Taking Stock of the HIV Fight

Anthony S. Fauci has been on the frontlines of the AIDS epidemic since the disease first came to public attention in the early 1980s. The director of the National Institute of Allergy and Infectious Diseases is a pioneer in HIV research and a forceful policy advocate for access to AIDS care and treatment on a global scale. Now, more than a quarter century into the epidemic, Fauci says the time is right to take stock of strengths and weaknesses in the battle against the disease. 'It's clear from my perspective that there are variable perceptions about where we are with HIV,' said Fauci, in a talk last month at the Bloomberg School titled, 'HIV/AIDS: Much Accomplished, Much to Do.' 'We have to guard against any notion that we've accomplished so much that we can even lesson our efforts a little bit,' he said. For every encouraging development that Fauci noted--the advent of antiretroviral drugs, which between 1996 and 2005 have saved 3 million years of life in the United States--he countered with an equally discouraging fact: Only 28% of people in low- and middle-income countries who need ARV therapy are receiving the medications. Fauci pointed to the success of programs like the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria in delivering AIDS drugs to Africa. 'The conventional thinking was that it cost too much and they could never have them delivered in rural settings to people who need them,' he said. But he also noted that for each person put on ARV therapy in resource-poor countries, between three and six become infected with HIV._'We can't treat ourselves out of the epidemic,' he said. 'We can't abandon it [treatment], but it's not the answer.' On the subject of prevention, Fauci listed several proven strategies in heading off HIV infection: education programs, condom use, needle exchanges, treatment of other sexually transmitted diseases, and interruption of transmission of HIV from mother to child. But he said new prevention programs must be developed to reach at-risk populations, including gay African-American males, and existing strategies should be implemented on a larger scale. In the United States, Fauci said one of the most telling indicators of the need for new prevention approaches is the fact that the number of new HIV infections each year has been holding steady at approximately 40,000 for more than a decade. Furthermore, he said that new figures soon to be released up that number to 60,000 new cases. 'It tells us that we've really hit a wall in prevention,' he said. In more than two decades of research on HIV infection, Fauci said that one of the most significant achievements has been the development of a detailed understanding of the complex mechanisms by which the HIV virus attacks the immune system. 'We know as much or more about HIV than virtually any other microbe or virus we've ever studied,' Fauci said. 'This leaves us with very fruitful targets for the development of therapeutics.' 'But despite all the investment in research,' he continued, 'The great mysteries of HIV are what happens early on in the infection that seems to do irreparable damage. Even when you shut off virus replication, much of the damage has already been done.' In the past few years, Fauci said, an important area of HIV vaccine research has focused on the initial 'burst of viral dissemination' that occurs in the early stages of infection and leads to a buildup of latent reservoirs of the virus. He said these pockets of infection remain even after extended ARV therapy, and present major obstacles to eradication of the virus in infected individuals. 'I really feel that despite extraordinary scientific and public health accomplishments, that 'Much to Do' looms very large for us,' Fauci said, referring to the title of his talk. 'We're 26 years into the HIV pandemic, but history will judge us by what we do in the next 26 years as much as by what we accomplished in the first 26 years.' [Reproduced with permission of the Johns Hopkins Bloomberg School of Public Health, Baltimore, Md.]