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There was one other project that rivaled us, I would say, and that was the Nairobi project, which Piot and I were also affiliated with. The CDC was not. Eventually, even I was removed from that. I removed myself because I got interested in the Orient. That is another story. I am looking at my map. The CDC set up a separate project independent of the NIH to get away from some of that friction, but also in an important area, West Africa, to look at this HIV-2, and that was in the Ivory Coast. Piot, for the clinical side, was still affiliated with that. So Piot was involved with all three of those major African cohorts.
Then Kampala, Uganda, eventually got a project going with Case Western and a couple of other universities. In fact, I am now in Kampala with a project in what is called the RAKAI project, which is operated out of Hopkins and Columbia [University].
Harden: What happened to the 25 freezers when everybody left? Did the specimens come back to the United States?
Quinn: The situation was that we split the specimens with the Zairians. We could not take them all, but separate aliquots were made, and we took half and they kept half. Ours are in Rockville, Maryland [at the American Type Culture Collection].
Harden: Are they still available?
Quinn: Still available, still there. All you have to do is come up with a research idea.. We just investigated the role of vitamin A in pregnancy and perinatal transmission. That study is just completed. We did another one on PCR [polymerase chain reaction] and viral load. We just pulled the specimens out and applied our tests. Because the epidemiological databases are still there. They are there at the CDC, and I have the specimens, and so we just get together.
The person who oversees that–as we got into the early 1990s, people on the team changed a bit, and a new epidemiologist was assigned to it–a man named [Dr. Michael] Mike St. Louis, who was just great. He was not the lead CDC person. That was still Robin Ryder at the time. He was a junior epidemiologist, but he was very, very good. Mike is now in sexually transmitted diseases at the CDC. He was no longer associated with AIDS when this whole thing came crashing down.
Some people on the team said, “I have had it.” My investigator ended up as a physician in Wyoming, not doing any more research.
Harden: Was this Chris Brown?
Quinn: Yes, Chris Brown. Yost Perriens ended up at WHO; he is still working there. Robin Ryder ended up at Yale. He got a professor chairmanship there. Jim Curran, as you know, moved on to Emory. Other people are moving on and I am still doing the same old thing!
I enjoy what I do. I enjoy this dual relationship between the NIH and Hopkins and being able to do international research. And we have moved on from doing the Zairian project, into Uganda, into Tanzania, and India, Malaysia, a little in Thailand, and a few other places.
Harden: What I wanted you to do to finish off today’s interview was simply to compare Projet SIDA with the Multicenter AIDS Cohort Study [MACS]. Were those working in this country aiming at the same things, and was the MACS as useful as Projet SIDA or more or less useful?
Quinn: No. They had different aims. Projet SIDA was quite diverse in its origins in the sense that it was not necessarily designed to describe the natural history of AIDS in a population. Actually, that was what the MACS was designed to do. [Dr.] Frank Polk was one of the big instigators of the MACS. He was here at Hopkins, and, in fact, we worked closely together. They really wanted to enroll people who were HIV-positive and find out how long it took for them to get sick and what could be done to prevent that. It was a real natural history of the disease project.
Projet SIDA, when it was developed, was how is this disease being transmitted? What is causing it? Is it the same virus? How was it being transmitted? That was not an aim of the MACS, how was it being transmitted. And then, in Africans, is the clinical disease very different? We really did not have the natural history aim. Yes, we listed it as an aim, but we knew that in the short term that was not going to be answered. For that, you needed a much longer-term, stable project of a cohort.
It was not until Robin Ryder showed up on the scene that he started to set up these cohorts, of commercial sex workers, of prostitutes, of pregnant women and their babies, and also of workers in businesses. It was very interesting how he did that. Robin had the same ideas as those organizing the MACS, but organizing the cohorts was not until 1988 or 1989, and that only lasted two and a half years to three years, and then it was shut down. MACS is more than 10 years now, so Projet SIDA did not even come close to MACS.
Is it as valuable as MACS? Yes. I think AIDS is an international disease that goes well beyond our boundaries. We have learned not more, but different, types of information from the African project. We learned that there were different viruses there, the different genotypes. That information came from our original investigations, that the Zairian strains were different from the American strains. We found that heterosexual transmission was occurring. We defined the rate of perinatal transmission, the risk factors for transmission in a developing country setting, where 90 percent of all HIV infection was going to occur in the future from here on in. And I could go on about different clinical features and so forth.
We do not have the treatment to give these people in Africa that we do in the States or in Europe. How do you take O76, AZT, to prevent transmission in pregnancy? In the United States, you give it for six weeks to the pregnant woman, six weeks to the baby. You give it intravenously during birth. You cannot do that in a developing country. You are lucky if you get a dose or two in the woman when she is in labor and maybe a dose or two in the baby before they leave the hospital. Then you have to see whether some shorter course is going to work. And those studies are underway.
That was the aim of Projet SIDA. It was to take the beginnings of the knowledge of this epidemic in the United States and Europe, what we did know, and ask the same questions in Zaire: Is this the same disease? Is it spread the same way? If it is not, then why is it different? And if it is different, will it become different in the United States?
That is where we then come back to heterosexual spread, because it was after our 1984 paper and our subsequent studies in Zaire that I came back to Baltimore and said, “This disease is heterosexually spread. It has to be.” I started looking at the saved samples I told you about with the new diagnostic test. And–this was published in the Journal of Infectious Diseases–what we found was that a high percent of the infected cases attending our STD clinics were all men, from 1978, I think, to about 1983. All of a sudden, women started showing up. Their numbers started increasing till they almost reached a one-to-one sexually transmitted rate of infection. So then we said, “How are these women getting it here? If it is like in Africa, it is heterosexual transmission, I bet.” But injecting-drug use turned out to be a big co-factor in the spread of HIV in these women. But many women got it because of sexual exposure to a man with known risk factors, and because she had syphilis or herpes or a sexually transmitted disease, just like what we were finding in Nairobi and in Africa, in Zaire.
That is when I got into my problems with the press, because it was in 1986 that I started talking about this actively, saying, “What is happening in Africa is going to happen here in the United States.” People said, “You do not have any proof, any evidence.” By 1988, I had all the evidence I wanted. I published the information in the New England Journal of Medicine and then I got attacked left and right. Critics said that these people were lying, they were really having sex with gay men, and they were shooting up and just denying they were shooting up. So my paper about heterosexual spread in STD clinics in the United States–it was in Baltimore, but it is U.S.-based study–came out about the same time that Cosmopolitan came out with their front cover saying, “Women, you do not need to worry. You can’t get AIDS.” I started going on these talk shows and television interviews and the interviewers said, “You are just an AIDS investigator who is trying to get money to do your research, and so you are saying it is heterosexually spread.” I was replying, “No, I am not saying this for funding purposes. That would be insane. I do not need to because my funding is for work in Africa anyway.” It was not until a couple of years later that other papers and reports, other scientists, were starting to support the idea that heterosexual transmission might really be happening here in this country. But it took a long time, I think, for us to come to that realization.
Harden: That is very interesting in a variety of ways, in part because you were a scientist, you were working from data. The data had convinced you. Why did the press, the media, or the talk show people, why were they not as convinced by data as you were? What were their objections?
Quinn: They were looking at AIDS cases. Counting the AIDS cases–not those with HIV.
Harden: Is this from their lack of scientific training?
Quinn: I will never understand it.
Harden: This comes up in a variety of medical situations.
Quinn: Yes, I know. I cannot understand why. I do not understand why. I will give you one example. There was a reporter here in Baltimore who writes a column every day, and he saw my report in the New England Journal of Medicine and an article about it in the New York Times. The New York Times was very supportive because its article was by Larry Altman. Larry Altman is a well-trained person, and he saw the data and was convinced. He said, “Okay, so some of the women may be lying, but not all of them. They are getting AIDS sexually. They have to be.”
Well, this Baltimore reporter did not call me. He called up the state health department. He said, “Look, there is this report about HIV infection. What are the statistics?” The state said, “We do not collect HIV data,” because HIV infection was not reportable back then. “But we count AIDS cases.” He said, “Fine. Tell me how many AIDS cases are women.” It was like a 10:1 ratio at that time, and I had a 1:1 ratio of HIV in the clinic. So he said, “Well, then, Quinn’s crazy. How can this be happening?” He wrote in his article that he was not sure where Quinn got his statistics, but they do not jive with the state health department’s statistics on AIDS. Therefore, women do not need to worry about AIDS as a heterosexually transmitted disease, period.
Now, Jim Curran–well, not so much Jim, who was very supportive of my initial reports on this, because the CDC was not buying this in any big way either–no, it was Harold Jaffe who was my antagonist at first. He and I have become good friends since. But I asked Harold, why did he fight me so much on that. He said, “Tom, I will tell you one main reason. You said that, just as in Africa, where there is a heterosexual epidemic, HIV can spread among high-risk heterosexuals, be transmitted male to female, female to male. You used the phrase ‘heterosexual population.’” He said, “The press does not hear the words ‘high risk.’ They hear the phrase ‘heterosexual population,’ which is 95 percent of the population. And you were saying just as in Africa, which has this huge epidemic, that this was going to be a huge epidemic here in the States.” He said, “They’re not listening to those few words.” So he said, “I have to counter that and tell them, ‘It is not going to be a big general heterosexual epidemic,’” which I never said it would be. He said, “They just do not hear the five words.” He said, “So I know they won’t hear that, so I won’t even say it at all. I will just say, ‘We are not seeing what we call tertiary transmission.’” I replied, “Who knows what tertiary transmission is. First, male to male, that would be primary. Secondary could be male to another male who is bisexual, who then gives it to a woman. No, sorry. Male to another male, who spreads it to a woman or something, who then spreads it back to a man. That would be tertiary. Or injecting-drug use being the secondary, which then eventually, without injecting-drug use, it is transmitted heterosexually. That would be tertiary.” And he just said that, in terms of AIDS cases, we were not seeing heterosexual transmission yet. This was early. See, we are talking about 1987 or 1988, and not a lot of people really understood HIV serology. The only reason I knew it was because that is all I had been doing in Africa with Jonathan Mann and Skip Francis. All our studies were that way. And it finally caught on. Then everyone was doing serologic studies. But not in STD clinics. So that is why the New England Journal of Medicine, I think, took our report, because it was controversial, and there were letters to the editor and things like that. The New England Journal of Medicine likes that kind of stuff.
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