P4P: We're here at the 11th Conference on Retroviruses and Opportunistic Infections in San Francisco, California, with Joep Lange who works at the University of Amsterdam, Academic Medical Center, The Netherlands. Doctor Lange, thank you very much for making an appearance here with us, so early in the morning. We really appreciate it. I know you've been doing a lot of international work, some work with former President Clinton and PharmAccess International Foundation that you chair. I'd like to ask you to explain some of what that work with PharmAccess involves and how the work is going.
Dr. Lange: PharmAccess came into existence in 2000 when the drug prices came down for antiretrovirals, and what PharmAccess wanted to do was speed up the process of getting people on antiretrovirals in Africa. It was our opinion that, a lot of the governments wouldn't be moving very fast, because the public sector in a lot of African countries is very weak, so we thought you have to start in places where they can do the job. What we did, we went to companies that we know have a presence in Africa, some multinational companies and national companies in different countries, and tried to convince them to start providing antiretrovirals to their personnel, and hopefully also to their dependents. Our first customer was Heineken -- they have breweries in 9 African countries, and they committed to start to provide therapy to their employees and their dependents, actually lifelong therapy. What PharmAccess does is, first of all, try to convince them (companies) that they should be doing this, and then secondly we provide the technical advice for them to be able to do it. What we're now ... this was the first step, because we thought you have to go there where they can do it. What we're now trying to do is link private sector programs with public sector programs, and also get the communities around the companies involved. It's not been easy. The public sector has been very, let's say reluctant to take this on. Obviously it would be great if the companies could provide the infrastructure. Because they have the infrastructure, they can provide a lot of things, where the public sector could then come in and get things for a relatively low price. We now got a large grant from a Dutch national for a lottery for Namibia, and in Namibia I think we will be able to really link public and private sector programs. Apart from that we have been engaged by the Clinton Foundation to be one of their partners in the work that they do, especially in South Africa and in Tanzania, and that's not private sector, that's really a public sector approach.
P4P: On the lighter side, when you mention Heineken, does that mean that we can look forward to any medications that we can take with Heineken?
Dr. Lange: (Laughter.) I must say that I usually drink Heineken now because they're doing such good work. They have been exceptional. They have also done a lot of advocacy with other companies trying to convince them to start doing this. They're one of the few companies that provide therapy to dependents. Most companies only provide therapy to the employees. And they have commitment for life-long therapy, even if people leave the company.
P4P: That's really excellent. In terms of IATEC ... The International ...
Dr. Lange: International Antiviral Therapy Evaluation Center.
P4P: Right. I know that's been in operation for quite some time. What are you doing with IATEC?
Dr. Lange: IATEC is a clinical research organization that tries to do independent clinical research on issues that we think are relevant. We have no real public funding, so we need to get money from customers, and that may be Pharma, it may also be UNAIDS or other foundations. We really try to do studies that we think are necessary. For instance, the 2NN, the study we did comparing nevirapine and efavirenz. We're doing a lot on prevention of mother-to-child transmission in Africa. So IATEC tries to come up with ideas and then secure the financing to put those ideas into action in clinical trials. Obviously you often have to compromise. We may have a very good idea about a strategic trial but you always have to adapt to funding possibilities.
P4P: Is there any connection with IATEC in terms of the Clinton Foundation? Are you going to be able to get any support from the Clinton Foundation for any of this?
Dr. Lange: No, PharmAccess is working with (the Clinton Foundation). So PharmAccess and IATEC, although they have the same roots, they are so different. One is really (focused) on scaling up access to care and the other is on research. I think there's a lot of potential for synergy, but the types of people who work in the two places are very different. It was actually better to separate them to a certain extent.
P4P: I know there's been a lot of work going on for Bangkok, for the upcoming World AIDS Conference there in July. How has that work been progressing in terms of organizing that conference? What kinds of good news is there, and what kinds of bad news is there?
Dr. Lange: I think the concept of the conference is very interesting, because it's different from every AIDS conference that was there before. I think it's increasingly acknowledged that leadership is extremely important, engaging political leaders in the fight against HIV/AIDS. In those countries where the political leaders have stepped up and been up front about HIV/AIDS have actually made a difference. There's still a lot of countries where the political leaders are not doing that. For Bangkok, we really want to pull in the leaders to come to the conference and make sure that they understand the importance of doing something about HIV/AIDS ...
P4P: Light a little fire underneath some of them.
Dr. Lange: Yes, in a constructive way, because if we just throw tomatoes at them or criticize them they're not going to do anything. What we really want to do is to try to bring together those that have performed and those that haven't. Obviously you can't bring all the leaders of the world. First of all they wouldn't come. Second, the security concerns become enormous. In Bangkok what we now have, apart from the scientific program and the community program, we also have a leadership program. Getting political leaders, also getting leaders from the business sector, getting leaders from the community, getting leaders from different religious affiliations, and try to bring them together and have special sessions devoted to leadership. We'll have a number of plenaries on leadership. We will also have meet the leader sessions where people can question the leaders. We're going to have symposia, where they can be interviewed. For instance, a number of people have already said they would be coming, your President Clinton will be coming, Kofi Annan will be coming, Mr. Wolfensohn, president of the World Bank will be coming, a number of national leaders are going to come to Bangkok. So from that perspective, I think the conference is going to be very interesting.
I think the bad news about the conference is that, of course, all of the promises that the big multilaterals have been making about how many people would be on therapy by now, I think it's going to become clear at the conference if they're honest, that the 3 By 5 Framework1 is not going to be met. And I think we have to be quite critical about that. It is an opportunity to not let them off the hook, and come up with an explanation of why we have this blah-blah, and why we're not going to reach that target.
P4P: And where we need to go to get there.
Dr. Lange: Yes. Because I think that the big problem is that, there's always blah-blah, but we need to do this, we need to do that, but still a decent action plan is still missing. And we've tried very hard to get this international collaboration going. We founded the International Treatment Access Coalition at a certain stage to really try to bring the players together. That has been replaced by 3 By 5, but I'm actually not impressed by the pace of progress that 3 By 5 is making. I think it's going to be a conference of accountability.
P4P: I'm really excited to hear about the leadership segment at this conference.
Dr. Lange: Yes, but it's only going to be successful if we can really also be engaged in critical dialogue and not just have blah-blah, we're doing this, we're doing that.
P4P: I think that would be very influential, if President Clinton and his foundation and other international leaders, like Kofi Annan ...
Dr. Lange: Nelson Mandela will come. President Machel, his wife is actually one of the patrons of the conference.
P4P: Once folks see who's there they have more of a tendency to perhaps want to jump on board.
Dr. Lange: Yes, that's the whole idea. And we'll have people from the media, from the entertainment sector. We've got a number of big actors from the U.S. that will be coming.
P4P: You're gearing up to do some vaccine work.
Dr. Lange: Yes, therapeutic vaccine work.
P4P: Therapeutic, which is good. Can you give me any information on where you're at in that process?
Dr. Lange: Yes, that has been an exceedingly slow process. This is a European Community grant that we have together with Brigitte Autran from Paris and Jeffrey Cantelejo from Rosano. It's a European-made vaccine funded by the European community. One of the problems has been, the first company was going to produce the vaccine and suddenly decided they were not going to produce it, so just getting the vaccine produced has taken an enormous amount of time. I've learned that the vaccine world is very different from the therapeutic world. It's not like you can start a trial overnight. It actually takes quite a while before you get somebody to produce the vaccine to support a trial like that.
P4P: The vaccine construct, it is designed for HIV-1 or the virus that may be particular, say, to Southeast Asia?
Dr. Lange: No, this is a B-subtype, so this is the virus that is the dominant virus in the U.S., and I was going to say in Europe, but that's changing rapidly, because of all the immigrants. Most of our new patients have non-B virus. There is another similar construct, which is actually made by EuroVac, that is a non-B virus, that is a C-subtype virus. The one that we're using as a therapeutic agent is a B-virus, and the idea of this study to see whether we can postpone the initiation of treatment or delay -- if you interrupt treatment -- the restart of treatment ...
P4P: Or increase the length of interruption.
Dr. Lange: Exactly, yes. There's another field that we've become interested in, and that's microbicides. We're getting heavily involved in microbicides research in Africa.
P4P: Are there any particular compounds that you're working with? I know they're doing some stuff with ... Gilead is doing some stuff with viread, where they're trying to develop gels and other things.
Dr. Lange: Yes, and Gilead is also doing this big study funded by (The Gates Foundation) with viread as an oral prophylactic, which I think is going to have the best chance of working.
P4P: Do you think viread as a preventive prophylaxis is really going work?
Dr. Lange: I think it's going to work.
P4P: You do?
Dr. Lange: I'm very ...
P4P: You're very optimistic?
Dr. Lange: And it's not just viread. Other drugs would also work. In fact, we did this study called SIMBA, which was presented in Paris last year, a study to prevent transmission from breast-feeding mothers to their infants, and for the duration of breast-feeding we gave the infants a single pill of either nevirapine or 3TC per day, and that actually worked. It was very effective in preventing transmission. So I don't see why an adult taking a pill prophylactically shouldn't be protected from sexual transmission.
P4P: That's really exciting.
Dr. Lange: Yes, it's extremely exciting, also because a vaccine is going to take ... before we have an effective preventive vaccine, if we're optimistic it's going to be 10 years ...
P4P: It's already been 10 years.
Dr. Lange: Yes, it's always ten years. First it was 2 years, then it became 10 years. It's always 10 years.
P4P: Doctor Lange, I know you're racing to get to another appointment this morning. Thank you so much for taking the time to sit with us this morning and answer a few questions. I know that those who are not privileged enough to be here at this conference will be very grateful to you.
Dr. Lange: Thank you, Jeff, and I hope to see you in Bangkok.
- 3 by 5 Framework: The WHO and UNAIDS global initiative to provide antiretroviral therapy to 3 million people with HIV/AIDS in developing countries by the end of 2005.
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