Focus; The Worldwide Hiv/aids Pandemic

Good morning and welcome to focus 580. This is our talk show for the morning. My name is David Inge. Glad to have you with us in this first hour today. We will be trying to do a little background about where things stand now with the worldwide HIV and AIDS pandemic and our guest with the program is Dr. Thomas Quinn. He is a professor of medicine at the Johns Hopkins University School of Medicine. And in his research and clinical interest he's particularly interested in hithe and the sexually transmitted disease. He's here visiting in the community. And we'll be talking tonight at Carl's seventh annual HIV conference at the Carl forum. That's tonight. Between 6:00 and 8:00 and I'm told that it is open to the public and anyone who is interested in attending I think should feel welcome to stop by if you're interested in asking questions or just getting a sense of the basic. Place that we are now worldwide with HIV. I think that's the kind of thing that I'll be talking about it of course that's also what we want to try to do here this morning on the show and for people who are listening if you have questions. They are certainly welcome with the only thing we ask of people who call is that they

are brief as possible just so that we can keep the program moving and getting as many people as possible. But anyone is welcome to call 3 3 3 9 4 5 5 toll free 800 2 2 2 9 4 5 5. Those are the numbers. Well thank you very much for being here. Thank you for inviting me. It's a pleasure to be in the town. I just like to I guess start out by talking some numbers and maybe the most basic number. First of all would be worldwide how many people have been infected with HIV. How many people have AIDS. So it's a it's actually the numbers are estimates. There are no one really knows the exact number. What we believe is since the discovery of the HIV virus and this is now its 20th anniversary because it was discovered in 1984 and as we move into 2004 be 20 years and

we have discovered the clinical condition of AIDS for years before that. And if we start with the cumulative number of individuals worldwide who have become infected with with HIV in this 20 year period. Yes and it's about 75 million people. It's probably now the greatest epidemic of our times. And it continues the march relentlessly throughout the world. Africa has borne the scorch of the epidemic. Right now there's about 28 to 29 million people living with HIV in every year two to three million people die on that continent alone from untreated HIV. And that has resulted in a huge response right now worldwide there is forty two million people living with HIV and about 25 million deaths from this epidemic. What is it about the fact that of course this is an estimate. I

think we have reason to believe that there are probably significant numbers of people who have been infected who are HIV positive but who don't know it. Is there any way to put a number on that. Actually there is said they estimate that in Africa somewhere between 80 to 90 percent of people still carrying the virus don't even know they have it. So they unknowingly will transmit it to other people that's why the epidemics out of control there. The same is true in Asia where it's a newer epidemic for the last five to 10 years it's been marching through India and China and Indonesia and Cambodia and many other neighboring countries. So in the developing world the estimate is 85 percent of people do not even know they're infected. Now what about the United States this the estimates from CDC is that approximately one third of people infected with HIV in this country don't even know they have the virus. It's because you get when you get infected with HIV you can be

asymptomatic. For five to seven eight years and unless you get tested either when you go there donate blood or you go into voluntary testing because you might have recognized you have a high risk behavior that put you at risk. You're not going to know until you have full blown AIDS. Now it's too late. You really need to be identified earlier so you can access treatment and get care. And we have great treatment for HIV infected people especially in this country Europe and the developed world what we're trying to do is move that great treatment into the developing world where the need is even greater. But if an individual's HIV infected gets properly counseled and gets on the right treatment. They don't have to develop AIDS. They may have HIV for their life but they may not need to progress to AIDS with the right treatment regimens.

I think you know early on of course people will call the first place the disease was identified was in gay men. Right. And so people figured that it must have something to do with sexual behavior. And indeed it does but not exclusively with a kind of sexual practices that that gay men engage in. What we came to understand was that the virus was in very high concentrations in certain body fluids it's in semen but it's also in blood. So that means if you engage in some kind of sexual behavior that involves exchange of body fluids or if you and engage in some kind of behavior that will lead to some kind of blood to blood contact like injection drug use. Or it could be some kind of medical procedure if you have poor infection control then that's that's what's going to happen. So it is possible in sexual contact between people of the same gender or people of different genders can be homosexual can be heterosexual but also drug use. And then a variety of other things that people might be doing that involve contact with blood. So if you look at

all of that and if we understand real well now how it is that it's transmitted what now are the primary avenues of transmission particularly in the developing world in the developing world it is. And in the developed world we can easily say sexual transmission is the leading mode of spread of HIV. Probably 80 percent of all those infections we just talked about the 70 million or thereabouts has probably been transmitted from one person to another through sexual contact and again as you said it's either homosexual or heterosexual transmission in the developing world. The vast majority of infections have occurred heterosexually the male to female ratio is one to one. So there for every male in fact that there is a female in fact the vice versa in the developing world because heterosexual transmission is so common and misuse of needles even for medicinal purposes that are un

sterilized has bred HIV in China a terrible tragedy had occurred just recognize and he non-problems just two years ago where they were not sterilising the blood transfusion. A quick moment. And over 100000 people got infected with HIV because of non sterilization a blood transfusion equipment and nothing to do with heroin or drug addicts or anything like that. So in the developing world where you might worry about reuse of medicinal purpose you know needles or transfusion equipment that's still a major way of spreading HIV. But. In this country and I always like to bring it back because people are in Africa and they want to know what's happening in their community and so forth. We still have the same modes of transmission that were recognized back in in the early 80s except for two. Two are pretty much

almost nonexistent now and that's it's almost impossible to get infected through blood transfusion now because of the way we screen the blood so rigorously for this virus. So that was a problem before you know nine thousand nine hundred five after that. The numbers of cases who have acquired HIV through a blood transfusion is almost zero. This second mode of transmission is from mother to infant transmission and that has almost been a radical in this country and in Europe because we every pregnant woman should be screened for HIV even if she's been monogamous with the same partner all along. They still should be screened because if they're found to be infected with HIV they can be treated. Prolong their life for 20 30 years longer but they'll also through treatment prevent the baby from getting infected. And if you look at the numbers in the U.S. it's we have almost very

few cases of infants who have acquired HIV from their mother. Now that's different in the developing world because once again those people don't have access to treatment. So that leaves us with really two modes of transmission left in this country and that is sexual transmission. We're seeing more heterosexual transmission than we ever did in the past but we still are seeing this resurgence of HIV spread among gay men again. This is very problematic very troublesome because this was the main way as you said in the beginning of the epidemic through education of gays about risk reduction the spread started to decline in gay men. Now because of we have access to treatment people are getting a little bit more careless. We're starting the see an upswing we have epidemics of syphilis rectal gonorrhea and now HIV in gay men in most

communities across this nation. That that is really something that I really want to encourage the gay community to to rise to the occasion and start to go back to risk reduction education. The other way we still see a lot of spread is through injecting drug use and that's a national problem. Every community has this it's particularly bad where I live in Baltimore. And I would say over half of the patients I see with HIV are heroin addicts and getting them to either stop the drugs is more problematic than I think a lot of people realize and so we try to go to needle sterilization if they're going to continue to use get them into methadone clinics get them counseled then educated get them treated. So those are the two main remaining. Modes of transmission heterosexual and homosexual transmission and

injecting drug use. I should introduce Again our guest for anybody who might have tuned in here last five or 10 minutes or so. We're talking with Dr. Thomas Quinn. He's professor of medicine at the Johns Hopkins University School of Medicine and his research and his clinical practice he's particularly interested in the development of HIV and sexually transmitted disease and of the care of patients who either have HIV or sexually transmitted disease. He's here visiting in Champaign-Urbana will be speaking at the choral forum as part of choral seventh annual HIV conference tonight from 6 to 8. It is open to the public so if you're interested you can attend questions here are also welcome. 3 3 3 9 4 5 5 toll free 800 to 2 2 1 9 4 5 5. What do we know now about the about how much virus a person must be exposed to in order to become infected. Well you just hit upon my life's work of study this is this is the area that I've been most active and researching. And we went into Africa to

actually study this in heterosexual transmission. And what we find is that an individual who is infected with HIV. We can measure in their blood how much viruses is present and we measure it per milliliter of blood it's like a teaspoon of blood how much viruses in that teaspoon. And if the amount of virus is above fifteen hundred variance per M.L. of blood they are infectious and the higher that level the more infectious they are. So if a person gets newly infected with HIV the viral copies in that teaspoon of blood will be over two million copies. They are extremely infectious to another individual and they may feel absolutely fine. They don't even know they've just gotten infected. That's the problem a lot. We believe over half of all transmissions occur

in that very early period. Probably the first three to six months of when one person gets infected they will pass it to another person. And to try and find those people and educate them and get them to do risk reduction is obviously very difficult and that's why our epidemic continues at the same rate for the last 10 years. It hasn't the Kleins any more than what it was 10 years ago. In fact in some populations it's increasing like the game and that we just talked about. So we can measure the blood we can try to assess how infectious a person is now. There's complicating factors to this. What kind of sex do they have. Are they using a condom or not. Are they engaging in anal rectal sex which is highly risky but Faddle sex will transmit this virus either way if the virus levels are high enough. If a person has herpes and is infected with HIV there are two to

three times more infectious to their partner because of the breakdown in the skin and the ulcer the virus will spread directly from that her Paddick ulcer. And I bring up herpes because we now know from antibody studies about 30 million Americans have genital herpes have been exposed or have at least markers of have having had genital herpes Now not everyone has an ulcer when they're having sex from it but it any given time probably 500000 Americans probably have active her pedicle serves and if those people come in contact with an HIV infected person without practicing safe sex they bad virus will get transmitted. So while we say the viral levels are the most predictive of transmission the factors that in Hants transmissibility are sexually transmitted diseases like herpes syphilis is another genital that will enhance transmission. We think gonorrhea

and clim Idia also enhanced the infectiousness of an individual by increasing the shedding of the virus in the genital secretions what you had talked about before. So once we knew this then you can go about with biological interventions. That is treat those sexually transmitted diseases we have drugs that can suppress herpes and keep people from getting all serves we can treat the chlamydia gonorrhea we can treat the syphilis so will decrease infectiousness if we could get those people to come to STV clinics medical clinics get them treated. The other is through education and the education is extremely important in terms of knowledge and how you might be able to protect yourself from getting infected. You know number one is abstinence. Number two if you're having sex then you need to use a condom. Number three is avoiding anal rectal sex. That's very risky. Even oral

genital sex seems to enhanced some transmission because the virus is in the genital tract and if you have some bleeding gums or some ulcers in your mouth or canker sore or whatever maybe the virus will get in. So I think people need to know that now. The more controversial response to treat two to trying to prevent transmission is to treat all the in fact that people with antiretroviral drugs. That's expensive and it means getting people into care early very early. We do believe though with treatment you lower the viral load you lower that person's infectiousness. Everyone asked me does can you reduce it to zero. So I don't have to worry. Answers no you can not reduce it to absolute zero. The virus is still there we've never been able to cure a person yet. So while I can assure someone that there are less infectious. They're still infectious and they need to

practice safe sex if they're having sex. Let me go back because there's one underscore to two points that you've made not to belabor the point one simply because I think from time to time there has been some question some people have questioned the effectiveness of condoms as a barrier against the virus HIV and I have raised this question What is it really true do we know for sure that the HIV virus cannot. Assuming that assuming that it's your you know using a high quality condom and you're using it properly Are we sure that it that it cannot somehow get through the cone it cannot get through the condom. You mentioned all the important caveats though. Did they put it on early before sexual intercourse began. Did they leave the condom on until after completely after sexual intercourse. Are there no breaks in the condom. Etc. etc.. So. So if you do all the

caviar. If it is protective. Now you know a lot of people say yeah but c'mon you know pregnancies sometimes occur when people say they were using condoms. The fact is they didn't use the condoms right. And condoms can be very very effective. There's several studies in the literature some in the US some in Europe and now some in Africa in which they took couples in which one was positive and the other one was negative. And so a lot of the listeners might say well how did that one person get infected. Well in the US could have been a male hemophiliac. And that male came the faily act got infected before the blood was carefully screened back in the 80s. But that male hemophiliac was married so they then followed the wives of those men. And for those that said they always used a condom when they had sexual intercourse none of those wives got infected. For those that said they use the condoms intermittently. Some got

infected. For those that said they couldn't stand condoms they didn't want to use them. You know 15 20 percent of the wives got in fact that the same study with different population was done in Europe. Same result 100 percent use of condoms with sexual intercourse was 100 percent protected. Actually no one got infected. So I honestly believe if they're used right. They do work is it seems to be suggested to us here because as you say people have studied it in particular and when it comes to control of other sexually transmitted disease or as a contraceptive method that you do have people who say well you know we used condoms and it didn't work and then you say to them OK now you use the kind of right they say oh yeah yeah it's OK. Did you did you have any kind of sexual contact before putting the condom on. Did you know if you if you go right down the line and say to them OK now you're telling me you did it just exactly the way we

say from the. You put the condom on from the very beginning. Make sure that it fits properly. You know do you ever make sure when the male partner withdraws the condom is still you know all this kind of stuff. Then you people start saying well maybe not really so. If you do it exactly like you're supposed to then it really is. It really is effective both as a method of contraception and as a method of limiting the spread of sexually transmitted. Absolutely that's exactly right. One study once of individuals coming to a clinic and we educated them about using condoms and then we'd have them come back and we would say did you use them. And there's this type of you might call it a positive reinforcement that that they they sit there across from the clinician and they know that the clinician is looking for the yes answer. I did use sort of like a student would do to a teacher if I did my

homework. But then do all the homework. The same thing's often true between a patient and their doctor relationship. They they sort of don't want to be told I told you to use it and you didn't and so forth so we then did some biological testing on the people who said oh yes I always use that and we found out they were in fact getting infected with Committee and gonorrhea. Fortunately no HIV in this population. So we went back to those who got infected versus those who didn't. And we found out with a very detailed careful questionnaire administered by a peer. Rather than a clinician that they actually owned up that they didn't use them all the time correctly. So there are these these factors that you know have put a sort of a cast of doubt on use of condoms as a means for protection and so people have moved back towards abstinence and now abstinence. I mean we might as

well put that on for the listeners hundred percent protective. If it's truly absence now remember I did say oral genital sacs can sometimes transmit that so you have to be careful when we say abstinence What's what does that really mean. But there's people who are sexually active. And for them to go from their sexual activity to an abstinent life is it is I'll just say the word problematic. It's you know it's part of basic nature many needs of many human beings and and people have alcohol and they lose their inhibitions and while they might have intended to be abstinent they then remain abstinent if that happens you've got to have some means of recourse to protect yourself. Have a condom ready. Well a lot of women would like is empowerment of themselves always asking the man to have that condom is you know relies on on her

dependence on him. So there is a major effort to looking at female condoms if you want to call them that too using microbicides that might work. A lot of money is being invested federally to investigate. There's a big study underway of diaphragm use with microbicides protecting the cervix from getting exposed to the virus and so forth. But we don't have the answers for those women yet. But those studies are underway and we hope that at some point we will be able to have a means from which women will be totally empowered to protect themselves from their sex partners getting infected. And I must say in the developing world I said this in the beginning there are as many women in fact that as there are men this is not a gay disease. This is a heterosexual disease in the developing world in the US. Now if you look at all the new HIV infections

40 percent are among women. So women are getting it. They are not safe from. Are protected in any way from getting HIV. Let me introduce Again our guest with his part of focus 580 We're talking with Dr. Thomas Quinn. He's professor of medicine at the Johns Hopkins University School of Medicine in Baltimore and he's here visiting is going to speak at the choral forum tonight as part of Carl's seventh annual HIV conference tonight from 6 to 8. It is open to the public if you're interested in attending. You certainly may. Questions here do are also possible as always. 3 3 3 9 4 5 5 toll free 800 2 2 2 9 4 5 5. One of the thing I also want to go back to that regards heterosexual transmission. And I think the reason I want to ask the question is because it seems to me that at some point at least maybe some years ago and perhaps people still have this idea they I think that they understand certainly that the HIV virus is

present in semen and that if they think about it they probably would also understand that that in vegetal secretions that it would be there too but that I think that people have this idea that may or may not be the case that it is more likely that an infected man will pass the virus to his female partner then it is an infected woman pass the virus on to her male partner for for some some basic reasons has to do with the mechanics. Sex. Is that indeed the case that is that that women are at greater risk of becoming infected in heterosexual sex. Then are men in this country the answer is yes. And now you might want to say why do you just. Why do you cage that answer with just this country. And there are some. All the heterosexual studies are what we call partner studies between a man and

a woman in which one is in fact that and so forth in almost every scenario. When you you know look at the odds ratios it's more risky. Male to female and female to male. So we went into Africa where as I mentioned you know half of the women are in fact. When you look at all in fact that people half are women half are men and you're saying well how can that be if it's more infectious going male to female and so we went into couples and we found that among partnerships that have been going on for more than a year in which there has been sexual activity on average about twice a week. Among these couples so that might be one hundred sexual episodes in a year or something like that. And we followed them for over four years counseled them gave them condoms that all the appropriate means to try and prevent transmission but nevertheless we found a trained 20 percent transmission rate over the year and

it was equal male to female female to male and we said what's going on here. We didn't think it would go that way. And we found out that that. Female to male transmission if the male is circumcised is not very efficient. If the man is uncircumcised. Then it's equal transmission. Male the female female to male. So a number of studies were then done to say is this true across Africa. There are some tribal rites in which circumcision is performed. Muslims of course circumcise throughout Africa and many other groups do not and we found out those men that are getting circumcised have much lower rates of infection than do men who are uncircumcised. I hope I said that right. Yeah. So we went back to the US studies and we

found out that in almost all of those couple studies the men were circumcised. So female to male transmission was less efficient than male to female. When the nail happened to be circumcised. So this was done in in Europe that they got it arrests and then most European men are uncircumcised unless they're Jewish. And it turns out lo and behold male the female female to male transmission is equal when the male happens to be uncircumcised. So it looks like biologically a circumcised man is less susceptible to this virus. I'm not saying totally. You know not at risk he said he will still get infected if given enough exposures or has herpes or it is a sexually transmitted disease but sexually circumcised men seem to be less infectious. So this is turned out to

be an almost fascinating as to biologically Why is that. Turns out an uncircumcised man not to get too much into dermatology here but it turns out the epithelium of the four skin is almost identical to vengeance. Empathy Ilium. And the virus seems to be able to cross that barrier when the four skins been removed and circumcision firers that that skin then becomes cornea fied stratified cornea fied becomes much more resistant to the virus. Unless there's an all star then it can get. And that's why I think herpes and syphilis and Hance that transmissibility to men because it's broken down that normal barrier to the virus. So so there is a lot. There are several three I think big trials underway in Africa right now circumcising men and seen if it's going to protect them over time. We have to do something to slow

this epidemic we don't have a vaccine ready to go. The drugs that we have are expensive for trying to get them over there. Maybe we can talk about that in the second half. But until then we're dependent on behavior. Change to try and slow this epidemic. And that hasn't worked real well over the last several decades. We've had some positive Uganda has lowered their infectious rate. Thailand has and low has lowered theirs because the political leadership and education of the people right down to every village possible. So we have a lot of work to do but this is a new means we've never done this before go around circumcising then to try and prevent them from getting infected now for the women out there. For every man you can protect from getting infected that means every female sex partner of that man you've just protected her.

So so this is it has been encouraging and we'll have to await the results of the trial should be out in two years. But in the meantime thousands of African men are getting circumcised. Well let's talk about treatment because that is indeed one of the big things that has changed. We now have. Medications pack sort of collections of medications that were giving people common combination therapies that have proven very successful and prolonging the life of people who are HIV positive. It's not a cure but what it is what apparently is happening is that it's and we're making it possible for those people to to live longer. The downside is that these medicines are very expensive and certainly is expensive for people in the United States to take them but it's an even greater issue when we're talking about the developing world. And of course a number of strategies have been undertaken to try to get these medications

to places where we do where the where the numbers of people with HIV the largest where the rate of increases is the largest where really we are talking about a devastating epidemic. And we were doing that trying to do it in a couple of ways simply by just allocating money by having the developed countries say OK well we'll give you this much money to help fight the disease. And then there's this other issue of OK we know we have these medications. What can we do to try and cut down their cost can we persuade the drug companies to sell them for less than perhaps the most comfortable thing is to say well we're going to say to hell with patents we're just going to if you know maybe you're if you're a developing country you're going to say well we're just going to set up our own plant we're going to make it and if you don't like it that's tough. We've got people dying here and that's what we're going to do. So can we talk about where we are with all of that. You know there's been a an enormous global response to this need for treatment for the impoverished individuals throughout the world

and includes the United States and there are communities that still have difficulty getting access to drugs for their people. But for Africa let's take that right now there's three million people that need to be treated in Africa. They will die within the next six months to a year. If we don't get treatment to them. The Global Fund for AIDS Tuberculosis and Malaria was first developed two years ago by Kofi on the secretary general of the United Nations the United Nations General Assembly approved this program and has raised several billion dollars for treatment. It's not enough. And the stream going in is is not has not been steady enough and they'll probably run out of money in a couple years if it doesn't get maintained. That's that's what we call up you know. Bipartisan or an international response President Bush and his group of advisors

came up about six months ago with a different plan. And it's called the president's AIDS Relief Fund for AIDS Tuberculosis and Malaria and some of that money it's 15 billion dollars over over five years. Some of that money will go to the Global Fund. But most of it will go to 14 countries that have been listed as the most hard hit countries in the world for AIDS. And the secretary of Health Tommy Thompson was just in Africa with all of Embassador Tobias who is in charge of this program. And we hope that by the end of January if they on the bus bill gets approved finally and so forth is that the political nature of AIDS is incredible but not keeping on the medicinal side. If these funds start to flow to these needed countries well actually we'll start to see movement

of treatment to these individuals. Now you raise the issue. Trade drugs versus generic drug and how do you address that. The pharmaceutical companies have reduced their prices for Africa because they that there's no profit there so they might as well give it cost because they can't afford it at the higher prices. Doesn't even get used to so they. They did work with the UN AIDS which is sort of the international coordinating body of this to lower their prices to cost. So when the generic companies start to say hey heck with this we're going to make our own drugs and heck with patents. Turns out the price of those drugs are to much lower than what the pharmaceutical companies are making their trade drugs cost available in that country. With this new money the WTO and again here comes the

politics and other groups have basically said hey. If the country has a national emergency with this epidemic they should be able to get drug wherever they can get it and if it means going to generic makers fine. They will not be penalized in the trade wars that we have going on internationally. This is a national medical emergency for that country and they can use whatever drug they can get their hands on. They can work the pricing levels and see what works best. The person who's been most active in bargaining for this is it was a surprise to me at least. But past presidents usually get pretty that OK to do humanitarian efforts we see that with President Carter The President Clinton has sort of dedicated his post-presidency to getting lower price drugs to the people who need the most and he just returned from South Africa from the Caribbean and has been very proactive in lowering prices of generics and of the

trade drugs so that people can get them right now in Africa. We can probably treat an HIV infected person with triple drugs which was sort of the standard now in the US for about one hundred fifty three hundred dollars a year a comparable price in the United States is about $15000 a year. So we really have gotten those prices down in in these impoverished countries. Even still if you think about one hundred fifty three hundred you might say oh wow that's great that's really low. But for people in Africa that is their total annual salary. To pay for those drugs. So they they would have to give it away their entire annual salary so how do they feed their family how do they take care of other problems. So even though we've gotten prices down we need the governments and private industry to step forward to help with the donations that help provide

these drugs. Finally after I don't know how many years South Africa has finally stepped to the plate for those people can't afford it. We will make the drugs available. Other countries are doing the same. We do that in the US if you if you cannot afford treatment out of your private insurance or if you're uninsured or whatever we have a safety net and people can access treatment. It's you know it's a bureaucracy we have to go through a lot of forms but people can be treated so I think two years from now we're going to see a huge difference. Right now I'm just frustrated that I don't have the drugs to treat my African patients the way I do for my Baltimore patients. Well certainly the pharmaceutical industry has come in lately for a lot of criticism because people say you know one of the things that can really contribute significantly to the high cost of health care is the high cost of prescription medications. And we have more and more people who are taking more and more medications.

And some people have really targeted the industry and said that they are making unreasonable profits and that something should be done about it and you know here's one of these cases where obviously the pharmaceutical companies have tried to address this issue if for no where the reason the public relations. How well do you think that they have done and are are they doing everything that they can can do you know can't can one say is that they're still unreasonable sort of profiteering going on here taking advantage of people who have this devastating disease. Or would you say well no in fact on balance they're they're not doing too bad in trying to make make those medications available to make it possible for people who need them to to go. I'm going to answer it a little indirect way. I'm going to tell you one of the issues that patients have to face and that is they don't take their drugs all the time. They're going to develop resistance bands as we call it and here insert patient

compliance to the drugs that's true with any antibiotic. And it's true with HIV mutates constantly. And if you stop taking your medication you miss a couple of those as the virus says OK and then it starts to evolve to a resistant form. The pharmaceutical companies have actually responded to that need. There are now 20 drugs on the market for treatment of HIV and more coming there's at least 20 in the pipeline now who pays for the research for the development of those new drugs. The generic companies do not. Generic companies just basically take what's already been approved and then copy it in their factories and give it at a reduced cost. And that's fine when patents run out and so forth. So what the pharmaceutical response has been we need to make some money on the licensed approved drugs that are out there. Take that money and turn it

around and put it in R&D and start to come up with new anti retroviral. So you know we often will look at the profit margins and we say where is that money going is it going to shareholders. Well people who own stock in the pharmaceutical companies will probably say yeah I do want my stock to go up for people who don't own stock and who say this is this is you know privateering and this is taking advantage of Port people. You know there is there is a segment of truth to that but but I must say some companies have been more responsible than others. I'm not going to name names but some of the companies have really led the way. They've donated money for the people and for institutions that need access to treatment like in Africa and they have made their drugs available for free. Charge no money. Some of those companies need to be applauded for what

they're doing not chastised for you know over pricing in other arenas. Some companies make a lot of money off of their cardiac you know Lipitor lowering drugs and hopefully if there is some money made there that will go to this other niche of the company to help develop treatment for HIV infected people. We need new drugs constantly. Somehow we have to depend on the pharmaceutical industry to make those drugs. They need money to make those drugs the only way they get it is through some of the profits that they get for charging. I just hope everyone understands the economy of that. I would love to see them give more drugs away for free for the people who can't afford them or to work with governments that will help pay for that as well. So it's an indirect answer but I hope I hope the listeners get to see both sides of the equation. We just have a couple minutes left. There's one thing I guess I wanted to touch on real quick the end and you

talked about the fact that the virus HIV is constantly mutating that's what makes it very difficult to deal with it's very tricky. What do you think the possibility is that at some point we might see a vaccine for HIV. Well I said there were 20 drugs that are licensed and can be used. There's at least 20 vaccines that are being tested. I don't know what's taking so long. This is probably this is been the biggest frustration for all the scientists in the field. The virus just keeps evolving it keeps changing and a lot of money a lot of effort has gone into trying to come up with a good effective vaccine. We've just completed internationally 2 trials for what we call Phase 3 trials this is for Africa say for protective. In this they failed. They did not work over 15000 people got vaccinated and it didn't

work at all. Very discouraging. Do we give up hope do we stay optimistic answers. Yes we have to stay hopeful that you know our technology keeps moving maybe at some point our technology will be a step ahead of the virus. We did it with drugs. We can now treat can't cure but we can treat people and keep the virus in check. I think we'll be able to come up with a vaccine. At some point I don't want to even put a timetable on it. If people think there's going to be a vaccine in five years forget it. You can take that long to just test the ones in the pipeline right now. So we're still talking 2010 before there's safe and effective vaccine out there. That sounds like a long time from now. Well we have come to the end of the time I want to again tell people who are interested that our guest Dr. Thomas Quinn will be speaking tonight at the carle forum this is part of Carl's seventh annual HIV conference that's tonight from 68. And it is open to the

public so people would like to hear more. They can certainly do that Tom Quinn is professor of medicine at Johns Hopkins University School of Medicine in Baltimore. Well thank you very much. Thanks very inviting me. Thanks for listening.