THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Week: 568.7 Guest: Dr. Anthony Fauci, Dir. National Institute of Allergy & Infectious Diseases Topic: NIH/AIDS update Producer/Host: Steve Girard

NEMA: We all felt the fear of AIDS and the HIV virus... after all, it is a scary scenario: a quickly mutating virus that could kill us in a number of ways by knocking out our body's defense systems. Well, we've recently had a spate of good news about the disease, its treatments and those afflicted with AIDS. There are new drugs, new ways to combine therapies, and strong programs to get people on the treatments. Things have changed for the better...but Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, says it's a long hard road to a solution...

Dr. Fauci: ...both in the pattern of the epidemic in this country, worldwide, as well as the kind of things we can do now for HIV infected individuals in the form of treatment, not only for their underlying HIV infection, but also for the complications of HIV infection. With regard to the pattern of the epidemic... raw numbers wise... the epidemic clearly on the whole in this country has plateaued. And as we've seen just recently, the actual number of deaths that occur from AIDS in the first part of 1996 has actually declined for the first time since the beginning of the epidemic. One could then say, as people like to refer to it, that the epidemic is plateauing and may even be on the wane. That's a little bit misleading, however, because it is still at a level that's an unacceptably high level. It's gratifying to know that a number of things have contributed to the stabilization of the epidemic within the population as a whole. But there are some sub-groups, within the whole, in which the epidemic still is raging and still excelerating - particularly among inner-city individuals, particularly women minorities...people who are disenfranchised from the usual access to the kinds of health care we hope most people would have. So it isn't as if across the board things are improving. There are some segments of population where things, in fact, are getting worse. But in general there has been a plateauing of the epidemic, so one would ask, what is the reason for that? The reason for that is probably several fold, one of which is the success in treating some of the complications of HIV infection, what we call the opportunistic diseases. Not only treating them when they occur, but also preventing or as we say, prophylaxing against them by treating for the infection before it even occurs. The next is the availability of new combinations of drugs. The decline in the deaths that we've just seen reported recently are a reflection of the success with combinations of drugs. Probably even those anti-dating the protease inhibitor combination, because the statistics began to show that turn even before the full impact of the protease inhibitors could be felt , so it's probably that we're going to see an even more impressive decrease. But that will be balanced off by the fact that some individuals who were delayed in the progression of their disease might ultimately progress a little bit later. And then also there's the question of the success in some respects of the prevention methods. The people who are entering into the pool of infected individuals, in some quarters, are decreasing. So you have those three things simultaneously going on and that's led to this stabilization and even decrease in the epidemic, from the standpoint at least of deaths and hopefully of new infections.

NEMA: Now, you mentioned that prevention efforts have been successful. Is it something to guard against - to get out a message that the reason we've improved is because we were trying the prevention methods...and not to let that slack off?

Dr. Fauci: Well, one of the things that's a matter of concern... to myself and other public health officials...is that when you start to get some good news in what has been a chronicle of bad news associated with this epidemic over the past several years, that there's always a danger that people in their breathing a sigh of relief, which in some respects is partially justifiable, they would then leave their guard down and feel that we don't need to be as aggressive in education, in preventive measures, in getting people to beware of the need, in certain circumstances, for behavior modification. We can not let our guard down. We got to this point of some improvement by a very aggressive effort both from prevention as well as treatment. And we can't assume now that everything is okay, because that's the easiest way of falling right back into an even more disastrous situation. So, rather than having this be something that can lead to a slackening up of efforts it should be an acceleration of efforts because it's been shown that these types of things work.

NEMA: Tell me more about those who are not getting the message...the areas where the disease still increases....

Dr. Fauci: As I mentioned one of the areas, or one of the groups that we're not seeing these improvements in are generally women, women of color, minorities in inner-city areas, heterosexual transmitted infection. Those components of the epidemic are, in fact, not going down... and there's a number of reasons for that. One of which is that group was later on in the epidemic where they had the major brunt, many of them come from areas, such as inner-city areas, where it is more difficult to outreach to them to get access to the kinds of care that one needs both from a preventive care as well as from a treatment situation. So there are a number of reasons why that particular group is not doing as well, so we need to target them more, particularly women, particularly in inner-city areas.

NEMA: Now a lot of people are, I mean many people are familiar with the term AZT, but I'd like to kind of bring them up to speed. You mentioned the protease inhibitors and I think that's something people aren't really familiar with, the technology or the biology behind that.

Dr. Fauci: Well, virtually every drug that's available for HIV targets a particular, vulnerable component of the virus in its life cycle. By its life cycle, I mean how it replicates or reproduces itself. One of the drugs, the AZT class of drugs, interferes with a particular enzyme that the virus needs in order to reproduce itself and that enzyme is called reverse transcriptase. Hence we refer to the AZT type of drug - and there are several of them that fall in that category - we refer to them as reverse transcriptase inhibitors. The protease inhibitors attack an entirely different target of the virus. Towards the end of the life cycle, the virus, when its getting ready to re-emerge from the cell that it has infected, it depends upon a particular enzyme to properly cleave different proteins. Hence the enzyme is called protease or proteinase. That enzyme is also vulnerable to a particular type of drug. The drug that has been developed to inhibit that enzyme is called the protease inhibitor. And that's the newest class of drug that we've had so much success with over the past year. Now there's a lot of other drugs in different stages of the pipeline, but those are the three major categories of drugs that are in use right now.

NEMA: These drugs are very expensive...there must be a variety of ways available to pay these expenses....

Dr. Fauci: Certainly, we need to make these drugs available for people by whatever means is feasible. There are a number of governmental, federal governmental, local, state and city government. Agencies that contribute, to varying degrees, in trying to get drugs paid for... so that people can get the optimal therapy. That, of course, will vary from city to city, and maybe even from region to region. But, in general, you have a combination of both federal and state and city aid.

NEMA: I understand...I've seen where New York City has really pumped money into making sure most AIDS patients have the drugs they need...but I guess there's more money available because of the large numbers of people affected there...

Dr. Fauci: I think what you've seen is that there was an increase in the Ryan White monies that were allocated to New York City and therefore allowed people to get greater access to drugs... and people are assuming, probably correctly so, that it's the accessibility and availability of the treatments which certainly contributed, at least in part, to the decrease in the death rate and deaths that were seen in individuals in the New York City area.

NEMA: Now, since we have seen a marked decrease in mortality in places like New York and across the country...what are the next steps? Where does the research go? What are the areas where we need to have better research and better tools to fight?

Dr. Fauci: Well, we need to do better in every area, including newer treatments... cause you like always to have newer drugs in the pipelines, so that when the virus develops resistant to the drugs that we have available - even though they're quite potent, and we're having great success with them - you always want to have a backlog of drugs that you can then come in and replace other drugs whose usefulness is no longer as great as it was previously. So, in the area of drugs, you certainly need more research and the development of different drugs with different targets or better drugs with the same target. Then there's a whole area of vaccine research, not only in this country, but worldwide. The solution to infectious disease epidemics like this is ultimately the development of a safe and effective vaccine. And certainly that has been a resurgence of effort here at the NIH and other areas of trying to develop a vaccine... putting new resources in an accelerated effort into that. So I think you'll be hearing more in the future, in the very near future, about accelerated efforts on vaccine development for HIV.

NEMA: Our thanks to Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases.

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.

NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.NEMAhealth.org ...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.