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Q.
Why did the first cases of PCP and KS attract
your attention?
A. Prior to these cases, CDC epidemiologists had investigated a variety
of new outbreaks, including toxic shock syndrome, Legionnaire's
disease, and swine flu. When the first cases of PCP were reported, many
of us who had worked with gay men in studies of hepatitis or sexually
transmitted diseases knew quickly it was an important problem that deserved
focused and immediate attention.
These cases were important because previously
healthy people were dying of an unexplained disease. It was clustered
among gay men, it was fatal, and the cause was unclear. We needed to find
out was it new? Was it restricted to Los Angeles and New York? Was it
restricted to gay men? Was it increasing? And what was the extent of the
problem?
Q. How did you and the CDC confront this problem?
A. The first step in understanding this apparently new epidemic was to
develop a case definition and conduct intensive surveillance for cases
of Kaposi's sarcoma and opportunistic infections, which we later
termed as AIDS. The case definition was intended—and subsequently
proven—to be highly specific. This definition was rapidly adopted
worldwide. It allowed for precise and consistent identification of epidemiologic
patterns in the United States and other parts of the world with sophisticated
health care.
Q. How did the disease come to be named AIDS?
A. After a year or so, we felt a need to pull together the collections
of opportunistic cancers and other conditions under a name that could
replace the various terms being used—Kaposi's sarcoma, opportunistic
infections, GRID
or gay-related immune deficiency. The CDC started to use the name AIDS—acquired
immune deficiency syndrome—to best describe the underlying problem
that ultimately was found to be caused by HIV (human immunodeficiency
virus) in 1983.
Q. How did HIV/AIDS evolve?
A. The period between 1981 and 1986 was a time of tremendous discovery.
During the first two years, modes of transmission were defined. Scientists
confirmed the disease among gay men, intravenous drug users, and their
sexual partners. They also investigated three cases of PCP among men with
severe hemophilia A and no other known risk factors. The identification
of these and other people with hemophilia provided solid epidemiologic
evidence that a blood-borne and sexually transmitted pathogen caused AIDS.
Completing the picture, investigators confirmed AIDS was transmitted from
mother to child and through heterosexual contact. The CDC took important
steps to protect health care workers and blood supplies and to educate
the public about transmission and prevention. In 1983, investigators at
the Institute Pasteur in France identified HIV as the virus that causes
AIDS. In 1984, the diagnostic test to detect HIV in the blood became available.
By 1986, Dr. Meade Morgan, a colleague at the CDC and an eminent RSPH
alumnus, predicted a total of 270,000 AIDS cases through 1991, thus forecasting
enormous morbidity, mortality, and health care costs for the nation in
the ensuing years.
Q. During this time, you led the CDC's effort to formulate recommendations
to protect the nation's blood supply. What was the result?
A. In early 1983, before the discovery of HIV, the CDC and the U.S. Public
Health Service recommended that persons at increased risk for AIDS not
donate blood. Testing the blood supply was a breakthrough. There were
relatively few tests for infectious diseases that were implemented before
the AIDS era. Now there are more than a dozen tests to protect the blood
supply. This was because of a tremendous effort to eliminate infectious
diseases from blood.
Q. When did the global extent of AIDS first become known?
A. Data collected by researchers at Project SIDA in Zaire demonstrated
an extensive epidemic there in 1984. It was the highest estimated HIV
infection rate in the world at the time. This year, the Joint United Nations
Program on HIV/AIDS reported more than 25 million deaths by the end of
2005 and nearly 40 million people infected worldwide. With nearly 3 million
deaths in 2005, HIV/AIDS is now the fourth leading cause of death in the
world. With 4.1 million new infections in 2005, deaths will likely continue
to rise.
Q. When did the first drug therapies for AIDS become available?
How did they progress?
A. In 1987, AZT (azidothymidine) was licensed as the first antiretroviral
drug to treat HIV. In the 1990s, the biggest news concerned two discoveries.
First was that providing AZT to HIV-infected women during pregnancy could
reduce the risk of transmission to newborns. The second was the availability
of highly active antiretroviral therapy or HAART. This therapy, which
combines at least three drugs, has greatly prolonged lives and improved
the well-being of millions of people throughout the world. Antiretroviral
drugs were discovered by a variety of people, mostly in this country,
and Emory has played a major role in their development. Two of the major
drugs—3TC and FTC—were invented here by researchers Dennis
Liotta and Raymond Schinazi.
Q. At the time of these discoveries, you observed a sense of complacency
about HIV/AIDS. Why?
A. In the early 1990s, a sense of complacency emerged, particularly in
the United States and developed countries, when the number of HIV/AIDS
cases began to level off. There was a feeling that the horizons were clear
and that people could understand who was at risk and who wasn't.
The general population began to implicitly accept the current number of
cases.
Q. How do you combat that sense of complacency?
A. We all exist in a social, cultural, and economic context. We also live
at a certain level of health and a certain level of public health. But
there are great differences in the health of some populations and in the
health of some countries. When a new epidemic or disease comes along,
we are tempted to say, "Oh my goodness, we've become such
an obese country. Oh my goodness, we have 40 million cases of AIDS throughout
the world. That's just the way things are. We'll just have
to accept that." Improving the health of a population or country
requires looking for ways to redefine the unacceptable and rise above
the status quo.
Q. How do you maintain commitment to HIV prevention?
A. It's important to realize that 4 million people are having sex
for the first time each year in the United States and that education and
prevention efforts must continue. We can't sit back and say, "Well,
we did comprehensive sex education 10 years ago. Why do we need to do
it now?" There's a need for constant renewal of information
to go along with the renewal of potential risk.
Q. From the beginning, HIV/AIDS has been a source of social controversy.
At one point, protesters spit on you, and your face appeared on 20,000
postcards sent out by activists. How did you react to that?
A. I, Tony Fauci of the NIH, and others from the CDC were speaking at
a public engagement when we were targeted. Many government scientists
were seen as representatives of the U.S. government as a whole. To some
extent, you have to take that kind of protest and figure out the meaning
of it and not take it personally. Is it legitimate? Why is it being conducted?
Is there truth in what they say?
Q. Was there truth in what they were saying?
A. There was an enormous amount of impatience regarding the government's
response to AIDS. People were dying. The diagnosis of HIV or AIDS was
a death sentence, so they were impatient to help find more effective therapies.
And they were mistrustful of government, particularly homosexual men and
women and injecting drug users who felt their behavior, and sometimes
their very existence, was seen as criminal by some people.
Q. What lessons from HIV/AIDS can be applied to other diseases?
A. There were lessons to be learned from tracking and combatting the disease
and working with communities and the social environment. There were advantages
in the discovery of drugs to combat it. For example, 3TC, which was invented
here at Emory, is also effective against the hepatitis B virus. The social
activism of the 1980s, which brought public and private attention to AIDS
as a health problem and as a public health problem, has been shown to
be effective for cancer and other diseases.
Q. In 1995, you left the CDC to become dean of the RSPH. What
was the HIV/AIDS research culture like at Emory?
A. There were a number of investigators working on HIV/AIDS across Emory.
Most of their work was domestic. There was little work globally. David
Stephens, director of the Division of Infectious Diseases in the School
of Medicine, and I formed an AIDS interest group. From there came a desire
to grow and coordinate AIDS research more effectively and to recruit more
expert faculty. In 1997, the RSPH, the School of Medicine, and the Yerkes
National Primate Research Center formed the Emory Center for AIDS Research
(CFAR), with funding coming from the NIH a year later.
Q. What has CFAR enabled Emory to do?
A. Emory is one of 21 federally funded Centers for AIDS Research in the
United States. Our center is unusually broad in its vision and initiatives.
Prevention is a central theme—health education, research on preventing
transmission among adolescents, developing and testing of HIV vaccines,
testing microbicides, and prevention and treatment of antiretroviral infections
and tuberculosis to prevent complications from these diseases. We work
with colleagues in Atlanta, throughout the United States, and in several
developing countries, including Rwanda, Zambia, South Africa, Ethiopia,
and India. Emory doctors care for 6,000 to 7,000 patients annually. That's
one of the largest HIV/AIDS patient groups in the country.
Q. What is CFAR's greatest accomplishment to date?
A. CFAR crosses schools and centers to create a multidisciplinary research
environment. We now have three directors—myself and Carlos del Rio
and Eric Hunter, who are both in the School of Medicine. We bring complementary
talents, interests, and geographic settings to the endeavor. There's
a huge difference in awareness, capacity, and accomplishments among AIDS
researchers at Emory compared to nine years ago. We have an active group
of more than 100 faculty who are really making a difference. In the past
nine years, funding for AIDS research at Emory has more than tripled to
$55 million per year.
Q. What comes to mind when you think of the face of HIV/AIDS?
A. Many times in public health, we categorize health in terms of numbers,
economic impact, social impact. We talk about rankings in terms of deaths,
increasing numbers of cases, decreasing numbers of cases. But the true
impact of the problem affects individuals.
They are people who suffer and die, often
needlessly. They are people who survive and overcome enormous difficulties
to become the beneficiaries of science and care and who become leaders
in their own right.
They are people who work on the problem.
People who study it. People who volunteer with organizations. Young graduate
students who are inspired to go into public health because of concerns
about AIDS or people they know with the infection. Generations of people
who often take their passion and mission in life from their experiences
or concerns about friends or citizens. They are scientists, doctors, nurses,
public health workers, and policymakers who willingly use their time,
social capital, and influence to deal with the problem. All of these individuals
have a personal stake in HIV/AIDS.
Q. What lies ahead for people with HIV/AIDS?
A. The next 25 years of HIV/AIDS will go by in a heartbeat, just like
the first 25 years. The high rates of infection in sub-Saharan Africa
will level off through intervention and a growing capacity among people
to speak frankly about risks, stigma, and HIV counseling. HIV/AIDS tends
to settle in places where poverty is greatest and where resources are
often diverted to other problems. It's still on the rise in China
and has become a substantial problem in India and Eastern Europe. Ultimately,
HIV/AIDS will remain a huge public health problem, barring the availability
of creative therapies and a vaccine. We need both.
I'm optimistic they will become available
and the world will find a way to use them. In the absence of that, prevention
is vital for a world where people, communities, and nations can talk openly
and comfortably about sexuality and the stigma of HIV/AIDS.
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A
Research Powerhouse |
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By
pooling resources and expertise, the Emory Center for AIDS Research
(CFAR) has become a powerhouse in the global quest to help individuals,
families, and populations affected by HIV/AIDS. Since its startup
in 1997, funding for HIV/AIDS research has more than tripled
to $55 million a year. Currently, 163
studies are under way.
Essentially, the Emory CFAR is
a giant umbrella encompassing the RSPH, where the center is
housed; the School of Medicine; Yerkes National Primate Research
Center; the Emory Vaccine Center and the Hope Clinic for vaccine
and microbicide testing; Emory Crawford Long Hospital; the Ponce
de Leon Center, a highly regarded outpatient HIV/AIDS clinic
operated by the Grady Health System; and the Atlanta Veterans
Affairs Medical Center.
More than 100 Emory faculty members
are engaged in CFAR through collaborations in behavioral and
social science, medicine, nursing, statistics, virology, pharmacology,
and immunology and through partnerships with government agencies,
private AIDS researchers and clinicians, and other universities.
Several service cores spread across campus support their research
in prevention science, vaccine development, AIDS pathogenesis,
and clinical science. Three of those units—the Biostatistics
Core, directed by Michael Kutner; the Social and Behavioral
Sciences Core, directed by Gina Wingood; and the Administrative
Core—are in the RSPH.
CFAR faculty stay attuned through
a website and through the Vaccine Dinner Club and the CFAR AIDS
Soiree, successful programs featuring prominent speakers. Just
as important, CFAR provides funding to help junior faculty jump-start
their research programs and to recruit key investigators.
Three co-directors lead the center.
James Curran, dean of the RSPH, serves as CFAR's principal
investigator. Carlos del Rio (below left), an expert on HIV/AIDS
in developing countries, treats patients at Grady Memorial Hospital
and the Ponce Center. Eric Hunter (below right), a Georgia Research
Alliance Eminent Scholar, is among the world's leading
experts on retroviruses and maintains a laboratory at Yerkes.
To learn more about CFAR, visit
the new website at www.cfar.emory.edu.
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