music // Title screen reads: Back to Basic Toronto 2014. Jon Cohen. Ending AIDS: Aspirations and Realities. Jon Cohen stands at the front of an auditorium at the Back to Basic conference. He is alone on screen. An on-screen graphic identifies him as a journalist and Staff Writer at Science magazine.
Jon Cohen: So, there’s a tremendous optimism today about ending AIDS. UN AIDS, last week, announced their 90-90-90 plan. The US President, where I’m from, has spoken about it, as has our former Secretary of State, Hillary Clinton. We hear it from the head of the Global Fund, Mark Dybul, who formerly headed PEPFAR. We hear this optimism all over the place, and we hear it from Canada, and Julio Montaner, in Vancouver, has been a loud proponent of this notion.
And I want to just jump back in history. There were a lot of years that were really horrible.
Cohen displays a slide labelled “The Bad Old Days.” It depicts a protest at NIH which he describes below. In the photograph, a man crouches in a field of makeshift tombstones bearing messages like “dead from drug profiteers” and “poisoned from AZT”.
And this is a protest at the NIH that I attended in 1990, led by ACT UP, primarily. There was not a single anti-HIV drug until 1987. The epidemic surfaces in 1981, the virus is identified in ‘83, in ‘84 you have the definitive proof that it causes AIDS.
In ‘87, the first drug comes on the market — AZT. It doesn’t work all that well. Keeps people alive for maybe 18 months extra. And the AIDS activism movement emerges and grows with frustration. And the frustration is — targets things like government, and big pharma, and there are very few successes.
Testing as a success. The development of an antibody test for HIV was a remarkable success. And condoms, and counseling, and education. I obviously can’t spell — that’s counseling and education.
And, by ‘93, when there’s a conference in Berlin — the International AIDS Conference in Berlin — it’s called the “doom and gloom” conference. Because there’s just so much frustration, and outrage, about how slow things are moving, and how the only drugs that exist, then — AZT, DDI, D4T — don’t seem to do anything, together, that people had hoped they would do. And people are dying. And they’re dying young.
Cohen displays a slide showing a Newsweek cover from 1996, which he describes below. The cover includes an image of assorted pills with the headline “The End of AIDS?”
But then, in late ‘95 comes a protease inhibitor that adds to a cocktail, and by ‘96, this leads to Newsweek putting on its cover the “end of AIDS” with a question mark, which is a trick that journalists use when they want to be coy and say something without saying it. But that’s how much optimism there was. Now, at the time, I attacked this cover as well as a cover the New York Times magazine in an article I wrote for Slate as premature triumphalism.
Cohen displays a line graph, the details of which are unintelligible from the audience. The overall trend, which he describes below, is that the line, which represents funding to HIV, rises sharply after the year 2000, and reaches $19.1 Billion at its highest point in approximately 2013.
We saw this enormous surge in funding that occurred after the Durban AIDS meeting, in 2000. And, basically, in Durban, activism became an international affair. And the world was put on notice that, as Jeffrey Sachs, the economist, said at that meeting, it would cost a movie ticket and a bag of popcorn to get everyone in the world who needs antiretroviral drugs antiretroviral drugs. This must happen. And there was a Supreme Court justice from South Africa, an HIV-infected gay man, who judged the world, and stood in front of the audience and said, “This is like Nazi Germany. This is like apartheid. This has to end.” And, lo and behold, to the astonishment, I think, of everyone, it did change the funding stream.
The video jumps forward to another point in Cohen’s presentation. He displays a bar graph depicting the HIV treatment cascade, and the relative drop-off in the numbers of people who are diagnosed with HIV, engaged in care, on antiretroviral treatment, and virally suppressed.
So, access doesn’t equal use. This is — today, the CDC put out this information about the United States and our treatment cascade, and I imagine most of you have seen this, but, basically, what it’s showing you is that, in the United States, 14% of the people who have HIV don’t even know they have HIV. And then, of the people who know, only 40% are engaged in care, only 37% in total receive a prescription for an antiretroviral, and the virus is only fully suppressed in 30% of people. If treatment as prevention is going to do anything, people have to be fully suppressed. They have to be taking their medication. If they’re not, treatment as prevention isn’t going to work.
Cohen displays a bar graph depicting the HIV treatment cascade in Ontario. The bars on this graph are higher than the ones in the bar graph from the CDC, but don’t reach 100%.
Ontario has one of the best-looking treatment cascades I’ve ever seen. So, you know, congratulations to Ontario [applause] but, before you dance in the streets [laughter] you only have about, you know, it’s 60% of the people who are fully suppressed. That’s probably not good enough to do much, in terms of ending an epidemic. It will certainly slow transmission. It’s a positive thing. But you’ve got to do better.
Cohen displays a photograph which he describes below. In the photograph, a man in a nondescript jacket stands in a hospital corridor as hospital staff work in the background. Mattresses have been placed on the floor.
The systems in much of the world are overloaded. There are patients on the floor, here. This is in Hlabisa, in KwaZulu-Natal, and not far from Durban, in South Africa. This is last September. A your ago. This is not an ancient photo. They’re so overwhelmed, they have about 33% prevalence in their pregnant women. Yeah, one in three. So, you know, when you get to that level of prevalence, you have an incredible challenge to help the infected people and to do prevention.
So, what can we do better in prevention? One thing is, we can target micro hyper-epidemics. And this works very well, theoretically, in concentrated epidemics. It would be hard to do this in South Africa, but here in Canada, in the United States, Mexico, and Europe, and in much of the world outside of Sub-Saharan Africa, the virus is in specific populations. So, it is in men who have sex with men, it is in people who inject drugs and share needles, it’s in sex workers. You can concentrate your efforts on those populations.
Cohen displays a slide labelled “Target Micro Hyperepidemics.” Smaller text reads “Community Viral Loads: Target populations most in need.” Two images display heat maps of communities in San Francisco and Washington DC. The details of the maps are not intelligible from the audience.
But, what San Francisco has done is broken out where the viral load is highest in the city. So, this heat map shows you, in the darkest blue, which neighborhoods have the highest viral load. You can then target those neighborhoods, because something’s going wrong in those neighborhoods.
Cohen displays a photo of a woman in El Bordo, Tijuana, Mexico. The woman wears a parka stands outside a tent, clutching a syringe in her teeth as the Mexican flag waves in the background.
The key affected populations are marginalized populations. In my blunt language, are the hated populations. These are people who, by some segments of society, are hated. And, because of that, they’re not given the humane care that they need for their complicated problems.
The video jumps forward to another point in Cohen’s presentation. A slide shows two images from clinics in New York City. In one image, a man in a check shirt hands medical supplies to a woman wearing a ballcap who faces away from the camera. In the other image, a clinic worker in a lab coat, whose face is partially obscured, passes a cup through the partition that divides the staff area from the patient waiting area.
In New York City, they reduced — New York City has more injection drug users than any place on Earth. There are an estimated 200,000 in that city. They have reduced the new infection rate — that shouldn’t say prevalence — the incidence to below 1%. That’s astonishing. That’s just astonishing. In many populations that don’t do anything for injecting drug use and harm reduction, you’ll see the virus introduced and it will go into 50% of the population within six months. That is an astonishing accomplishment of New York City. That’s because they very aggressively offer clean needles, and syringes, and opiate substitutes, and counseling, and reunite people with their families. It’s a whole package.
Cohen displays a photo from Port-au-Prince, Haiti. In the photo a man and woman dance together in a classroom setting as specators watch.
There are creative ways to reduce risks as well. This is a dance instructor in Haiti teaching sex workers how to become dance instructors, so that they have an alternative way to make money.
Cohen displays a slide labelled “Exploit New Diagnostics.” A photo labelled “GeneXpert” shows a tray of labelled and colour-coded sample containers on a workdesk. A photo labelled “Abbott Architect” shows a man standing at a computer terminal, conducting an analysis.
There are new diagnostics now that more readily can detect acute infection with nucleic acid testing — in big machines like the one at the right. This is San Francisco, which recently has introduced it with its most progressive Department of Health, that I think all of us can learn from.
But there are these major structural issues that are underlying HIV transmission and treatment everywhere.
Cohen displays a photo from Tapachula, Mexico. In the photo, a man wearing a ballcap stands in front of a Spanish-language sign and a map of Mexico and Latin America.
Migration and deportation is one of them.
Cohen displays a photo from Providence, Rhode Island, in which a male inmate wearing a brown prison uniform sorts through pill packets in his bunk.
Prison is another. Prison is an excellent environment to get people on good treatment and care. They are captive and there’s a terrific program in Rhode Island, led by Jody Rich, that is a model, I think, for the world, of how to get prisoners on treatment and keep them on treatment. They use blister packs for their pills, and so, they can take them to their rooms and pop out their pills, and keep track of when they need — they teach them how to take care of themselves. And in a very good environment.
Cohen displays a photo from Birmingham, Alabama. Two men sit together in a modest bedroom, wearing shorts and t-shirts.
Mental health and homelessness are pervasive everywhere when people are having trouble staying on treatment. These were two transgender men getting help from a program in the United States that the federal government supports for housing for HIV-infected people. The man in the yellow shirt had jumped off a bridge and tried to kill himself, and the one on the left had also tried to commit suicide. They both need a lot of help. They need a lot of care to stay on their antiretrovirals. And, as the guy on the right said to me, “Why do I care about taking my antiretroviral drugs? I don’t want to be alive.” So, if that’s where you’re at, it’s going to be hard to get undetectable.
Cohen displays a photo from El Bordo, Tijuana, Mexico. In the photo, a man stands half inside a manhole while two others, wearing winter jackets, stand at street level and lean down to speak with him. City skyscrpaers can be seen in the distance.
This guy lives in this sewer hole. He has for many years. That’s his syringe, in front of him. When you’re living in the sewer hole, it is hard to receive help. These are Christian missionaries who are helping him, but they’re not helping him with his HIV problem, which is HIV risk.
Cohen displays a photo of Timothy Brown and Matt Sharp standing on opposite sides of the railing on a restaurant patio.
Cure is possible. Timothy Ray Brown is on the right side — [correcting himself] the left side of the image. Timothy had leukemia; he’s famous for his bone marrow transplants that apparently have led to his cure. And his two bone marrow transplants were for leukemia. He had an unusual situation, where his doctor realized that there were naturally resistant people, who had a mutation on their CCR5 receptors — one of two receptors HIV uses — and he found a donor who had those mutations. So, he received conditioning for his bone marrow transplant, which means he was — his whole body was irradiated. He was given chemotherapeutic drugs to kill off his own immune system. He, then, was given a donor’s blood, who had this weird mutation that’s in about 1% of Caucasians. He then also had graft-versus-host disease, because the donor attacked his body, as often happens with transplants. But graft-versus-host disease, as we know from leukemia, is also graph versus leukemia disease, which is good. And it’s also probably graft versus HIV. So, he had all this stuff going on. It’s been hard to figure out exactly why Timothy has been cured. But it’s a lead.
The guy next to him, by the way, is receiving a gene therapy that’s trying to do the same thing. That’s Matt Sharp, and he’s getting his own cells taken out, and his own CCR5 receptors crippled by the gene therapy, and then put back into him, to see if that might lead him to control his virus more effectively.
The video jumps forward to another point in Cohen’s presentation. Cohen displays a slide listing the “ingredients” to end the HIV epidemic: tests (HIV, TB, STIs); clean needles and syringes; opiate substitutes (methadone, bupenorphrine); condoms; circumcision kits; antiretrovirals; TB drugs; monitoring devices (CD4, viral load).
We know the recipe. We know how to end the AIDS epidemic. I just put it into recipe form, because it’s not that big of a deal. We know it all. These things have been proven scientifically to work.
Cohen displays a pictograph from UN AIDS, which he describes below. The details of the pictograph are unintelligible from the audience but the overall trend is that a wave of blue dots continues to fall at the same time as a wave of red dots continues to rise.
And, our character is our destiny, as the Greeks say. This is a new slide from UN AIDS that shows the two alternate scenarios. In blue, it shows what would happen if we used the tools we had today to try to stop the AIDS epidemic around the world, we could do it. We could bring new transmission rates below 1. In other words, we could bring each infected person down so much in risk that they were unlikely to infect another person. But the other trajectory, in red, is what’s going to happen if we just keep doing things at the rate we’re doing them right now. I’m afraid we’re far more red than blue. That’s my bottom line assessment.
Cohen displays a photo from El Bordo, Tijuana, Mexico. In the photo a woman in a yellow safety vest reviews a series of documents with a man who warmly wraps his arm around her shoulders. They sit on the edge of a cement slope while other men and women crouch around them.
Aspirations can match reality. The woman in the yellow vest works with the University of California at San Diego as an outreach worker with the injecting drug users who live in the canal, here. The woman in the yellow vest lived in the canal for eight years. She’s HIV-infected, she’s undetectable, and has been for years. She’s been off heroin for 14 years. She’s doing really, really well. And she’s my great sense of what can happen.
Cohen displays a slide labelled “many thanks” with a photo of a woman celebrating at a party. She laughs into the camera and raises her arms in delight.
And I just wanted to thank everyone, including OHTN, for having me, and all the people who have voluntarily allowed me to show you their photos. Everybody’s given me permission for that. And Malcolm, the photographer I’ve worked with for many years, and Science, which has given me this phenomenal job, where I’m able to cover this epidemic and travel as much as I’ve been able to. So thank you all very much.
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