only remember those who have succumbed to the epidemic, but also to raise awareness about what we can do end the epidemic. For the ID clinician, that would mean that we still have to be advocates for a broad, public health response to the epidemic involving all parts of society. We need to acknowledge that the epidemic is far from over, with 15 million infected people in the world still without access to lifesaving antiretroviral drugs. Advocacy still is job number one for ID clinicians and, in fact, for all clinicians and public health practitioners. Also, I think that for World AIDS Day, the message for the infectious disease community is that we have the drugs that can both bring infected people back from illness and help prevent people from getting infected in the first place. We need to spread the word to the non-ID clinicians and practitioners of all types that the drugs work, and they need to be used for both treatment and prevention.

References:

WHO. HIV/AIDS. http://www.who.int/news-room/fact-sheets/detail/hiv-aids. Accessed November 29, 2018.

World AIDS Day. About World AIDS Day. https://www.worldaidsday.org/about/. Accessed November 29, 2018.

Disclosure: Marlink reports no relevant financial disclosures.