Podcast: Ebola in DRC, a new HIV treatment, and the proposed US budget

Interviewer: Benjamin Thompson

Hi listeners, Benjamin here. I mentioned last week that we weren’t going to have a regular edition of the Nature Podcast, but we’re very lucky here at Nature as a bunch of our colleagues from across the globe have joined us in London. One of them is senior reporter Amy Maxmen who’s based in San Francisco and she’s joined me in the studio for a quick News Chat. Amy, our first story today is about Ebola and listeners, I’m sure you’ll remember the big West African outbreak that went on between 2014 and 2016 which had a significant death toll and economic impact, particularly in Liberia, Sierra Leone and Guinea. But Amy, there’s not been so much news coverage of what is the second largest outbreak, and that’s currently going on in Central Africa in the Democratic Republic of Congo or DRC, and that started in August 2018. What’s going on there at the moment?

Interviewee: Amy Maxmen

Yeah, so as of the 11^th March, it’s at 925 cases and 584 deaths, so as we’re approaching 1,000, most researchers are really worried and some of them are saying it’s time for the WHO to sound their highest kind of global alarm which is called a Public Health Emergency of International Concern.

Interviewer: Benjamin Thompson

Well, how does this outbreak compare to the one that went on in West Africa?

Interviewee: Amy Maxmen

Well, that one was far larger, however it also went on for longer, so we’ll see how this one goes. What’s worrisome is that although if you look at the situation report put out by the World Health Organization regularly, it does seem like okay, in recent weeks there’s maybe fewer cases than there were in weeks prior, however epidemiologists are worried not simply because of the case numbers per week, but they’re worried because of other numbers they look at as well that make them think that maybe the virus is spreading within communities and going undetected for a long time. That means people pass it to one another before they come in, get isolated in a clinic and stop transmitting it.

Interviewer: Benjamin Thompson

Right, and what are these other numbers showing?

Interviewee: Amy Maxmen

So, for example, in February, nearly half of the people who died from Ebola in the two cities that are hit hard right now, Butembo and Katwa, they were found dead within their communities and that means they’re not isolated in hospitals at the very late stages of the disease, in the last few days and after death when the viral levels are surging and they can pass it on to other people. Three quarters of those who are diagnosed with Ebola, they had not been previously identified and been under surveillance at the time when they reported their symptoms, which again means they were walking around and mixing with people. And then one official I spoke with at Doctors Without Borders, she pointed out a worrying number as well, which was that the death toll is somewhere around 60%, and that’s despite the fact that care is much better for patients in this outbreak compared to the one before –there’s experimental therapies, there’s a vaccine – and yet we haven’t really made a dent in that number, and that’s because people are showing up late. When somebody’s in the very late stages it’s hard to save them.

Interviewer: Benjamin Thompson

And why might that be?

Interviewee: Amy Maxmen

What these numbers are saying is that people are not going into clinics as soon as they show symptoms which means they don’t really trust Ebola responders. And when I spoke with a first responder whose kind of a frontline worker on the ground in Butembo, he told me that they’re being threatened every day. So, in addition to at least three attacks so far on Ebola centres, he says that there’s some areas where his team will be stoned, where they’ll get little folded up pieces of paper that are death threats, they’ve been assaulted. So, all of this mistrust bodes really badly, and that also speaks to why there’s people who are just found in their communities with Ebola.

Interviewer: Benjamin Thompson

Well, clearly an awful lot going on then in DRC. What needs to be done and by whom maybe to contain this outbreak?

Interviewee: Amy Maxmen

It’s a very hard question. So, when I was reporting the story and when I talked to Doctors Without Borders, one of the big groups treating people there, they had decided to withdraw from the area. You know, there’s always some mistrust in Ebola outbreaks, but the fact that there’s these sort of attacks going on eight months in, they themselves said they’re questioning themselves on how well they’ve communicated with people and so they’ve decided to suspend their activities for now. I think other groups such as LEMA were there – they’ve pulled out. The US, the UK, they’re not sending bilateral support there, so who’s left? The WHO is there and the DRC Ministry of Health is there, and they’re worried. So, they’re looking for support from UN troops to maybe help secure their centres and also protect their people around their compounds – that’s another fraught issue because you bring guns in and that might cause more mistrust. It’s actually a genuinely very hard situation. There are some health policy analysts who are saying if WHO sounds this major alarm, there’ll be this massive shift in support for the region. That’s even controversial because on the one hand, some people think that’s sort of what turned things around in West Africa, on the other hand, people worry well, what if this causes other countries to block borders, to block trade, and that could have all sorts of problems like depressing economy, when refugees flee, having them cross borders informally and that could be a big problem, so it’s actually not a simple answer.

Interviewer: Benjamin Thompson

Well, Amy, let’s move on to our second story in this extended News Chat, and this is about HIV. Last week, we reported on the second instance of a very specific treatment for HIV that involved a stem-cell transplant. Now, there’s been news of another type of treatment and one that’s rather different.

Interviewee: Amy Maxmen

Yeah, so the first results were reported from a phase 3 clinical trial on some long-acting injectable drugs for HIV, and researchers are saying this might herald a new era in HIV treatment in which rather than taking a handful of pills every single day, people could just take an injection of antiretroviral drugs once a month, and people are hoping to extend it to once every few months, and that would make this even closer to something that looks like a chronic disease that can be managed by going into a clinic a handful of times each year.

Interviewer: Benjamin Thompson

Right, so as we know, antiretroviral therapies have existed for a long time and are very good at controlling HIV infection. What specific improvements does the injection have then?

Interviewee: Amy Maxmen

One of the thorniest problems in HIV has actually been adherence, so it might seem simple to take some pills every day, but it’s kind of a lot to ask and for some people it’s really hard. That could be people who live very far from clinics where they get the drugs every month or so, it could be people who might have substance abuse disorders or mental health issues, or teenagers have a very hard time taking a pill every day. It’s actually a huge challenge. Every day those pills are supressing the replication of the virus so if you miss doses, the virus multiplies, you have a higher level of HIV within the body and you can transmit to someone else easier, you can get sick, so it’s actually a huge problem and it has to do with the transmission and continuation of the epidemic as well.

Interviewer: Benjamin Thompson

And so, this trial has been done then comparing the injections to the antiretroviral pills – what did it show?

Interviewee: Amy Maxmen

They found that the injectables work as well as the pills, and what’s more, at the end of this year-long trial, more than 85% of people who had been taking the injections said they preferred that regiment. So, there’s going to be some people that still prefer a pill to shot, but the majority of people like shots and so the idea isn’t to rule one out for the other but to give people an option.

Interviewer: Benjamin Thompson

And what sort of difference might this make to people?

Interviewee: Amy Maxmen

So, one of the lead investigators I spoke to, Chloe Orkin at Queen Mary University of London, she just said it’s going to be a massive change in HIV, she felt like. She’s used to seeing people with HIV and instead of being reminded 365 days a year that they have this disease, now it could be 12 and in the future, it could be even fewer.

Interviewer: Benjamin Thompson

Well, phase 3 clinical trials are quite far along then, and to have what seems to be a successful one seems to be a fairly big deal. What happens next? When can this sort of be rolled out potentially to a wider group of people?

Interviewee: Amy Maxmen

The drug company that has sponsored the trials, they’re called ViiV, they will be submitting their results to the FDA, maybe they already have, the Food and Drug Administration, and they expect as early as next year to have a green light. And everyone I spoke to also pointed out these aren’t perfect, there’s some soreness at the site of injection, but there is a bunch of other long-acting HIV drugs in the pipeline, so these might just be the first round just like we had the first HIV drugs in the 90s and they’ve gotten better since then, so this is why people are saying it’s kind of the beginning of a new era, not just these drugs but what else is coming up.

Interviewer: Benjamin Thompson

Well, let’s move on to our final story this week. On Monday President Donald Trump announced his proposed budget for fiscal year 2020 – how might this affect science?

Interviewee: Amy Maxmen

So, across the board, there’s mainly cuts for science, and remember this is a proposed budget so we’ll have to see what Congress does with it. We were just talking about HIV so maybe I’ll jump in there. So, President Trump in his address to the nation, he had said he wants to fight HIV at home in America and abroad, but his budget doesn’t totally support that. There is an increase within the CDC for HIV but it’s at the expense of other programmes, so there’s an overall cut for the CDC and he cut the National Institutes of Health funding across the board and so that includes the institute that has HIV research. And he also made a massive cut to international programmes that deliver HIV care. But moving on from HIV, to go back to National Institutes of Health, he puts a budget at US$34.4 billion – that’s roughly US$5 billion below the current level. His budget requests include US$7.1 billion for the National Science Foundation – that’s 12% below 2019 – US$6.1 billion for the US Environmental Protection Agency – that’s a 31% drop from the agency’s current budget. NASA has just a 2% cut but it’s now down to US$21 billion. There’s going to be steady funds for human and robotic exploration of the Moon, but there’s cuts to astrophysics research and other areas of research within NASA.

Interviewer: Benjamin Thompson

So, swingeing cuts across the board then, but does anybody actually benefit from this proposed budget?

Interviewee: Amy Maxmen

The Food and Drug Administration does increase by US$362 million, so that is an increase and the plan furthers Trump’s hopes to tackle opioid addiction and also, he put in US$55 million to speed digital health technologies. So that is a win, but however, Steve Grossman, who’s Deputy Executive Director for the advocacy group Alliance for a Stronger FDA, he’s pleased with that increase but he did note that details of the budget are unclear, so just as with the CDC getting more money for HIV, there were cuts to other programmes.

Interviewer: Benjamin Thompson

And what about other researchers – do they share these concerns?

Interviewee: Amy Maxmen

So, right, no, they’re not happy at all. They’re only holding out hoping that Congress, like last year, doesn’t go along with the whole budget. For example, Benjamin Krinsky who is Associate Director for Legislative Affairs at the Federation of American Societies for Experimental Biology said, “I think it would be a disaster for science if it was enacted.”

Interviewer: Benjamin Thompson

Right, well I mean what happens next then Amy? This is as you said a proposed budget – what are the next steps?

Interviewee: Amy Maxmen

Soon the Senate and House of Representatives will meet to discuss the proposed budget and they’ll decide which proposals to take forward, and researchers are of course hoping that just like last year, these cuts will mainly not be made.

Interviewer: Benjamin Thompson

Well, Amy, thank you so much for joining me. Listeners, for more on those stories head over to nature.com/news. That’s it for this special extended News Chat, and we’ll be back next week with a regular show.