'This has been completely explosive, where you have literally a half a million people in the United States dying in a year's period of time.'
by Renee Raketty -
SGN Contributing Writer
I first met Dr. Anthony Fauci high atop the Sheraton Hotel and Towers on a summer's day in Seattle 13 years ago while he was in town for the 2007 AIDS Vaccine Conference. That was long before SARS-CoV-2 was identified at the end of 2019 and Seattle became ground zero for COVID-19 in the US. However, he was well known at the time for his role in battling the HIV/AIDS epidemic and leading the scientific effort to eradicate the virus. It was in that context he sat down for our first interview.
Fauci had led a team of researchers looking into HIV back in 1981 before becoming the director of the US National Institute of Allergy and Infectious Diseases (NIAID) three years later. He has made "seminal contributions to the understanding of how HIV destroys the body's defenses, leading to its susceptibility to deadly infections," according to the NIAID website. LGBT icon and early HIV/AIDS activist Larry Kramer, who passed away last May, said of Dr. Fauci's efforts on HIV/AIDS that he became the "only true and great hero in all of this, in the government, in the system," acknowledging him "every chance I can, because we certainly got off to a rocky start."
As the director of NIAID and chief medical advisor to President Biden, Fauci has shown leadership on COVID-19 that will likely far eclipse his legacy on HIV/AIDS in the minds of Americans and the global scientific community. The New York Times and New Yorker magazine have described him as being among the most trusted medical figures in the United States. He served on President Trump's White House Coronavirus Task Force and remains a frequent guest on national television programs regarding COVID-19.
In addition to his role at NIAID, where he oversees a $6.1 billion budget, Fauci is the longtime chief of the Laboratory of Immunoregulation and is ranked ninth out of 2.5 million authors in the field of immunology by total citation count between 1980 and January 2021. He has also advised seven presidents during his service in American public health.
I asked Dr. Fauci to speak with me again - virtually this time, from the NIAID headquarters in Bethesda, Maryland - about his new worldwide fame, HIV/AIDS, and, of course, COVID-19.
Dr. Fauci: Hi. Hello.
Renee Raketty: It's nice to see you again. It's been a long time.
Fauci: Yes, I'm really sorry. I'm a little late. I'm running in multiple different directions. But it's good to see you again. How have you been?
Raketty: I'm great! Thank you for asking. I want to thank you again for doing this interview. I know that you're a very busy person these days.
Fauci: Well, it's a pleasure to be with you. Happy to do it.
Raketty: I think I speak for the vast majority of our readers when I say that we appreciate your candor and reassuring presence during the ongoing COVID-19 pandemic. As you know, we in Seattle have been acutely touched by COVID-19 - especially during those early days of the pandemic.
I often tell people that you appear to be the same person - in a figurative way - that I met high atop the Sheraton Hotel and Towers in 2007. You were in town for the AIDS Vaccine Conference. I was wondering how has your life changed in personal and professional ways since becoming a household name?
Fauci: Well, there's the good and the bad about that. It's been a most unusual year, somewhat surrealistic in the enormity of the problem and the acuteness of the problem, which is really in many respects different than HIV/AIDS. The importance and impact of HIV/AIDS is stretched over decades. It was something that started off, you know, insidiously, and there were a few of us in the early years of the '80s that got involved. Then, as it became clear we were dealing with a global pandemic, it was the gradual appreciation of the globality of the outbreak - a lot of science, a lot of investment - but it was over many, many years.
This [pandemic] has been completely explosive, where you have literally a half a million people in the United States dying in a year's period of time. It's completely transformed what I do, because I've had to be involved in it from a scientific and from a policy standpoint. It's been, in many respects, almost a surrealistic year of working literally every day. I have not had a day off in over a year, not a single day off, but it's important and I hang in there and have the energy to do it. Because of the enormity of the problem and the acuteness of the problems.
You know, a lot of strange things have happened. I've gotten caught in something that's quite different than what we went through with HIV, where we had activists who were confrontational. They were theatrical. They were iconoclastic. But what they were trying to say was very important. They wanted to gain our attention, my attention. They did gain my attention.
When I listened to them, which is one of the best things I've done, it became clear that what they were saying made absolutely good sense and that the federal government needed to change the paradigm of how we interacted with the activist community - how we interacted with the entire LGBTQ community - because we were dealing with a very unusual disease that was evolving before our eyes.
The ultimate end game, despite the early confrontation, was a very positive thing. We embraced the community. The community was value added; they made contributions. The AIDS effort was far better off as a result of the initial confrontation, which jolted us into a really enduring relationship with the community and the constituents. That's really different from what's going on right now.
What's going on right now is we're trying to address an outbreak in the context of very severe divisiveness in society. The confrontation is against the principles of public health, where wearing a mask or not wearing a mask or being in a crowded situation or not being in a crowded situation has become sort of a political statement of where you are in your ideology, which is really unfortunate. As you know, when you are dealing with a disease, a disease doesn't know.
We used to say this back in the early years of HIV: "It's the virus that's the enemy. It's not the people." In this situation, we try to get people to appreciate that it's the virus that is the enemy, and the only way we're gonna effectively address it is by pulling together in a unified way. Unfortunately, that's not been the case.
How that's affected me is that - since I've stood up for the truth, science, evidence-based and database approaches toward everything - I have been, on the one hand, praised and idolized by many and, on the other hand, scorned by others who took a more political outlook at what I'm doing and don't like the idea that I'm talking about the public health principles that we need to live by if we really want to get this outbreak under the control.
It's a little bit of a schizophrenic thing, you know: half of the people love me and half of the people hate me, which is something that I did not have to go through with HIV. With HIV ...when one's attention was gained, it was a very good cooperation, collaboration, and synergy between the activist group and the scientists and the regulators.
Raketty: I remember that Larry Kramer, an early HIV/AIDS activist, said about you originally - before he met you - that you were an "idiot." Then later, he called you a "hero," when it comes to efforts to combat HIV/AIDS in the early days of the epidemic. You certainly won over the LGBT community in the end there?
Fauci: Yes. Yes.
Raketty: What would you say to that person who's living with HIV/AIDS, who sees this robust response to COVID-19, how quickly these vaccines have been developed, manufactured, and deployed and wonder why a similar effort wasn't made in those early days of the epidemic?
Fauci: Yeah, you know, that is a good question but not infrequently subject to misunderstanding - understandable misunderstanding.
Getting a vaccine against HIV is quite problematic because the fact is that the body does not make a very adequate immune response against the virus. One of the principles of developing vaccines... is to mimic natural infection, because when you have diseases like smallpox and polio and measles - even though they cause a considerable degree of morbidity and mortality - at the end of the day, the body very, very, adequately handles those viruses, eliminates them from the body, and leaves you with enduring immunity against reinfection with the same virus.
When vaccinologists like myself and my colleagues back in 1983-84-85 started working on a vaccine - we put in a lot of effort - the body did not give us that proof of concept, because the body does not handle HIV very well.... We've invested literally billions of dollars in research trying to develop a vaccine that does better than what the natural response to the virus.
Whereas with COVID-19, even though it's caused a lot of sickness and death, in the majority of people, the body's immune system handles it extremely well, eliminates it. At least 30-40% of the people who get infected with SARS-CoV-2 don't have any symptoms at all, yet their body's immune system eliminates the virus.
So, all we had to do with COVID-19 was develop a methodology where you expose the body to the very important spike protein - which is the protein that binds to the cells in the upper and lower respiratory tract - and induce a good immune response. Then, all of a sudden, bingo, you get a highly effective vaccine to the point of 94-95%. That's the reason why there's a difference, not because of lack of trying. It's the inherent inability of the body to mount a truly adequate immune response against HIV, as opposed to the ease with which the body mounts a good response - most of the time - against SARS-CoV-2.
Raketty: Now in 1981, you began looking into the virus. Three years later, you're the director of the NIAID. How could we have stopped the spread of the HIV/AIDS virus in those early years, and what kept us from containing it?
Fauci: ...Apart from... injection drug using, which is a disease.... if you look at the modality whereby this virus was spread, which was predominantly - not exclusively but predominantly - a disease or infection of gay men [not only in the United States], whereas internationally, such as in southern Africa, it was predominantly a heterosexual disease, [it was] that we did not have a vaccine. Early on we didn't have treatment - despite the fact that we have spectacularly effective treatment now, due to a lot of effort that was put in with resources and scientific commitment.
The fact is that the disease is spread by a very natural function, namely, sexual activity. That's one of the really complicated issues... that many people are practicing risk behavior [but] did not even know they were practicing risk behavior, and then that seeded an outbreak, which then spread really very, very robustly throughout the gay community and then internationally - particularly in countries such as [South] Africa, where the conditions there are amenable to that type of a spread.
I'm not so sure what could have been done. Maybe early on if the Reagan administration had sounded the alarm. Whether or not the gay community would have listened to that is still unclear. We'll never know, because it never happened. I guess one of the things that could have been done back then would have been to use the bully pulpit of the presidency to get out there and warn people about the danger of the sexually transmitted disease.
Raketty: Now, we won't get our own "Operation Warp Speed," but what will it take to end HIV/AIDS in the United States?
Fauci: We put together a plan in 2019 that really got rolling in 2020: to end the epidemic in 10 years in the United States. By implementing the tools that we have, by doing things like better and more extensive utilization of PrEP, including the more easily usable injection - long-acting cabotegravir - to get as many people on the treatment as possible. To allow treatment as prevention to occur, namely, undetectable equals untransmissible; that's an important area. Then finally, to get a moderately effective vaccine.
I believe if we do all of those things in a very proactive way, over the next 10 years, we can decrease new infections by 75% in five years and by 90+% in 10 years. I still hold that hope. The anticipation is that by the time we get to 2030, we will have ended HIV as an epidemic. End it as we know it.
I don't think we're going to eliminate it...at least not in the very foreseeable future. I think we can end it as a truly threatening epidemic in this country by 2030. If we continue to get people into treatment programs, to get as many people utilizing one form or another of PrEP, and hopefully, [an] at least moderately successful vaccine.
Raketty: I hope you're right. Julia Raifman at Boston University's School of Health has said that while it's unclear that COVID-19 poses additional risks to people living with HIV, it is clear that COVID-19 has disrupted the health system: making it more difficult, more challenging for people living with chronic conditions like HIV. Also, people are having a hard time getting their PrEP. You know, there are disruptions for transgender people: having to postpone their surgeries and experiencing interruptions in hormone therapies. What role can the federal government play to ensure that these disruptions are minimized?
Fauci: That is a good question. I'm not sure the federal government can do much, but perhaps... subsidizing the state's capability of making sure that the flow of drugs and the availability of testing and a number of the programs of implementation science continue with substantial support.
If you're talking about where the federal government plays a role here, one of the things would be to continue the support for HIV/AIDS, for the NIH [National Institutes of Health], for the CDC [Centers for Disease Control and Prevention], and for the HRSA [Health Resources and Services Administration]. If you look at the plan, in a paper that I wrote with my colleagues in 2019 in the Journal of the American Medical Association, we described all the things that we need - particularly implementation science. It involved multiple agencies, not only not only the NIH but the CDC, the ASPR [Assistant Secretary for Prevention and Response], the HRSA, the ?SAMHSA [Substance Abuse and Mental Health Services Administration] - a variety of agencies - all of which need to cooperate, collaborate, and synergize in trying to end the epidemic.
That's what I believe the federal government can do: to continue to support these agencies that are essentially the implementers of the ending of the HIV/AIDS epidemic.
Raketty: I wanted to ask you what role can the federal government play [regarding] Truvada and how these antiretrovirals can reduce the severity of COVID-19 - or is there no relation between taking these antiretroviral drugs and the control of the coronavirus?
Fauci: We've been studying what impact [the pandemic] could possibly have on HIV besides the interruption of the services that you appropriately and accurately mentioned several minutes ago... if HIV-infected individuals have some of the underlying comorbidities that make them prone to have a more serious outcome were they to get infected.
I refer specifically to premature aging, because, you know, the older you are, the more likely it is that you're going to get a severe outcome. You know that persons living with HIV have metabolic issues that make it make it appear, if not in reality, that they are aging a bit more quickly: chronic renal disease, the fact that HIV-infected individuals have more hypertension, heart disease, liver disease - those underlying conditions. When people did analyses of this, they found it wasn't HIV in and of itself, but it was the comorbidities associated with HIV.
Now, if you have HIV that's out of control, and you're immunosuppressed with a CD4 count of 10 and a viral load of 700,000 to a million, obviously, you fall into the category of being immune deficient, which is one of the one of the risks of advanced disease.
Even a person who's got a CD4 count of 600, 650, 700 and is on antiretroviral drug with an undetectable viral load... if that person had been infected for a considerable period of time, particularly if they didn't get on to drugs early on, they could have some of the morbidities that would make it more likely that, not that they would get infected but that they would get a serious outcome.
Raketty: Should the United States and the states in particular, who control the distribution of the COVID-19 vaccines, make people living with HIV a priority for the vaccine, or should the vaccine be targeted to communities with a higher level of HIV infection?
Fauci: You know, it becomes a slippery slope when you designate people by a particular race, a particular ethnicity, or a particular subcategory. I think HIV-infected individuals fall within the category of underlying comorbidities, that is for sure. It's definitely recommended.
As soon as the priority opens up for people from 16 to 64, which is where most of the people living with HIV fall into, that is a priority for vaccination in level 1C. Some jurisdictions are already at 1C, and many will soon be at 1C. So I think that that prioritization is coming soon.
Raketty: We've had an overtly hostile administration, referring to the Trump administration, toward the LGBT community. And as someone who has advised multiple presidents and sort of seen - in your own history - how the LGBT community felt ignored, what are the public health implications of this overt hostility... and these policies toward the LGBT community?
Fauci: I mean, it's very natural, Renee. When you have hostility towards anyone, it is detrimental to everything about that relationship - including the health of the person. We are right now in a different era.
It's become very clear that President Biden and Vice President Kamala Harris feel that there should be equity in every respect - for all people - regardless of their age, their sex, their sexual orientation. I mean, in any aspect... there should be equity. He feels very strongly about that. So, I think you're gonna see the fruits of that in the coming years.
Raketty: I know the CDC admitted earlier this month in a report that because of long-standing social inequities and a higher prevalence of severe underlying health conditions, sexual minority populations might be vulnerable to COVID-19 acquisition and associated severe outcomes, but [they] also admit that because data on sexual orientation are not collected in existing COVID-19 data systems, the effect of COVID-19 on sexual minority populations is unknown. How can we address the concerns of the LGBT community if we don't know the extent of the problem or the areas of concern?
Fauci: You know, that's a very good point, Renee. I have to get back to you on that. I know we had a discussion like that with the CDC. They gave some reasons why sexual orientation has not been used, and I think it's almost as if people don't want to put it down. That's one of the real problems. I think that may be an inadequate answer. So hopefully we can get an answer for you.
Raketty: It's often said that privacy issues around orientation or concerns about refusal to answer questions has been used as justification for not including this information on public health surveillance and patient record systems. The CDC itself and its BRFSS [Behavioral Risk Factor Surveillance System], the National Health Interview Survey, and the National Survey on Family Growth have demonstrated the feasibility of collecting sexual orientation data from a civilian, non-institutionalized, population on an ongoing basis. Is it time to standardize the collection of this information? Especially since many states and municipalities refused to do so or declined?
Fauci: Yeah. Likely it is. Again, since that's not what I do, Renee, I don't want to get out of my lane, but it sounds like something reasonable.
Raketty: Thank you... What would be your recommendation to someone whose partner is refusing to get the vaccine or has concerns about, potentially, the health effects of it? What can they do? And what can we do as Americans to encourage people to get vaccinated?
Fauci: I think you need to just explain to them the procedure that went into showing its safety and efficacy: thousands and tens of thousands of people in the trial; the decision about safety and efficacy [having been] made by an independent and transparent process; the fact that so many of us, confident in its safety and efficacy, have gotten vaccinated publicly, including me and the president and the vice president of the United States. So that's a good reason, I think.
Raketty: Absolutely. Thank you so much.
Fauci: All right. Thank you.
Raketty: You have a great day.
Fauci: You too. Take care. Bye-bye.
This interview was conducted in partnership with Unite Seattle magazine, which will include a version of this article in its spring edition. Full video is coming to SGN.org in April.