Belgium-born infectious disease specialist Dr. Kevin De Cock is the director of the World Health Organization ( WHO ) Department of HIV/AIDSa position he has held since 2006. Prior to signing on at WHO, Dr. De Dock spent six years as the director at the U.S. Centers for Disease Control and Prevention ( CDC ) in Kenya and as director of the CDC Division of HIV/AIDS Prevention, Surveillance and Epidemiology in Atlanta.
Windy City Times had the opportunity in July to speak with De Cock in Atlanta.
Windy City Times: Two new studies were released with findings of a significant decrease in HIV/AIDS transmission by using PrEP and the drug Truvada. Can you explain to us why these new findings are so important?
Dr. Kevin De Cock: Sure. In the past couple of years there's been a tremendous sort of resurgence of interest in HIV prevention and important scientific findings concerning new interventions. At the international AIDS conference held in Vienna in 2010, a study was presented showing efficacy of a vaginal microbicide containing Tenofovir. The study showed that it offered partial protection for women in regards to becoming infected with HIV. The important thing about that study in 2010 was that it, firstly, showed that it was possible to develop a vaginal product that women could use, that was under the woman's control and that this could be efficacious. But of course the product contained an anti-retroviral drug so it was … proof of concept also of pre-exposure prophylaxis; in other words taking a drug before an exposure to prevent the establishment of infection. It's just in this case the drug was delivered topically rather than taken by mouth.
So that was the first study last year and then, as you know, about eight months ago there was another study in gay men that showed that taking the pills by mouth also prevented the establishment of infection in uninfected men. And now we have two studies in heterosexuals showing protection in men and women. An additional reason that so much attention is going to these two studies is that a few months ago there was yet another study called a FEM-PrEP study which actually was stopped early because it wasn't showing any benefit. So in a way these additional studies that have just come out are sort of supporting the study in gay men and suggesting that that negative study in women, the FEM-PrEP study, was probably negative, you know, failed to give a positive result, for other reasons.
In addition to all of that, there have been other very important data showing that treatment of infected people reduces their likelihood of transmitting the infection to an HIV-negative person. So all of this, what all of this shows, literally in the space of about a year, is just a tremendous amount of new information highlighting the very important role that anti-retroviral drugs play … or can play … in HIV prevention.
WCT: How important is mass education in the wake of preventing and possibly finding a cure for HIV/AIDS?
KDC: Well I think AIDS is the kind of problem for which we'll never have a single magic bullet because, you know, it's fundamentally a disease … or it's an infection … that is transmitted through behaviors, through very common and human behaviors relating to sexual behavior, drug-using behavior and reproductive behavior, you know, having children. We have pretty much completely closed down the transmission of HIV through blood transfusion; certainly in high-income countries and to a considerably large extent in low and middle-income countries as well. So transmission of HIV through blood as a blood product is not a huge issue anymore the way it was at the beginning of the epidemic. But, you know, human behavior will remain a constant issue as we try to control HIV-AIDS and then there's, of course, also a very important behavioral aspect related to healthcare seeking behavior, adherence to drugs, adherence to interventions, you know, and so on. So there's much more to it…to HIV/AIDS than just commodities and biomedical intervention.
WCT: From your experience to someone reading this interview having just been diagnosed with HIV/AIDS, what are the major differences say, today, as opposed to being diagnosed 30 years ago?
KDC: Oh it's a night and day difference. At the beginning of the epidemic…it's difficult to describe what it was like. I don't know how old you are. Were you around?
WCT: I'm 28, so I was not around. Almost, but
KDC: Well that's amazing actually. I mean it's…it's difficult to describe what it was like. It was…I mean the fact that this disease apparently came out of nowhere…that wasn't understood, the virus hadn't been discovered, and there wasn't a blood test. What you saw was initially gay men and then drug users and then the recipients of blood transfusions and transfusion products…particularly young hemophiliacs. You saw these people presented with terrible infectious diseases that basically were incurable. And these people were young, by and large, and they rapidly went on to die.
KDC: And then the numbers started increasing and the spectrum of the disease broadened, in other words, other things started to be noticed like men would lose weight and develop swollen lymph nodes, and that was a pretty sure sign that down the line they were going to get the full-blown disease. So there were just so many things to work out. Then we saw women getting it…becoming ill. Clue by clue was pieced together and…for example, the first cases in women were very puzzling but then it was found that, well, yes, but their husband had had male-to-male sexual contact when he traveled away from home, and one saw these sorts of observations. And then, you know, the recognition that this wasn't just in the United States, but in other industrialized countries cases were seen, and then in Europe black Africans were showing up coming for treatment from Africa. And then, I mean, it just went on and on and on and just more and more information, and it was just…it was extraordinary. It was really a steep change from before.
But today, we are familiar with AIDS, we understand the infection, the natural history of the disease, there are very good blood tests and other tests, and most importantly, of course, we have very effective therapy. Having said all of that, this is not a disease that anybody wants. This remains a…you know, it's not a good disease to have. It's difficult taking medicines for the rest of your life, because the drugs do have tough side effects. And we don't really know yet, because we haven't been doing this long enough, you know, whether people with HIV who go off to therapy, whether in fact they will live a normal lifestyle or not. It wouldn't be surprising. It's what we see with most other diseases that in fact, you know, life is shortened. But we don't really know that, because the therapies are very effective and we haven't been following people for long enough. But, so in other words, it's a completely different situation today, but we still need a lot of attention to it. People still need support. There still is stigma and discrimination. People still need prevention support to make sure they don't transmit the infection to others. They need to adhere to their drugs, etc., etc. So it's not…simple, but it is completely different.
WCT: Are there specific areas in the world where we see a pattern of an increase or decrease in the number of newly infected individuals?
KDC: No, I think…there's reason to be optimistic, but there's also reason to be concerned. I think that globally we're seeing a reduction in the numbers of new HIV infections, and that's continuing to occur. The peak in new infections was probably about 10 years ago, and the number of new infections has continued to decline and is still doing so, so that's encouraging. Nonetheless, it still means we're having well over 2 million new infections globally every year…about 2.5 - 2.7 million new HIV infections or something like that. That's still a lot of new infections and it's just adding to the total burden of people living with HIV. With our better understanding of prevention and these new modalities, I think we have remarkable opportunities to do even better and to really have a substantial impact on the epidemic, particularly through expanding HIV treatment based on some of the new science that has come in.
Having said all of that, and I think of interest to your readers, because of your area of focus, I am very concerned about the epidemic amongst gay men…men who have sex with men. Firstly, we are not seeing a reduction in new HIV infections in gay men in the United States. The number of new infections has been quite stable for quite some time at over 50,000 new infections; about 56,000 is our estimate in this country, and that hasn't really changed. And one has to ask; the way trends are...can we accept this? Is it just…do we have to sort of just think that it is just inevitable that in the life of a gay man, there is a very high…probability that he will become infected with HIV before the end of his life? I mean that's a terrible thing to accept, but you know the cumulative risk for gay men remains very high.
The other point to emphasize, the second point, is that we now recognize that, of course, there are gay men all over the world, men who have sex with men, all over the world, including in countries where we didn't think or where very little attention went to this issue. And when studies are done, we do find that gay men have increased rates of HIV infections compared to