Interview with renowned expert in HIV treatment - Prof. José Gatell from Barcelona
Professor, let me start by asking you how do you like the Czech Republic? I know you've been here several times...
I've been to the Czech Republic several times. The first time was more than 40 years ago. I've been back several times because of my work. The last time was two years ago for the same medical symposium on HIV/AIDS treatment. I must say that the Czech Republic is a beautiful country and Prague is a wonderful city. I felt the same way 40 years ago when I was here for the first time. I like the architecture, the people are very nice and you have amazing beer.
In Pilsen you participated in an international symposium on HIV/AIDS treatment. One of the main topics was the ageing of people living with HIV and their care. Due to stigma, HIV+ people still face barriers at work, in society and often in medical care. In addition, as time goes on, we have more and more older HIV+ people in the world who may encounter entirely new challenges. Can you tell us what you and your colleagues in Pilsen have been discussing on this topic?
First of all, I would like to clarify that the reason for such meetings is the new developments in the field of HIV treatment that appear every year. As experts, we then discuss these innovations together and work out how to implement them in practice. But you are right. Nowadays, HIV patients are living to a long age, thanks, among other things, to modern effective HIV treatment. People who were infected in their 20s or 40s are now 40, 50 or 60 years old, and by 2030, up to 70% of HIV patients will be over 60. It is clear that these people face stigma, but I think the main issue is stigma itself, regardless of age and regardless of whether they are men or women.
But I've heard that older HIV+ patients can have problems if they have to go to, for example, a hospice or a nursing home where they had no previous experience with these patients... Could this cause a problem in your opinion?
I've never thought about it, but it's possible that you're right. 20 or 30 years ago, HIV+ people had problems if they had to go to a hospital. They often faced some form of discrimination, but this has been overcome in most countries and hospitals now accept HIV patients in most countries without problems. But it is true that a large number of HIV+ people are getting older, there may be some problems when these people come to nursing homes or hospices, and we have to fight against this.
What are the ways?
The basic thing is by educating the managers of these facilities. Let me remind you that the main benchmark and information should be that a person who is being treated and who has a good response to treatment does not transmit the HIV virus and becomes what is called an 'undetectable, non-infectious patient'. Last year marked the 5th anniversary of the N=N (undetectable = non-infectious) initiative, which informs and educates the public worldwide and explains that a properly treated patient becomes non-infectious, i.e. does not transmit HIV. Which is a huge medical achievement and an important step towards destigmatizing HIV+ people. This should be the main message for managers of facilities for older people, but also for everyone else. No one has to worry about any problems.
Stigma is also being fought against by an initiative by SAP, IBM and Deutsche Aidshilfe, which has spread from Germany to Austria, Slovakia, the USA and also the Czech Republic. Do you think that initiatives like this can open people's eyes more, or is the current society not yet ready for them?
I don't have detailed information on this initiative, but I think that stigma and discrimination, and even criminalisation of HIV patients, is still a problem in some countries and any initiative that tries to minimise this is welcome. So any effort to destigmatise is positive and can open people's eyes.
Last year marked 40 years since the first cases of HIV were reported (5 June 1981). How do you yourself remember that time?
I was working in Boston at the time. In 1982 we were diagnosing the first cases, so I saw the first cases in Boston, but after that my whole professional life was in Barcelona. However, during the first year, nobody knew anything about the origin of this new disease, which gave rise to a whole series of theories and conspiracies. It was a mess.
Just as it was and is now with coronavirus?
It wasn't. Coronavirus and SARS were identified about a month after they first appeared. The first mentions of coronavirus were sometime in November 2019 and a short time later the virus was identified and the all was clear. With HIV, it took almost two years before it was identified, and that's a long time for all sorts of speculation. Since I was involved in infectious diseases, I got involved in HIV research as well.
In 40 years, medicine has made tremendous advances in the treatment of HIV/AIDS. Today, HIV is no longer a clear death sentence. What new developments in treatment have occurred in recent years?
Let's review the biggest milestones and innovations of the last 40 years. The first milestone was the discovery of the virus, which was in 1983. The second milestone was the discovery in 1986 of the first active drug that showed activity against a virus. This was a treatment that was very effective, but not very convenient for patients and quite toxic. It was a so-called monotherapy, i.e. the use of only one drug, but within a year or so, resistance had developed, meaning that the virus had learned to fight back, and the treatment stopped working. It took a further 10 years, until 1996, before an effective combination treatment, consisting of multiple active ingredients, was developed.
Since 1996, there have been several breakthroughs that have made the treatment simple and well tolerated by patients. Now, thanks to this, treatment can be carried out on the principle of one tablet a day. This makes the treatment effective and convenient for patients. As a result, their quality of life is at a high level. The maximum life expectancy of treated HIV+ patients has approached the maximum life expectancy of the general population.
What can we expect between now and 2030?
In terms of treatment, we will be able to treat our patients with products that have a long-lasting effect. Current scientific research is focused on developing drugs that will be effective, well tolerated and will not need to be taken as often.
The Independent reported that England, for example, expects to stop the spread of HIV in the country completely by 2030. Is there any chance of achieving this?
I don't think they were talking about completely stopping the spread of the virus. They were probably talking about minimising the spread of the disease. I don't believe the disease is going to go away. It may disappear in a city or a region, but not overall. The goal of the World Health Organisation is that by 2030, the target they define as 95-95-95 will be met, which will ensure that the impact of the epidemic is substantially minimised in at least some geographical areas. What do we mean by this target? It is to identify 95% of patients who have been infected with the virus. Of these 95%, at least 95% should go to hospital, and of these 95%, 95% should then receive very effective treatment. In countries where these targets can be achieved, the epidemic will be minimised, but I am not so positive as to think that it will disappear completely.
The previous targets were 90-90-90, which have been achieved in many parts of the world, and have of course had a positive impact on the evolution of the HIV epidemic. If we are able to move even further in the next ten years, we will be better off.
Going back to coronavirus for a moment, is there any research that has been done on HIV that could help in the fight against coronavirus or vice versa?
That's a good question. Every research always has some side benefits. For example, a lot of things from HIV research have been applied to hepatitis viruses and now it is possible to cure the disease. If we focus on the coronavirus, antiviral drugs against this disease have been developed in a relatively short time and it is because of the spin-offs from HIV research. Unfortunately, we do not yet have a preventive HIV vaccine, but mRNA vaccine technology has been developed as part of HIV vaccine research. Although this type of vaccine (mRNA) has not worked for HIV infection, the technology has been successful for coronavirus and has helped to rapidly develop a vaccine for coronavirus.
José Gatell is a world-renowned expert in HIV treatmentPhoto: Foto: se souhlasem José Gatella
Do you think the coronavirus pandemic has put other diseases, including HIV, on the back burner?
I wouldn't use the phrase "on the back burner" as it's a bit pejorative. But it does have an impact on the way healthcare is delivered. Whether it's a turn for the better or worse I'm not entirely sure, but a significant amount of healthcare for HIV patients is now done virtually and over the phone, and we have to wait a little longer to see if it's been beneficial or not. But it is true that the coronavirus has changed the way healthcare is delivered, not just for HIV but for other diseases as well. It is not such a problem in Europe, but in more underdeveloped countries, the coronavirus has disrupted the delivery of antiretroviral therapy, and that is bad.
There are occasional articles in the media about so-called elite controllers, people who can cope with HIV infection without medication. How is it possible that some people are able to fight the virus on their own? Can they somehow contribute to finding a cure for HIV, or even a mechanism to destroy HIV in the human body?
Statistics tell us that 1% of people infected with HIV are able to control the virus without treatment and without antiretroviral therapy. We can speculate why this is possible, but there are several factors. Not all of these patients have the same reason for being able to control viral replication. It has to do with the genetics of the patient and the capabilities of the immune system. Some patients may have this because they have been infected with a so-called "viral cripple". However, "elite controller" patients may not be for life. Some may only have this ability for a year or five years and then lose it. That these people will help us find a cure for HIV, I'm a bit pessimistic about. If we have one person who can control the virus without treatment, the logical thing to do would be to do an in-depth analysis and apply the findings to other patients so that they have that ability as well, but it doesn't really work that way. Because everything is due to the "genetic background" and we are not able to change the "genetic background" of people and therefore we are not able to apply these characteristics to other patients.
What are your impressions of the medical symposium in Pilsen?
I had the opportunity to meet leading experts in HIV treatment, professionals and colleagues from other countries, including those from the Czech Republic. During the symposium we discussed and together with other experts the current situation in the field of HIV and AIDS, new developments in the treatment of patients and, among other things, the ageing population of HIV+ people. I feel good not only about this symposium but also about the fact that we are succeeding in treating a significant percentage of patients with new drugs. I believe that we will gradually take another step forward in the treatment of HIV+ patients.
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Date of approval: January 2022
