||Describe your research on TB transmission.
focus is multi-drug resistant TB in resource-poor countries,
with a particular emphasis on how drug resistant TB is transmitted
in the hospital and other settings, and how it should be treated
given the great expense of second line drugs for treatment.
Along with several faculty members from New Jersey Medical
School, I am involved in extensive research in Uganda, a country
that has been greatly impacted by the AIDS epidemic. We are
working with faculty from Makerere University in Kampala,
Uganda, and the London School of Tropical Medicine and Hygiene
to study host and bacterial factors contributing to resistance
and susceptibility to TB. A project funded by the NIH looks
at lung immunity and is based in Mexico City. We are planning
to assess how host immunogenetics and genetics of the bacteria
impact on resistance to tuberculosis.
is Uganda one of the few countries in which the incidence
of HIV is falling?
on, President Museveni acknowledged that AIDS is a problem
and welcomed expatriates and non-governmental organizations
to contribute to control measures and research. The result
was a loud prevention message. This led to behavior changes
with delays in start of sexual activity, greater monogamy/abstinence
and increased use of condoms. With declining prevalence, there
is the danger that HIV prevention approaches will become lax
and the introduction of antiretrovirals will promote unsafe
sex. I am somewhat involved in a prevention program funded
by the Bill and Melinda Gates Foundation to avoid such a regression.
is the incidence of tuberculosis on the rise?
increases the risk of TB 200- to 500-fold by increasing the
risk that a latent TB infection will reactivate and a new
infection or re-infection will progress to disease. Overall,
30 to 40 percent of AIDS patients die of TB. Before the occurrence
of HIV infection, TB was the most common fatal infectious
disease in the world. Now the incidence has increased in large
part because of HIV. Other factors such as war, social disruption,
famine and migration of populations also play a role.
did you become interested in studying the interactions
between tuberculosis and HIV infection?
involved in TB research before the epidemic spread of HIV
infection, at a time when there was little interest in this
disease in the U.S. When HIV emerged as the public health
problem of our time, I decided to maintain my interest in
the interactions of HIV with TB and other mycobacteria rather
than switch my research focus entirely to HIV. I was involved
in the U.S. through the AIDS Clinical Trials Group in issues
related to management and prevention of TB and mycobacterium
avium infection in the HIV-infected. I also was asked to take
the lead with Dr. Frederick Robbins in developing a proposal
to study AIDS in Uganda. Dr. Robbins received the Nobel Prize
in Medicine for his role in cultivation of the poliovirus.
After serving as chair of pediatrics at the then Cleveland
Metropolitan General Hospital, dean of Case Western Reserve
University and president of the Institute of Medicine, he
returned to Case as Professor Emeritus and took on the challenge
of developing an international collaboration in AIDS research.
He asked me to help him organize the program and grant proposal,
and in 1988 we launched the Case Western Reserve University
- Uganda Research Collaboration, which developed to an unprecedented
extent, giving me access to large numbers of patients with
dual TB and HIV infections. I became the principal investigator
of controlled clinical trials of the prevention and management
of TB and HIV. David Hom, Robert Wallis and Stephan Schwander,
now faculty in the Department of Medicine at NJMS, were involved
in these early studies. Bob Wallis and I were jogging in Florence
when we had an interesting Eureka moment. It suddenly seemed
obvious that TB might accelerate the progression of HIV by
activating the immune system. We proved this hypothesis to
be correct and proceeded to studies of interventions that
are still ongoing.
you believe HIV will ever be eradicated?
to think the only hope was a preventive vaccine. I organized
programs in Uganda related to vaccine preparedness and served
as principal investigator of the first AIDS vaccine trial
in Africa. Unfortunately, an effective vaccine is not yet
in sight. So I have changed my thinking to doing what can
be done, short of the "big-fix." Prevention measures of the
future potentially will include microbicides for women, treatment
of herpes simplex virus infection, adult male circumcision
and primary prevention in high risk populations. I do believe
that HIV will be eradicated at some point by the development
of an effective vaccine and the dying out of the infected
populations who represent a reservoir for transmission. Until
this happens though, everything possible must be done to prevent
the spread of HIV, including treatment of those already infected.