On 28 April 2011, after their traditional breakfast of pancakes, eggs, toast, hash browns, and bacon, Myron Cohen and his team had their traditional 3-hour wait before a meeting at the National Institutes of Health (NIH). It was the tenth progress meeting for the HIV Prevention Trials Network, the blinded clinical trial dubbed HPTN 052. Behind closed doors, statisticians spilled through data from 1763 couples in nine countries. The scientists loitered nervously, some with indigestion, expecting to learn whether HIV treatment reduced transmission.
At the end of a long day, Cohen and his team were summoned to a room packed with people, including the agency’s number two official. “Guess what,” he said flatly. “It’s a home run.”
The researchers learned that morning that their research had led to one of the most important breakthroughs ever in the control of HIV: Effective treatment, they learned, blocked 96% of HIV transmission. Compared with the control group, 27 partners were prevented from contracting HIV. It was a clinical triumph. Science named it their Breakthrough of the Year for 2011.
These interview highlights were edited for brevity and clarity.
Q: How did you get started in global health and infectious disease work?
M.C.: I’d like to say I have a brilliant, linear answer. I wasn’t a high school whiz waiting to be an expert in sexual disease -- nothing like that. To some extent, the answer lies in a combination of timing and carpe diem. I think my evolution started in the 1970s when I was at Yale [University]. I had gone through my medical training and was there working as a scientist -- as a pretty serious biochemist. My wife is a China scholar and Yale sent us to China for a year, where I worked on hemorrhagic fever. That was my introduction to working in global health.
Q: What made you decide to go to China?
M.C.: My mentor, Richard K. Root, said, “Go to China for a year.” He was one of my best friends and one of the smartest people I ever worked with. But it’s the most random thing. I was working on biochemistry. Why did I think it was good idea to go to a country that I had nothing to do with and where I didn’t speak the language? It was frankly crazy. But, had I not gone on that trip, none of this would have happened. I needed to live in another country to understand something about global health.
Q: Do you think your willingness to take chances was important for your career?
M.C.: I wouldn’t call it a willingness to take chances -- I’m a pretty risk-averse person -- but to seize opportunity. Each opportunity I see, I force myself to say, “Even a broken clock is right twice a day.” When I think an idea is crazy, I tend to be even more careful not to reject it.
Q: What would you think if one of your protégés had an idea analogous to your trip to China?
M.C.: I would think they’re crazy.
Q: When you came back from China, what made you move to the University of North Carolina?
M.C.: I knew I’d leave Yale when I got back. I ultimately took the job at UNC, in part, because of another philosophical point: Always like and trust your supervisor. At UNC, I’ve only reported to people who I like and trust over my entire career.
Q: At UNC, how did you transition from biochemistry to infectious disease research?
M.C.: I was working on oxygen chemistry, and interactions between white blood cells and gonorrhea. I became increasingly interested in transmission. We’d count the number of bacteria [in genital secretions] and we showed that when you gave patients antibiotics, gonorrhea disappeared within 4 hours.
As a physician, I saw my first case of HIV in 1981. By 1985, 14% of all the admissions to UNC hospitals had HIV infections. There was no treatment. They all died. You can’t blind yourself from that clinical problem. Around 1988, I started taking the gonorrhea experiments and extrapolating them to HIV.
Q: How did that evolve into international work?
M.C.: A gentleman named Peter Lamptey came to me -- because I’d lived in China. I was the only infectious disease person at UNC who had worked internationally. He said, “We’re going to compete for a grant to do HIV prevention internationally and we want you to go in with us.” We won it and divided up the world.
Q: Why did you choose Malawi, now UNC’s flagship international research site?
M.C.: We took a map of the globe and we threw darts. We knew nothing about Malawi. But once we got there and treated HIV patients, we found a big range of HIV in semen -- there could be a small amount or a very large amount. We hypothesized that the lower viral load would lead to less transmission.
Q: When you were designing the HPTN 052 trial, what were the big hurdles?
M.C.: A door opened at the NIH, but they said in order to do this study you have to find the drugs yourself. They have to be U.S.-made and they have to be free. This was a challenge of unbelievable magnitude, because there was no incentive for a company to give away these drugs.
Q: How did you convince the six drug companies to donate HIV drugs?
M.C.: Negotiating skills -- back and forth, iteratively. It took all my energy. I would go to them and say the answer is “yes,” how are we going to get to “yes”? For the last drug company representative, who's a very good friend of mine now, I sent her a dozen roses. With that drug, I was ready to go. So, tenacity: It's so much more important than brains. Brains are good, but tenacity is irreplaceable.
At the same time, I had to bring on a team of people that were going to do this study around the globe. This is where trust came in. I had to get all these people and trust them. And they had to trust that I was going to get this off the ground.
Q: In order to develop that trust, did you go to the 13 trial sites and oversee progress?
M.C.: The last thing we would want was me trying to get under the hood and micromanage. Other, much more competent people were doing everything in the study. The strengths that I brought to the table were optimism and cheerleading. If you were an expert, I would cheerlead you. I would never think I could do a better job than you could do.
Q: It must have been difficult to always be optimistic. How did you manage to do that?
M.C.: I had to give myself pep talks. I’ve had a thousand moments of fatigue and anxiety. For everything you want to do, there’s a thousand people that say it’s not worth doing. For this study, there were very famous people who told me I was wasting my time.
Q: Did you ever think they were right?
M.C.: Never for a moment. I knew exactly what I wanted to learn in the study: the magnitude and durability [of treatment as prevention]. The real question is, “Is the juice worth the squeeze?” We assumed that by treating people we rendered them less contagious. Did we really need to know how much less contagious? From my point of view, that was an important consideration.
I’m very concerned about making sure we’re asking important questions and questions that have legs -- not dead end questions. Does it have immediacy and urgency? How important is it to clinical medicine or public health policy? Sometimes as a scientist, you get enamored with a question but no one cares but you. If it’s trivial, why do it?
CREDIT: Lisa Chensvold
After presenting the HPTN 052 trial results at the International AIDS Society meeting in Rome in July 2011, Myron Cohen prepares for a live television broadcast.
Q: Is that a key to a successful scientific career?
M.C.: That and you have to be passionate about your questions. And be able to convey that passion.
Q: Going back to the trial, what did you think of the recognition you received for HPTN 052?
M.C.: For me, it’s about the journey and not the outcome. I take great pleasure in small accomplishments. When I came home and told my wife the results, she said, “You prevented 27 cases of HIV.” It's unbelievable, but I was focused on just making sure the trial worked. I hadn’t gone there myself.
Q: After you published the results, ran a cover story posing “The End of AIDS?” Do you think this is the end of AIDS?
M.C.: No. It’s a sine qua non -- without which there is nothing. The work is a cornerstone, but translating it to a public health intervention takes a lot more. Though, I think the “96%” is a catalytic number. It gives a stronger belief in the power of intervention than could have ever come from aspiration. Next is quality assurance. We have to make the intervention work.
Q: How do you feel about the next stage of your career?
M.C.: I won the O. Max Gardner award a few years ago [a UNC-based award for “the greatest contribution to the human race”]. In the acceptance speech I gave, I said I can only hope that my most important contributions are still in front of me, not behind me. That's exactly how I feel today.