As Anthony Fauci marks 40 years since HIV emerged, he regrets how the extraordinary disruptions that Covid-19 have wreaked upon society have hampered efforts to tackle the major pandemic that preceded it.
The longtime National Institute of Allergy and Infectious Diseases (Niaid) director was one of the chief architects of a federal plan, launched last year, to meet the audacious goal of largely ending the HIV transmission in the US over the next 10 years.
Now, at 80, Fauci looks back half a lifetime to that foreboding early summer of 1981, when he read the first case reports about what would become known as Aids. He marvels at how epidemiological history in many ways repeated itself with Covid-19. And he hopes that the HIV fight will also benefit from a vaccine.
Fauci also knows what an unsung debt the Covid-19 response owes to HIV research. The nation’s top virologist said he would “argue forcibly with anybody” that had the HIV pandemic not helped train vast armies in the scientific, medical and public health sectors to mobilize in a moment of crisis, the battle against Covid-19 would be much further behind where it is today.
“It’s no accident that a lot of people who jumped in to address Covid right away are people who are involved in HIV,” said Jennifer Kates, director of global health & HIV policy at the Kaiser Family Foundation. “They’re a group of diverse scientists, activists, epidemiologists who said, ‘An emerging infectious disease that’s starting to harm people and kill people – we’ve been here before.’”
Fauci said: “What I learned from HIV was very helpful in my appreciating how Covid-19 evolved.”
The highly effective Covid-19 vaccines now sending the US epidemic into retreat were whisked with lightning speed through clinical trials thanks, in many ways, to HIV paving the way.
In March last year, Fauci began overseeing the retooling of three major HIV global clinical trials networks into the Covid-19 Prevention Network (CoVPN). This meant teams of investigators already skilled at recruiting and retaining diverse participant populations, dealing with byzantine regulatory requirements and paperwork and conducting necessary statistical analyses soon enrolled tens of thousands into trials that have given the world the Moderna and Johnson & Johnson vaccines.
Fauci praised the “elegant science” that went into selecting the most promising Covid-19 vaccine candidates – a process, he stressed, facilitated by the pioneering efforts of HIV vaccinologists. Over the decades, such researchers honed the methods that in Fauci’s words allowed scientists to “determine the precise confirmation of the SARS-CoV-2 spike protein that allowed maximal immunogenicity, thus leading to high efficacious vaccines”.
Larry Corey, director of the HIV Vaccine Trials Network – one of the three National Institutes of Health–funded networks that collaborated to launch the CoVPN – said that without the HIV research field, scientists would not have had at the ready the non-human primate research model that was used to transition from laboratory studies to human clinical trials of Covid-19 vaccines.
“We were able to do this in 11 months, start to finish, because science does build on science,” said Corey, who has run the HVTN out of the Fred Hutchinson Cancer Research Center in Seattle since 1999.
On the east coast, Myron Cohen, a professor of medicine at the University of North Carolina and co-principal investigator of the HIV Prevention Trials Network, a CoVPN collaborator, took his own global team’s expertise in developing broadly neutralizing antibodies against HIV and channeled it into the increasingly fruitful effort to bring to market cocktails of monoclonal antibodies that attack SARS-Cov-2.
Other HIV experts have leapt at the chance to lend their skills to the Covid-19 endeavor. One is Steven Deeks, a leader in the HIV cure research field at University of California, San Francisco, who said his lab’s extensive experience with the thorny logistics of establishing long-term research cohorts allowed them to start a study following people with “long Covid” in mere weeks.
HIV specialists have been among the most prominent voices educating the public and combating misinformation about Covid-19. Monica Gandhi of UCSF has championed evidence-based optimism and sanity in the face of anxiety and hysteria; Julia Marcus of Harvard has advocated harm-reduction methods to curb SARS-Cov-2; and Carlos del Rio of Emory University has covered anything and everything in between.
Each scientist has tweeted up a storm and given hundreds of interviews.
‘Many people with HIV fell out of care’
Fauci was keen to stress that the HIV epidemic trained the public health sector to prepare for – and mitigate – the disproportionate impact of Covid-19 on marginalized populations.
As for how Covid-19 has in turn affected HIV’s trajectory, US epidemiologists remain in the early stages of analyzing surveillance data. But an initial read of the tea leaves has troubled many experts, who fear that progress in combatting HIV has stalled or even reversed since Covid-19 hit.
This comes as the Centers for Disease Control and Prevention newly estimates that annual HIV transmissions in the US declined by only 14% between 2009 and 2019, from 40,500 to 34,800 new cases. Perhaps unrealistically ambitiously, the “Ending the HIV Epidemic” plan seeks to reduce the latter figure to below 3,000 by 2030.
The CDC recently reported that between March and September of last year, the US saw an estimated 21% fewer prescriptions for the HIV prevention pill, known as PrEP, than expected. Concerningly, HIV tests conducted by CDC-funded community-based organizations plunged 73% between March and August 2020, compared with that period in 2019.
“It was very clear that many people with HIV fell out of care in 2020,” said Hansel Tookes, an infectious disease physician at the University of Miami who reported an increase of people presenting in the emergency room with Aids-defining illnesses.
“I think that we have a lot of ground to make up post-pandemic,” he said.
“We’re definitely seeing our outcomes get worse in 2020,” agreed Andrea Kim, chief of HIV and STD surveillance in Los Angeles county, which saw modest but worrying declines in the proportions of the local HIV population retained in medical care and successfully treated.
“Overall, I think that Covid was extremely negative for HIV,” said Gandhi, who cares for a highly vulnerable population at the Ward 86 safety net clinic in San Francisco. Her team saw the likelihood that a patient’s virus wasn’t treated and fully suppressed soar 31% following the spring 2020 lockdowns, leading them to quietly recall their patients to in-person visits.
Critically, state and local health departments have diverted staffing and funding from HIV and STD control to Covid-19. By June 2020, 20% of such departments reported to the CDC that STD programs were completely disrupted and 76% reported significant disruption.
Covid-19 has also apparently fueled the opioid crisis. With Nora Volkow, director of the National Institute on Drug Abuse, expressed concern that the US will see more HIV outbreaks like the those among people who inject drugs in West Virginia and Boston.
“As bad as it is now, I think it’s probably worse,” said Sally Hodder, an infectious disease specialist at West Virginia University, predicting the 89 HIV diagnoses tied to injection drug use her state saw in 2020 would prove the tip of the iceberg.
‘Get the ship righted’
Not all news is gloomy. Covid-19 has spurred two states to move toward expanding Medicaid programs, a shift found to benefit HIV populations. Lockdowns have also sparked innovations in healthcare delivery that could benefit people with HIV, including vastly expanded use of telemedicine and an increase in multi-month prescriptions.
Fauci noted that the extraordinary success of the mRNA Covid-19 vaccines has thrilled HIV vaccinologists, who are already pursuing vaccines based on the cutting-edge technology. Deeks said HIV-cure therapies could also rely on mRNA.
Fauci said he holds out hope that the three HIV vaccines in advanced clinical trials will prove at least 50% efficacious, justifying a global rollout. But he now hopes mRNA or other advanced technologies could yield even more powerful HIV vaccines.
Then there’s Fauci’s hope of capping his storied career by the time he turns 90, by ending as a public health threat the epidemic that changed his life 40 years ago.
“I hope that as we get the Covid-19 under control, we can play a bit of catch up with HIV and get the ship righted again,” he said. “I still think there’s a good chance that we’ll get there.”