An Interview with Dr. David Cooper—A Life on the Front Lines of AIDS Research
July 2007—Dr. David Cooper will co-chair the International AIDS Society’s Conference on HIV Pathogenesis, Treatment and Prevention in Sydney, Australia, 22-25 July. As head of the National Centre in HIV Epidemiology and Clinical Research at Sydney’s University of New South Wales, Dr. Cooper has worked with HIV/AIDS doctors and researchers around the world, but perhaps nowhere as closely as in Asia. He has been a stalwart supporter of the TREAT Asia Network since its inception. Dr. Cooper spoke with the TREAT Asia Report about the successes, failures, and prospects for the future of HIV treatment and prevention in Asia.
TREAT Asia Report: Looking at the national responses to AIDS in Asia, which strategies do you think have been most successful?
Dr. Cooper: The responses around the region have been variable but there have been some spectacularly successful programs. Early on, the Thais responded with a 100 percent condom use policy that certainly turned the epidemic around there. Unfortunately, some of that progress has not been as good recently, particularly amongst men who have sex with men [MSM] in Bangkok and perhaps injecting drug users. Similar successes have occurred in Cambodia, with condom use and treatment implementation.
Other countries that have injecting drug use epidemics, such as Malaysia, Indonesia, and China, have really been much slower to respond and less successful because of the stigma and illegality associated with injecting drug use. Having said that, there is much more happening now than even five years ago.
Dr. David Cooper
TREAT Asia Report: Has any progress been made to address the shortage of trained doctors in Asia?
Dr. Cooper: This is still something of a problem. I don’t see a new generation of doctors coming through the ranks in many of these countries. The leadership now is the same you have been seeing for five to ten years, with some exceptions. My belief is that this is very much related to the medical system in many countries in Asia. Because government jobs in public hospitals are not particularly well paid, physicians have to moonlight, if you will, in the private sector after hours, which gives them very little time to pursue some of the education and research aspects of academic medicine.
Unless we can train more physicians and provide better salaries and conditions to engage in academic medicine—which not only includes patient care but research and teaching—we are not going to solve the problem of leadership. On the other hand, there are more and more physicians providing direct HIV care in many of the countries that I visit.
TREAT Asia Report: As an advisor to TREAT Asia, you have watched the network develop since its inception. Where has its work had the greatest impact?
Dr. Cooper: TREAT Asia has made an enormous difference by highlighting the fact that HIV treatment and care in Asia is still very patchy. There is a serious epidemic there, just as there is in sub-Saharan Africa, and the approaches to it may be different. And TREAT Asia has successfully involved physicians and other health-care professionals in leadership positions.
The HIV observational database [TAHOD] has also been extremely successful. TAHOD provides many of the TREAT Asia sites with their first opportunity to participate in research and to see how it works—and how difficult it can be to achieve good quality data. The outputs and the publications that we have generated about people with HIV in Asia have been very positive and show that treatment in Asia is successful just as it is in other areas of the world—if not more so, in some instances.
Some of the other programs in TREAT Asia, particularly the MSM project, have been very helpful in linking advocacy for MSM in the region and showing that the vulnerability of MSM is a problem across the region, not just in one country.
When I first got involved in Asia in the early 1990s, many Asian physicians told me that there was no such thing as a gay man in Asia. They said there wouldn’t be an AIDS epidemic because there weren’t gay men like in the developed world. The awareness that TREAT Asia has generated in terms of MSM being vulnerable populations and Asian MSM from different countries and cultures working together to promote prevention has been very successful.
TREAT Asia Report: Have any results from TAHOD surprised you relative to the data on HIV/AIDS treatment that you have seen from the Australian HIV database?
Dr. Cooper: What perhaps surprised me is the remarkable consistency of the data from all over the world, which shows that people do pretty well if they have access to treatment, no matter where they are from. Specific to Asia, we have documented certain problems, particularly high rates of tuberculosis, recurrent bacterial infections, complications of hepatitis, and the toxicity of HIV drugs. An important finding from TREAT Asia’s studies was that toxicity is one of the main reasons for treatment changes, and that the toxicity that we are seeing in Asia is very similar to what we find in the developed world. The problem in Asia is that when toxicity occurs, it’s much more difficult to switch people to different drugs because there are fewer choices.
TREAT Asia Report: You performed clinical trials on raltegravir, an integrase inhibitor that is expected to be approved for use later this year. What impact do you see for these new drugs in the resource limited countries in Asia?
Dr. Cooper: The big issues right now are second-line drugs and what to do with the first-line failures of the fixed-dose combinations such as D4T/3TC/nevirapine. At the moment the only drug that can take care of first-line failure to a large extent is Kaletra. That has been an expensive option and not without side effects. Plus we have recently seen unpleasant disagreements between Abbott [Laboratories] and the Thai government in terms of purchasing Kaletra at a price that the government thinks it can afford for second-line therapy.
So as far as some of these new drug classes such as integrase inhibitors and CCR5 inhibitors, I think it is important in Asia that we explore how we can roll out some of them as second-line regimens. More competition in the availability of second-line drugs may also force price reductions, just as has happened with first-line regimens.
TREAT Asia Report: On the question of drug availability and pricing, where do you see things going, given the increasingly fraught relationship between the drug companies and national governments, both in Thailand and in India?
Dr. Cooper: I think at the end of the day we will be dependent on generic drugs, particularly for the least developed and intermediate developing countries in Asia. The price of medicines is still fairly unaffordable and generic competition will bring prices down. Everyone is afraid about India observing patent law for new drugs and worried about what impact that will have on generic competition. But there are also real concerns about the fact that the generic manufacturers in some settings can’t make the drugs, particularly second line, to the same quality as the originators. That is a very big worry as we move down to the more complex drugs.
TREAT Asia Report: Do you think the sort of confrontation that Thailand and Brazil are staging with the drug companies over pricing is an effective political tool?
Dr. Cooper: That’s a very complex issue. On the one hand, we wouldn’t have any drugs without research-based pharmaceutical companies. So patent protection in the developed world must be maintained at all costs to allow them to develop new drugs for all diseases. But it’s reasonable that governments in the developing world are challenging pharmaceutical companies to give them the best price. I just don’t see anything wrong with that. Now, whether it’s a reasonable tactic to break patents and allow generic manufacture, it’s difficult to say, but if a government has a serious public health problem, then I think it is justified, and if they can force pharma to give them a better price, then they should.
The problem that worries me immensely is that governments in developed countries are balking at some of the prices that pharma is charging for their products there. This is particularly a phenomenon as the baby-boomer generation ages and becomes a huge consumer of health care. I am afraid that that pressure could have an impact on pharma’s ability to cross-subsidize drugs and sell them more cheaply in the developing world.
TREAT Asia Report: You were recently named a fellow of the Australian Academy of Sciences. Among your scientific achievements, which are you the most proud of?
Dr. Cooper: The scientific achievements that I am most proud of are my contributions to antiretroviral therapy. I have been involved in the development of almost every antiretroviral that is now available for treating people with HIV, from phase I to phase IV, and in some cases I have been involved very extensively. For example, the studies of combination therapy in the early HAART era or more recently the raltegravir studies. We were one of the first groups in the world to demonstrate some of the more serious toxicities of these drugs, particularly the lipodystrophy syndrome, at a time when there was so much optimism about treatment. And I think that was an effective catalyst in getting research-based pharma to look for better and safer drugs.
This hasn’t been something that I have done by myself, obviously. However, I am most satisfied when I can get clinicians, laboratory researchers, pharma, government sponsors, research sponsors, and so on to work together in small and large clinical trials to get the best outcomes. That is really what I enjoy doing.
TREAT Asia Report: What would you say are the main priorities and challenges for AIDS researchers right now?
Dr. Cooper: There are a number of priorities. In the developing world, the regimens that we are using are just too toxic for first-line use and we have got to move away from them. The second priority is to work out what to do with second-line drugs.
The third priority is to get much more clinical research going in the developing world, as we are doing in TREAT Asia. We need to train a new generation of leaders in academic HIV medicine who will be able to take these advances forward. It is a great pity that the rollout programs have not funded research in general—I believe that at least 10 percent of the funds should be mandated to do research, because if we get the rollout wrong, the donors will not be happy with us in terms of continuing to sustain the rollout.
For example, what we are seeing in many countries is a very high early mortality among people starting antiretroviral therapy because people are coming in too late and sometimes their illness is too advanced to benefit from medicine. So we have to look at new ways of rolling out treatment earlier, which is a big step, because right now most people in the developing world come to the doctor only when they are sick.
The other huge challenge is prevention. Behavioral prevention can only achieve so much. Safer behaviors are not sustainable 100 percent of the time and therefore we really need to move forward on the biomedical prevention agenda. Vaccines have been extremely difficult to achieve but we must continue to work on them. At the end of the day a safe and effective vaccine is the best prevention for HIV/AIDS.
Other methods of biomedical prevention such as microbicides, preexposure prophylaxis, and treatment of herpes will require a lot of planning and input if they are proven efficacious. The implementation of male circumcision will be an important first step in this approach now that it is proven to work. We aren’t going to break the back of the epidemic without rolling out treatment and prevention together.