We return from the heart of darkness, having seen the light, courtesy of Tony Fauci
The morning session at the HIV Prevention Trials Network Annual meeting at the $309 a night Marriott Wardman Park Hotel in Washington began with a bounteous breakfast buffet including unlimited fresh orange juice, scrambled eggs, sausages of two kinds and long and perfectly done slices of bacon, meeting the highest standard of English country house weekends of the past century.
We ate as much bacon as we reasonably could, in honor of the hapless victims of AIDS around the world and the public spirit of many of them in agreeing to participate for very small reward ($10 or $20, we were told, is typical)
in testing revolting drugs which may help stave off the depredations of a retrovirus which is entirely to blame for their ailments, according to every single person present at this meeting, for which no fewer than 861 people had signed up.
Bleary from a unsuccessful fight to find anything but trash on the 27 inch tv in our room last night, this morning we simply sat down beside two Thai girls at the nearest table.
Destiny, however, took a hand. A friendly woman sitting at the same table proved to be administering the very pilot study that had Myron Cohen exploding with enthusiasm yesterday afternoon.
She informed us of the answer to the puzzle that had challenged us since. She explained how the “statisticians” had allowed them to launch a study which would detect the effects of nevirapine on the transfer of HIV positivity from man to woman or vice versa, even though this mostly (after initial infection) occurs at such a low rate that for all practical purposes it can be ignored as nil.
This was the last point in the day when pure logic ruled, as it turned out, and it was interesting to explore it with her. We have to say we are still not quite sure if the study design makes sense in principle. In case you can and wish to comment, we explain our difficulty in a hidden section which will emerge if you click (show):
The conundrum is as follows: if Nancy Padian, Gisselquist and numerous other mainstream reasearchers agree that on the whole it would take heterosexual discordant couples (one HIV positive, one negative) one thousand couplings on average to effect one transfer of HIV positivity, how could a dose of nevirapine or anything at all make any discernible improvement in this almost negligible rate?
(The rate is even lower, one thousand to ten thousand, according to the slide by Myron Cohen yesterday, endorsed by other speakers in the meeting, which noted that after the acute phase, during the lengthy period of dormant virus before actual AIDS breaks out ten to twenty years after, the chances of transferring the cirus heterosexually were 1/1000 to 1/10,000, as shown in a slide which we will reproduce here
)
The brunette beauty told us that “the statisticians” had worked out how to do the study. Apparently there would be about 4000 men and women roped into this trial, and that the expected maximum total of successful transfers of the positive virus antibody status in five years would be “88″. If there were more than 88 the trial would be halted, she said, since it would be clear that nevirapine was not working to inhibit the rate.
How does that work? we enquired. You mean, if it takes ten years for the average couple, at the rather generous level of two bouts a week, to transfer HIV positive status to the other, then if you have 2000 couples, you can expect many more events? And therefore if there is any improvement with nevirapine, you will be able to see it (assuming there is a control group, which has often been missing from NIAIDS trials, according to the Harpers piece)?
Yes, she agreed. But unfortunately the first talk had started, and she had to excuse herself with advice to look at their web site and see what the statisticians had explained.
We must say we couldn’t immediately decide whether their approach made sense or not. Perhaps readers can advise.
If ten men take ten hours to paint a house, then twenty men would take five hours, sure. But if ten men can eat lunch in half an hour, twenty men can’t eat lunch in fifteen minutes. Which principle applies to this study?
Is the principle of a faster paint job applicable to the statistics of HIV transfer? Assuming that HIV is transferred through sex at all, which seems questionable (the 1 in 1000 Padian found seems to have been raised from zero during the trial by a somewhat circuitous and apparently invalid logic) especially since the lower end estimate on the slide yesterday from Myron Cohen showed 1/10,000? (We reproduce the chart in black and white for clarity here)
Unless we are mistaken, the average couple would be corpses in their graves before their number came up. At the lower, once a week copulation rate that is the normal assumption of researchers, that rate would be 50 copulations a year, or 500 in ten years, so 10,000 would take a couple 200 years. So the bottom line would be that the average couple would take 20 to 200 years to transfer HIV.
The approach suggested by the statisticians, the lady explained, was simply to use this figure to project how many events would occur in a group of 2000 discordant couples. Since the typical couple will take 20 to 200 years, and the events occur at random, anywhere from immediately for an unlucky couple to forty years for a lucky one, a five year study of 2000 couples should produce about one quarter ie 50 to 500 transfers of HIV.
In other words, if one couple takes an average of 20 years to transfer, then two thousand couples all copulating simultaneously will produce more such events in a shorter time. Presumably if the curve is flat there will be 50 to 500 in five years, more or less. So where does this mere “88″ come from? Apparently the statisticians have chosen the 1 in 10,000 bouts average rate of transfer.
This is an interesting fact, that heterosexuals can find very comforting even if they believe in the dangers of HIV. Apparently anyone’s chances of contracting HIV in sex from another person of the opposite sex in a single bout is a very low 1/10,000, not 1/1000, according to the assumptions of the statisticians.
All this seems to be logical, and is a standard approach in HIV?AIDS research, we believe, but somehow one still wonders if there is any sense in it at all. Surely such a fantastically low rate of transfer for an individual couple probably reflects the reality that HIV just does not transfer in heterosexual sex at all, and nevirapine or any other factor is therefore going to make no difference whatsoever, except for producing illnmess and even death for some, if the critics are right.
Of course, the fact that condoms could certainly achieve the desired result without any nasty medication whatsoever is not relevant, because this is not permitted to be mentioned by the granting agency, the federal government.
That was the last time we examined anything with a critical eye today, it turned out. For having demolished as much bacon and orange juice as possible on behalf of the trial participants unable to attend this meeting, we joined the 861 listeners in the main hall presentations, and from that moment on we found ourselves increasingly unscientific in mood, as we were caught up in the group spirit.
By the end of the day, in fact, we had seen the light. Suddenly there was no need to criticize at all. Right in front of our eyes was the best evidence that HIV medication research was on the right track, and that anyone who was going to criticize was simply an outsider who hadn’t got the message.
This overwhelming evidence included:
1) The vivacious and warm personae of the participants, who seemed so much more content and agreeable than complaining HIV critics, one has to say, and who set an extremely good example for the populations of underdeveloped countries to follow. If belief in HIV had conferred such vibrant health and energy on the 861 people gathered in this meeting, surely it would bring the same blessing to the people of Africa and Asia.
2) The extraordinary cohesion and sense of mission shared by all. There was not a single doubter or skeptical mind in the bunch, as far as we could tell. This was enormous team spirit, equal or perhaps even greater than a school of fish, all swimming in unison in the same direction. The effect was overwhelming. The latest science has revealed that the mirror neurons in one’s brain tend to bring one’s mind in line with another human being as one observes them in action. We found it impossible not to empathize with 861 people in close proximity who have the same idea all at once.
3) The inspiring positive spirit of the HTPN and DAIDS leaders, including at least three with enormous charisma and oratorical talent, who we found could stir even a skeptical outsider with a sense of mission and accomplishment as we all moved forward together into the future where thanks to advanced science and sophisticated drugs the entire world will be able to live with HIV/AIDS, if not actually avoiding HIV altogether.
Such exceptional orators included Myron Cohen, Jonathan Kagan
and the celebrated Anthony Fauci, whose sense of mission, vigor and confidence in the future imbued us as well as everyone else listening to them. In fact, we suggested to all three that perhaps we should name them “Heroes of AIDS” in a magazine piece, but unexpectedly Anthony Fauci, after three seconds reflection, declined.
4) The powerful arguments advanced to this reporter to the effect that any doubts in the relevance of HIV medication to AIDS were as absurd as Holocaust denial, and probably the moral equivalent. “Come and see for yourself!” cried at least two busy researchers with massive trials ongoing on the Dark Continent. One tall African-American active in Zambia told me that I would see how they brought in ailing AIDS victims so weak they had to be wheeled in barrows. Three months later, the anti HIV regimen had them returning to their villages.
5) The level of organization and authority reflected in the slides presented, with their perfectly worked out diagrams, arrows, columns, tables and lists, jargon, acronyms, and labels, showed everything labeled, named, ordered, computed and Powerpointed and explained clearly and logically (we assume, since the slides often slid by too quickly for real inspection). Nothing is more convincing and authoritative than a scheme mapped out and charted in clear order, we found.
6) Clear agendas. All Friday morning one agenda after another was presented and explained, in slide after slide - the currently very popular microbicides research agenda, the pediatric research agenda, the antiretroviral, behavioral, substance use and STD control research agenda. In fact, it could be said that nowhere had the public monies been more intensively applied than in this effort to map a future research agenda, which had so clearly achieved its goals. One could have nothing less than complete confidence in all these agendas, whatever their underlying rationale.
Questioning any agenda so thoroughly mapped would be like questioning the course of a tightly disciplined, immaculately maintained ship - a Navy ship, say, with clean uniforms (in fact there was one officer of the CDC present in full gold banded cuffs and medals, of whom we took this snapshot) and all sailors at their posts, steaming ahead to do battle, guns polished and loaded and course steady. As an observer on the bridge you would never dream of challenging the competence of the captain, even if the prow was aiming at a stone harbor wall dead ahead.
7) Keeping their own house in order. Nothing instils confidence in an operation than keeping its own house in order, as we say.
One half hour presentation, by the proud designer of a new DAIDS computer reference system, explained how it would allow everyone applying for a trial grant to check at any moment, day or night, the precise position the application had reached in winding its way through the bureaucracy. This admirable order of priorities in the concerns of all involved won appreciative applause.
The tremendous presentation by the NIAIDS director. The week long session ended on a high note as Anthony Fauci, looking extremely dapper in a nicely tailored dark grey suit with subtle color threading, reassured his troops that funding might have leveled off from its previous 45 degree ascent, but they shouldn’t feel depressed. He had found a slide from the early years of the plague in which he predicted that funding would be tight, but as it turned out it was only just beginning its steep climb. The same thing might happen again, he suggested, and meanwhile he personally would make sure that the number of trials they were administering didn’t drop too far.
Fauci’s confidence was fortifying, and we felt quite reassured that the whole effort to test the effect of rather unpleasant drugs on the world’s ailing poor was unlikely to slow down noticeably.
In fact, we took the opportunity to ask him about his reaction to the new Harpers article, by Celia Farber, mentioned earlier, which calls into question the entire scientific quality and even the rationale of the 20 year effort to combat HIV?AIDS that Fauci has led with such success in the eyes of the world and the White House.
Unlike every other major figure in the NIAIDS and out of it that I had asked yesterday and this morning, Fauci, however, informed me that he hadn’t yet read it. By sheer coincidence, however, his talk had contained a spirited defense of the HIVNET nevirapine trial in Uganda which Farber had revealed was a complete mess, according to its embarrassing initial internal reviews.
Fauci had repeated the endorsements of the Institute of Medicine and other defenders of the study, who had claimed that despite the failures of controls and other flaws pointed out by critics, the final result, as rewritten by the responsible official in NIAIDS, was that nevirapine was an effective drug and should be funded with large chunks of the $15 billion in AIDS aid promised by President Bush.
Apparently this section of the speech was not in any way designed as a response to Harpers, then, but Fauci was interested to hear that it applied. When I mentioned that he hadn’t replied to the second half of the Harpers piece, however, he asked me what I meant. I told him it contained a fine summary of Peter Duesberg’s activities and critique of HIV. “Oh, that’s all been dealt with on our web site!”, he said dismissively.
Ed Tramont, Director of the Division of AIDS (DAIDS) of the NIAID (National Institute of Allergy and Infectious Diseases, NIH) and others, who all admitted to having read the Harpers piece, seemed to think there was no cause to take it seriously either. His reason, he said, was that as soon as he saw Peter Duesberg mentioned in it, he knew he didn’t have to take it seriously. (However, having discovered that we took Duesberg’s reviews seriously as scientific literature, peer reviewed in the best journals, he rushed to tell Tony Fauci that we believed in Duesberg’s critique.)
With the single exception of one key bureaucrat at DAIDS, who when asked his reaction to the Harpers piece looked miserable, and said “I just do my job”, noone seemed to feel that it deserved taking seriously. “They can write anything they like but it doesn’t make it right!” said a female John Hopkins scientist. Those willing to discuss the topic - and there were several of these - insisted that the drugs, including nevirapine, worked very well, and any time I wanted to visit Africa I could confirm this for myself. Their very real conviction was apparent, even in private conversations.
But one thing was noticeable. No one was able to explain how Peter Duesberg had been able to publish continuously over two decades complete scientific eviscerations of the HIV claim in some of the most reputable peer-reviewed journals in the world, where the referees included the greatest experts in the field, often extremely wary of his cause and anxious to prevent publication but evidently unable to prove what he said was factually wrong.
The only answer to both Peter Duesberg and Celia Farber seemed to be as the brunette scientist from John Hopkins put it, “They can publish what they like but it doesn’t mean it’s right!’ Fauci’s “Go to my web site!”, and the testimony of African trial administrators (one from Harvard, no less) that if one didn’t believe the drugs were valuable, “come to Africa and see for yourself.”
Immersed in today’s clubby experience, however, that seemed good enough. Power and money certainly provided a more attractive form of truth than tiresome and remote scientific journals that no one important needs to take seriously.
After Tony Fauci had presented several networking awards to a handful of hard working trial administrators, the meeting broke up and closed lunch sessions planning the future of trials took place.
But we had already learned enough, and full of enthusiasm for the marvelous example of these lively servants of a great cause, which they had so powerfully reassured us was the right one, we returned on the train to New York with what we had sought from the horse’s mouth - replies from the mouths of the biggest horses in the business to the best written and most tightly edited and checked challenge to HIV research and ideology to be published in mainstream journalism for two decades.