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IRA FLATOW, host:

This is TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.

First up this hour, the latest news in the fight against AIDS. Circumcision may be one of the best short-term techniques to prevent the spread of HIV, the AIDS virus, say world health organization officials. They released a study at the annual AIDS conference taking place this week in Toronto. We'll start the hour with a report on the meeting and get a status report on HIV/AIDS worldwide.

Our number, as always, 1-800-989-8255.

Richard Knox is a health and science correspondent for NPR in Boston. He joins us today from Boston. Welcome back to the program, Richard.

RICHARD KNOX reporting:

Thanks, Ira.

FLATOW: Let's talk about - let me start with the circumcision quote there. This is something that was unexpected, or was it expected?

KNOX: Well, I think its been brewing for a while. I mean the notion that circumcision could actually make a big difference in reducing the number of HIV infections, especially in high incidents countries such as in sub-Saharan Africa has a lot of evidence there. It's not clinching kind of evidence.

It's based upon the observations that parts of Africa that have low rates of circumcision have high rates of HIV, like east Africa. Other parts that have high circumcision rates have lower rates of HIV. And then last year there was a study that came out of South Africa in which they randomly assigned men to be either circumcised or not, and then they followed them for a couple of years.

The ones who were circumcised had like 60 percent fewer HIV infections. And so now there are a couple of studies being done in Kenya and Uganda to see if that can be duplicated. There are a lot of people in the public health community and, you know, some of the big leaders who are talking as though they think it's going to come out positive, and therefore they're gearing up to do a circumcision campaign in Africa.

FLATOW: But you don't want - there are a lot of ifs here. One is if it actually would be successful in telling enough people or getting enough people to be circumcised, and I guess you'd be starting with children, newborns first?

KNOX: Well, it's - I don't think any - the strategy's not written yet. I think that the idea would be to start with adult men who are now transmitting the virus, and hope that you can interdict that. It's - surprisingly, there were a couple of stories that came out of Toronto that indicated there was this pilot project to see how acceptable circumcision would be to adult men in Africa - one in Zambia, one in Swaziland. And there was a great demand for it. I mean even before they'd done any social marketing or anything, men were lining up and they had to turn them away.

FLATOW: Interesting. Of course, there are - that fits into a more general, broader issue of prevention that was talked about at the meeting.

KNOX: Oh, yeah. In fact, there was a lot of emphasis. One of the major themes of this year's conference was prevention and trying to find new methods of prevention. You know, the last three AIDS conferences, beginning in '96 - and they happen every other year these days - have been about treatment.

And that's understandable because, you know, ten years ago, there was this revelation that you could actually control HIV infection and transform it from a, you know, a death sentence into a chronic disease. So then that put enormous pressure on to get treatment out to parts of the world where people were just dying in great numbers.

We can come back to that. But there's been, you know, the focus has been on treatment before now. This meeting was I think quite deliberately targeted to prevention and towards new methods of prevention, circumcision just being one.

FLATOW: Uh-huh. What else were they talking about? Condoms, things like that? Or...

KNOX: Well, condoms are - the oldest style, and we're not doing terrifically well on that. The UN Population Fund says that, you know, Africa's getting about half as many condoms as they need. But some of the newer ideas range from something as simple as urging women to use diaphragms, because much of the HIV infection in women takes place at the cervix, the entrance to the uterus, which is covered by a diaphragm.

Another hot topic is the use of what's called pre-exposure prophylactics. It's basically a fancy term for using anti-viral pills on a preventative basis. Taking one a day to see if you can prevent people who are likely to be exposed to HIV, such as commercial sex workers, maybe truck drivers who use prostitutes a lot and so on. Get them to be protected against infection.

There were some studies indicating that that may be safe. We don't know whether it's effective or not. The holy grail of neo-prevention - if that's the word - is really microbicides. These would be creams or gels that women could use - primarily women, although anybody could use a tube in advance of having sex - to prevent the HIV virus from actually infecting you.

There were no breakthroughs. There were no announcements about effective new microbicides. There are five trials under way with different candidates. We won't know for some time whether they work or don't. But there was a lot of talk about pushing for more research, pushing for getting ready to, you know, to implement that as soon as the research shows there's something to use.

FLATOW: You know, when you said holy grail, I thought you were going to say AIDS vaccine. Doesn't seem to be news of that happening yet.

KNOX: No, and don't hold your breath. I mean it's just, I think that some of us have an appreciation now, a very hard-won appreciation, that it's just going to be very difficult. The vaccines that are in wide scale, so-called phase III trials out there in the real world right now, are not expected to be very effective, frankly, because they only target one of the two parts of the immune system.

And it's thought that they'll - that an effective vaccine will have to work on both parts of the immune system. Generating antibodies to block the virus when it comes into the body and also generating so-called cell mediated immunity to get those cells which are already infected with the virus out of action.

But it's going to be very difficult to do that, so I don't think anybody's - that's another grail but it's further off.

FLATOW: Did they talk about overcoming some of the cultural stigmas that some of the countries have with women admitting that, you know, or even talking about AIDS.

KNOX: Oh, that's - you know, that's a big continuing problem. It get recapitulated everyplace that AIDS enters, like now in Eastern Europe and Russia. But even in the places where it's been for a while, such as in sub-Saharan Africa, it's just an enormous obstacle to get people to, for instance, come forward and be tested.

FLATOW: Mm-hmm.

KNOX: People are afraid to be tested because they'll be ostracized and stigmatized. People are afraid in many instances to get treated because the people learn that they're taking the AIDS drugs and that will mark them and, you know, people won't buy their vegetables at the market or, you know, women will be abandoned or brutalized.

FLATOW: Mm-hmm. Mm-hmm.

KNOX: And that's - you know, every AIDS meeting that I recall, and I've been to most of the 16 over the past 20 years or so, have wrestled with that, and I think it's an endless problem.

FLATOW: Right, right. You talked about the ten-year anniversary of the treatments. The effective treatments have been available now for ten years. Are they available now in the poorer nations as well as the more able nations as they were at the beginning?

KNOX: That's a real bright spot. And I think the picture - the numbers are very encouraging. We got some new numbers this week and they paint a picture, sort of a glass not half full yet; it's more like a quarter full. More than 1.6 million people in the so-called poor and middle-income countries are getting HIV treatment - effective HIV treatment now, these drug cocktails. And that's something like 24 percent of the 6-point-something million who are thought to need treatment today. So, you know, we're three quarters of the way not there...

FLATOW: Yeah.

KNOX: ...but it's still pretty remarkable because ten, you know - three years ago there were, you know, ten times fewer people in sub-Saharan Africa who were getting treatment.

FLATOW: I read an also sort of interesting sidebar that it was announced, that was talked about at the meeting - maybe you can talk about it - and that was the discovery of a new and very strong strain of tuberculosis that was showing up...

KNOX: Yeah...

FLATOW: ...in AIDS patients.

KNOX: A dark cloud on the horizon. In South Africa, in the rural part of KwaZulu-Natal province, they discovered that - they looked at 1,500 people who had tuberculosis, which often people with HIV also are infected with tuberculosis, and that's not a good situation. Out of these 1,500 TB-positive people, 53 of them had this really scary strain of tuberculosis that is resistant to every known anti-TB drug.

FLATOW: Mm-hmm.

KNOX: There are about half a dozen or so. And it's not the first time that they've seen these - it's called XDR, which means extremely drug-resistant. It's not the first time an XDR tuberculosis (unintelligible) has been known, but this is a much, much higher incidence than is seen before. And also there's evidence in that particular place that it's being communicated in the community. It's being transmitted. It's not just that people are getting TB and then within their bodies it mutates to this drug-resistant form, but it's spreading.

FLATOW: Even some of the health workers were dying.

KNOX: Yeah, a couple of them died. Yeah.

FLATOW: Taking care. So there is - that is pretty scary, a form of TB that has no successful treatment.

KNOX: Yeah, the only thing to be done is to try to use classic public health methods to prevent transmission. You know, you would sequester people who have it. It kills very fast. I mean, the median survival time once people got it was like 16 days.

FLATOW: Yeah.

KNOX: So you need to keep those people away from others in passing it on and hope that it will burn out.

FLATOW: Well, were people more or less optimistic, do you think - upbeat about the meeting toward the future or more were just trudging along as fast and as hard as we can?

KNOX: I think it was a more hopeful meeting than many of them have been. I think that it was - you know, it's mixed. And I think you can't be realistic about HIV and AIDS and not have a strong mix of emotions and...

FLATOW: Mm-hmm.

KNOX: ...expectations just because it's such an enormous problem and it's such an intractable - intractable is probably not the right word because we've shown that it is tractable - but it just requires so much effort.

One benchmark here: We're spending about $9 billion a year on treating AIDS and preventing AIDS in low and middle-income countries, and that's, you know, that's a good thing because that's one target. Five years ago, there was a special session of the U.N. General Assembly and it said this is where we should be and this is where we are in terms of spending. But the other way of looking at it is that we need to be spending $20 to $23 billion dollars a year by 2010, which is only four years off, and that's a big jump. It's going to require more and more and more. You know, there is fatigue that sets in...

FLATOW: Yeah.

KNOX: ...so-called donor fatigue.

FLATOW: Yeah.

KNOX: And there's prevention fatigue, which a study in Uganda presented yesterday showed. People just need to get the message over and over and over again.

FLATOW: Well, Richard, thank you for taking time to talk with us and good luck to you.

KNOX: You're entirely welcome. Thanks.

FLATOW: Richard Knox health and science correspondent for NPR in Boston. We're going to take a short break and come back and talk about your online privacy. Stay with us.

I'm Ira Flatow. This is TALK OF THE NATION: SCIENCE FRIDAY from NPR News.

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