Neal Nathanson

Neal Nathanson, Ph.D., is 71 years old. A world leader in viral epidemiology and professor emeritus at Penn, where he chaired the Department of Microbiology for 15 years, he was recently asked to come out of retirement to assume his new post as director of the National Institutes of Health's Office of AIDS Research.

The situation facing him in his new post, he says matter-of factly, is grim, but important enough that there was no question whether he would un-retire to take the challenge.

The world-class virologist comes out of retirement to helm the Office of AIDS Research. His goal? A cure, of course.

Photo by Candace diCarlo

Current AIDS data shows more than 10 million have died as a result of the disease since the late 1970s. About 30 million current infections, with new infections occurring at a rate of 250,000 monthly, are documented worldwide. In 1997, an estimated 2.3 million people died of AIDS - a 50 percent increase over 1996.

Q. How did you come to un-retire to direct the OAR?
Well, I was recruited for this. It wasn't really a job I applied for - I was pulled out of retirement. I had mixed feelings about it, and I guess I still do. It was clearly an important job and they needed somebody with a fair amount of seniority. The reality is certainly proving that - in the sense that you really didn't have time to learn on the job. It's also a hectic position - a lot more than any academic position, maybe with a few exceptions.
   There's a major political and public relations element to it. AIDS is really different than any other disease. There are other diseases that kill more people, but I don't think there's any other disease where there's anywhere near as large and diverse and proactive a group of activists. So, you have a lot of people to keep happy, and you become a target even if it's something personally you don't have much control over.

Q. Is that the most hectic part of the job?
No, but it's a major part. For instance, one thing that's going on is the Black Caucus in Congress has recently been raising a tremendous amount of dust about inadequate attention to AIDS in minority communities. And they have some justification, although that's hard to evaluate. There's also the very active gay community, as well as all the sticky issues about needle exchange for drug users, which is really quite effective in preventing transmission of AIDS, but which is politically an extremely hot potato. So, every time you turn around, there is another really controversial, politically high-profile issue.
   You know, with heart disease, you can get a little passionate about how much salt you should eat, but it's nothing like the passion that surrounds AIDS.

Q. Are AIDS cases decreasing in the United States?
What happened in the United States is that the number of new infections peaked in the early '80s before we really isolated the virus, and it kept dropping partly because the blood supply was monitored and kids with hemophilia or people taking blood transfusions were no longer at risk, and partly because safe sex practices were introduced, and particularly gay men started practicing much safer sex.
   There was a dramatic drop in the number of infections and that hit, in 1990, a sort of plateau of about 40,000 new infections every year. We hit a wall at that point because the information isn't perfect. It's hard to measure precisely. So, in a sense, we stopped making progress and one of the real goals is to try to break through that glass floor and further reduce the number of new infections - that's been the history with other viruses like polio or measles and so forth. You want to keep reducing the number. Because it's a transmissible disease, you can do that.
   So, the good news is that you have this multiplier effect every time you prevent an infection. That means that individual then is not going to pass it on - you've broken a link in the infectious chain. And that's not true of a disease like heart disease or cancer. But the bad news is that we're still not on a downward slope. So that's one of the real pushes now.

Q. What ways are you trying to push the slope down?
What we're really focusing on now is what we call intervention research, which is to really bring to market better drugs and more effective intervention strategies. That's a leading focus of what we're trying to do - anything that can be done to either intervene to prevent new infections or intervene to keep people who are infected from developing AIDS and people with AIDS from dying. From a public health point of view, it's much more effective to prevent an infection than to try to treat it. That's always been true of infectious diseases. So, the highest priority has to be intervening to prevent infection.

Q. What's most effective on that front?
There are a number of things. One is needle exchange, which unfortunately is not being supported by the federal government, but we're still continuing research on more effective ways of setting up needle exchange programs, hoping at some point there will be the political will to implement them. And those are being implemented, but by state and local funds and some more enlightened places in the United States.
   But Congress has specifically refused to put money into that on the perverse grounds that they think it rewards people who are drug addicts and, rather than being rewarded, they should be punished. That's a hard reality.
   The second thing is perinatal intervention. In theory, the best regimens are to treat the pregnant women and then at birth, and the baby after. You can actually cut down the number of transmissions that way from about 20 to 40 percent to 1 percent.
   Another thing that we don't have anything yet ready to be used but is a major research agenda is making a decent vaccine. Eventually, that will replace some of these other interventions, because, in theory, if you could immunize everybody on a pre-exposure basis, like you can for polio or small pox or measles - that's a very effective, and cost-effective, way of intervening. But, so far, that's a ways from happening.
   We're also more and more going to emphasize behavioral interventions, because one thing that is very apparent is that even when you have an effective new approach, people don't always use it. It can be something as low-tech as a condom, or it could extend to something as sophisticated as a drug treatment.

Q. Vaccine research accounts for 15 percent of your budget. Should it be increased?
We're increasing the vaccine research budget faster than the overall AIDS budget. It's hard to say if it should be more. Money is necessary, but not by itself sufficient obviously. And, at a certain point, you can't improve things by just throwing more money at it.

Q. When might a vaccine become available?
Even if we had something that looked like it would be effective, it could still take five, six, seven years. The FDA is very careful about checking for adverse effects. Their emphasis has always been on safety rather than effectiveness because their first obligation is to protect the public from new products that are unsafe. So, it's a slow process. I would guess it would be five to 10 years in this country. Other countries with less stringent standards may have something sooner.

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Originally published on October 15, 1998