HIV and the future of medicine
Andrew Jack talks to Deborah Waterhouse of ViiV Healthcare and Yusef Azad of the National AIDS Trust. (Unedited live audio from FTEngage event of November 21 2017. 1h 15m)
welcome everyone to the Financial Times. I Am very pleased to see all of you here. My name is Darren Dodd from the FT Health Team. We've got, hopefully, quite an entertaining evening ahead for you.
Just a few words before I had over to Andrew for the main debate. Tonight's event is part of a new strand that conference team has called FT Engage, small-scale event, which enables us to kind of actually get to know our readers, let you get to know us. We find they've been very popular so far. This is the first one in our health's trend. So hopefully, we'll do more of those in the future.
And as part of the deal, everyone who attends got a special subscription offer. So we will put the details on the screen. And you can get that from there.
The format is quite simple. I'll hand over to Andrew in a moment. And we'll have a discussion with our guests Andrew introduce in a moment. And then Rebecca's got Rosie mic'd, so we'll open up for a bit of discussion. So we'll have a chat for an hour or so. Then we'll break, have some more drinks. And we're going to end by 8:30 or so.
So I'll just point out a few of the FT people here so you. Those who don't know, Andrew Jack, if you know already, he's our global health expert, former performance correspondent, and many other things, head of curation, which you can ask him what that means later on. We're still trying to work it out. We've got our fantastic global pharma editor, Sarah Neville, over there. Was also, as she reminded me yesterday, been chronicling the problems with the NHS for 30 years.
probably the only person in England who understand how it works. And we've got a fantastic science editor, Clive Cookson, over here. There he is. And we'll have a few of the colleagues who were just in and out once they finished working their stories for this evening. So without more ado, I'll hand over to Andrew. And he can introduce our guests. And we'll take it away.
Great. Thanks very much, Darren. And yeah, if I could ask our two guests to join me on the stage here. So we'll chat for, perhaps, half an hour or so, but very keen, then, to open it up to you for reflections, discussions, questions to the panel-- try to wrap up over the next hour or so. And then we can sort of dissolve into a more informal conversation after that.
So Deborah Waterhouse, chief executive of Viiv, and Yusef Azad from the National AIDS Trust-- maybe just by way of introduction, Deborah, perhaps, first, you just want to get a couple of words about who you are, where you come from, how you came to be involved in HIV issues in your current role at Viiv.
Excellent. So hi, everybody. Lovely to see you here tonight. Thanks for coming. So I'm the CEO of Viiv Healthcare. We are a company that discovers, develops, and commercialises medicines for people living with HIV. We only do HIV, nothing else. So that is our life.
I have worked for a company called GlaxoSmithKline for about 20 years. I spent a number of years in the public health space in both HIV and vaccines. GSK owns 78% of ViiV Healthcare, along with Pfizer and a company called Shionogi. So I have kind of moved from one part of the family to another.
But the part of the family that I'm now involved in, which is Viiv Healthcare, is, basically, my passion and my life. So I'm very HIV-focused. And I'm very honoured to be here tonight to talk to you about what is my favourite subject. So Andrew is going to have to manage things very carefully to keep me in my box, so I don't kind of get too excited about everything. So that's a little bit about me.
Sure . And when did you first start doing things around HIV?
In 2000. So I was heading up the UK and then our European HIV business between 2000 and 2006.
At GSK. And then when they formed Viiv, I went to work in kind of Asia, Australia, and New Zealand, and the US for GSK. But I was waiting for this job for 10 years. They got so fed up of me nagging them about it, they said, go on. Have a go. So far, I've been in in role for about 10 months.
We'll try not to destroy your career while we're here.
I should say, unless there's any kind of sensitivities, that this will be recorded. And so it we'll actually also have a kind of podcast of our hour's discussion or so that will be available in the next few days if you want to, then, listen to it, including on our FT Health Newsletter, which is also published on the website. Yusef, just sounds a little bit about you and your background, as well.
Yes. So I'm Yusef Azad. I'm Director of Strategy at the National AIDS Trust. A bitch about National AIDS Trust maybe first-- well, we're like Viiv, in as much what we do is HIV. And we are, purely and specifically, an HIV policy and campaigning organisation.
You may have seen us in the news last year. We went to judicial review around PrEP, which we might talk about a bit later. And whilst we focus on the UK, we also do stuff with others across Europe as well. And we, obviously, have an interest globally in what is going on with HIV. We cover the policy, spectrum, looking at prevention, testing, treatment access, legal discrimination issues, social care, you name it.
We haven't, actually, done until, really, PrEP, that much around drug and patent policy. Because it hasn't been a particular issue around HIV treatment access in the UK to date. But that may be changing. And again, that may be something we talk about a bit later.
I've only ever had two jobs. I've been at NAT since 2004. And before that, I was a clerk at the House of Commons. So my background is policy. In the end, I thought, though I love MPs, I needed a bit of a break. And so I looked for another policy job. And HIV is certainly something that I'm passionately committed to and engaged with also. So I'm looking forward to our conversation this evening.
I mean, maybe let's just start sort of with the historical perspective. There is a bit of a sense of how the situation with HIV has changed, particularly in the UK, kind of your geographical focus, as it were, over the past couple of decades, in terms of the nature of the epidemic, and the responses, the tools that are available to deal with it.
Well, couple of decades is interesting. Because, of course, it was '96, '97 when anti-retrovirals came along globally and in the UK. And they came along very quickly as soon as there was evidence of their impact.
And I think, certainly, in the first years after anti-retrovirals came along-- obviously, you have to take many of them. They were very highly toxic. There were lots of side effects. And there was a lot of government activity, in terms of funding prevention campaigns, funding a particular social care fund for people with HIV called the AIDS Support Grant.
And over the years, I guess what has happened is that treatment has improved, in terms of how many pills you need to take. You can now just take one pill, depending on your regimen. It's much more tolerable. There are very few side effects.
So in that sense, the lives of people with HIV, in terms of purely treatment, are, of course, a million miles away from what they were, certainly, before treatment was available, and even compared to the early days of the epidemic. What has also happened, probably-- and again, we can talk about this-- is a kind of dilution of the early focus on HIV. Some people call it normalisation.
And maybe that's right. No one can pretend we're in the same world as we were at the time of the AIDS crisis. But I guess one of the things we need to think about, thinking about treatment of people living with HIV, is that-- and people living with HIV will really stress this when one talks about treatment and care-- life isn't just about the antiretrovirals.
And it's not just about having an undetectable viral load. And there are issues with co-morbidities, mental health, social care, a bubble of stigma and discrimination, which we are really not yet addressing as well as we should in the UK. So there is still a very significant policy agenda to address.
Yeah, the whole living with HIV.
And how that changes ageing and other conditions.
The one final thing I'd add, in terms of prevention, is the biomedical revolution that we've seen over the past four or five years, as we've realised that 96% of people on treatment have an undetectable viral load. We know now they cannot possibly pass HIV on. And that's an incredible psychological liberation for people living with HIV. And it's also revolutionising the trajectory of the epidemic.
And then the second element of this biomedical revolution is PrEP. I don't want to talk too much about that. We'll come back to it.
Yeah, that's a very important thought. And Deborah, even in your slightly shorter, perhaps, historical perspective than Yusef's, what do you see, in terms of the real evolutions, in terms of the response to the HIV epidemic that have struck you as most important?
So I think when we first identified the HIV virus, on average, you were to become diagnosed. And you would probably have 18 months to two years to live before. Unfortunately, you would die.
Today, it's very interesting to know that, if I was HIV positive, if you were not HIV positive, we would live the same amount of time. So actually, the key revolution that's taken place is this is turned from something that was a crisis, as it was described-- the HIV crisis-- into actually a condition that can be managed with the appropriate medication in a way that means life expectancy is not impacted. So we've got quantity of life.
Of course, now, we've got two things that we're looking at. So of course, cure is our holy grail. So that is what we all dream, either a vaccine or a cure. That would be the best thing that could ever happen. And we work very hard, scientifically, to sort of explore that avenue. But in the short term, that's probably not going to happen.
So then my sort of question is, how do we now develop treatments that are the easist possible to adhere to, that have the most limited amount of side effects? So actually, not just the quantity of life is the same, but the quality of life is the same. That's absolutely what we spend our time thinking about. And those are really the medicines that we're bringing to patients today, tomorrow, and in the medium and long term.
So I think we've seen a revolution where science has helped us manage this virus in a very positive way. But actually, we need now to give quality of life. And we also need to tackle together stigma and all the things that still make living with HIV for patients very challenging.
And you talked about the cure. And we'll come back to, perhaps, the science of that. But you've raised an interesting question about the business model around R&D in HIV. And over time, obviously, there have been a number of companies that have fallen out a little bit, disinvested. ViiV, quite the contrary, is nothing but. I mean, tell us how the kind of economic prospects look now today. Is it still a very attractive area for companies to invest a lot of R&D and still for, perhaps, relatively small returns?
So Burroughs Wellcome discovered AZT. We we then have 3TC. We've been on this journey as a company, Burroughs Wellcome Glaxo Wellcome, GlaxoSmithKline, and now ViiV. It's been a journey of company names, but the same people.
So somebody that worked for me was actually one of the two people that actually discovered AZT back in the '80s. So we have a huge longevity of staff and a phenomenally committed cohort of people who just live to kind of bring about a better outcome for people living with HIV. So the market-- just to talk numbers-- at the moment, the market is worth about 20 billion pounds annually.
All of that revenue and profit is generated in Europe, Australia, Canada, and, of course, the US. So the developed part of the sort of the world generates all of that 20 billion in revenue and whatever the profit from that looks like. However, you cannot, as a company that works in this area, take a view that that is your prize and you are only going to focus on the 20 million. Because you're actually only touching 2 million people who are living with HIV. And in the world, there were 37 million.
So what you have to do, and what we at Viiv are totally committed to, is thinking about the business model that allows you to charge an appropriate price in developed markets, where either the government or in the US commercial payers fund your medicines. Then in the middle-income countries, you usually work through tenders, which allow, again, maximum access. So we've seen that, for example, in Brazil, where we strike a deal with the Brazilian government to allow access to our medicines at a price that's affordable.
And then for the rest of the world-- and actually a vast majority of the patients living with HIV-- we give voluntary licences to generics manufacturers who locally then take our intellectual property. We then work in partnership with those generic manufacturers to help bring them up to speed with the technology and the quickest possible way that they can start manufacturing at low cost. And then you actually allow the generic companies to supply those least-developed countries.
So I think a great example of that is our recent partnership with UNAIDS Bill and Melinda Gates Foundation, and the Clinton Health Foundation, where we have brought to bear a triple single-tablet therapy based around our own [INAUDIBLE] product for $75 a year. That is utterly incredible. That's probably what it may cost for a week's treatment or a day's treatments in other parts of the world. And $75 a year is actually affordable in pretty much every country around the world if the government wishes to apply its resources to managing--
And you can cover your costs at that, no premium, obviously.
No, so if we do supply developing countries, we just charge the cost of goods plus distribution. But actually, if I make a pack of product in North Carolina or Stevenage, it's not as cheap as people that are producing in Bangladesh, or India, or Nigeria. Not that those products are in any way inferior. They're absolutely bioequivalent to ours. But their cost base and where they produce is lower.
So, for me, it's a big market. It's worth 20 billion pounds. There's four companies that take their share of that market in the main. But it's not the 20 billion that you need to think about. It's, how do you show up as a commercial entity in a way that is about supporting patients living with HIV, people living with HIV, and not about putting the profit in the shareholder first. It's an unusual disease where you have to think differently.
Now I'll come back in just a second to the access thing. But Yusef, in terms of what you see as the pipeline of the pharma industry, do you think there is some gaps? Or do you see there is a kind of continued and sustained investment in research for innovative products and so on that will be useful or necessary?
I think it's striking how-- again, talking to people living with HIV-- how the news is so good about treatment. And not only can you have a normal lifespan, in fact, there's some evidence that people living with HIV can have a better lifespan than the general population, because the monitoring is such that things are picked up even earlier. But nevertheless, a cure remains something that, I think, very dear to many people, in terms of ambition. But it's clearly a tough and not happening anytime soon.
I think another exciting development is long-acting antiretrovirals, where, again, there was something in The Lancet just the other day about early and very encouraging trial results. At the moment, everyone living with HIV really has to take-- I'm sure you know this-- pills every day. And that is a constant reminder of your dependence, that you have a lifelong condition. And obviously, it's one, sadly, that still is stigmatised.
I think it would be it would be a revolution, certainly in terms of the way many people with HIV feel about their condition, as well as helping with adherence and all sorts of other issues, to get long-acting antiretrovirals here sooner rather than later. But they are being developed. So I think that is a very good thing.
More generally-- sorry, just, I think, about the treatments-- I mean, there has been, as I said, immense progress, in terms of tolerability. There are still, I think, marginal improvements that could be made. But we have pretty good-- putting aside how frequently you have to take it-- we have a pretty good array of treatment options available.
Yeah, I mean, on the subject of long-acting, that's a medicine that we're developing. So there is a situation where you could, instead of taking a tablet every day, have an injection every four weeks or, we hope, every eight weeks. And then, obviously, what we then dream of is, OK, so what other technology can we develop which would allow it to be every three months and every six months?
Because obviously, if you can deliver HRT or contraception through the kind of advance mechanisms that we do, can you find a way through patches or implants to actually have the same approach with HIV medicines? So that's the area that we are scientifically exploring at the moment. So we know we can have it as an injection every eight weeks, every four weeks, depending on how the trials turn out. But how can we go further than that?
Because having to take a tablet every day has a massive impact on people living with HIV. So imagine that you go to your friend's house. And you have a few too many glasses of wine. And you decide you don't want to drive home. Or you have a more party kind of lifestyle than my own.
I had a party lifestyle once. I don't try anymore. But maybe you want to go out clubbing. And you just want to go home, and have kind of breakfast at 9:00, and take that tablet absolutely on the dot. Patients talk about feeling shackled to the disease, because of the way in which they constantly have to think about how they take their meds.
And do they carry it with them, but then everybody would see it? And how do they kind of hide the fact that they are HIV positive? So I think, for some patients, an eight-weekly or a four-weekly-- we hope eight-weekly shot-- could be such a liberation. And when we hear the voice of the patient as we design our studies and develop our products, it's utterly exciting in a way that it's hard to imagine.
It's probably one of the biggest evolutions since combination therapy, isn't it? But it's a good push to the next stage. Because already, as we were economically, long-lasting is going in that direction if that were to be eventually, let's hope, a cure. And the [INAUDIBLE], I suppose, is Hep C, for example.
But actually, what does that mean for the business model? One pill, potentially [INAUDIBLE] or injection, and that's it? I mean, it would completely change, wouldn't it? Because of the income flows, potentially, the financial attractiveness, the push back, potentially, of a single dose at a very high price-- I don't know-- of a cure or treatment. How would you adjust or are modelling that sort of outcome?
So first and foremost, you have to be in it for the patient. And for me, if we discovered a cure, I would be the most delighted person, even though, actually, it would probably have a significant impact on our business. But fundamentally, pharmaceutical companies and particularly the one that I lead, have to be in it for the patient first.
So we invest heavily in cure. We truly hope that a cure is found, either that or a vaccine. And ultimately, it would have an impact on our business model. Because you wouldn't have continuous chronic treatment once all of those people who kind of have the virus were cured. But that's fine by me.
Because actually, that's how science is meant to work. We conquer one thing. And then we move on to another. And so I'm absoltuely fine with that. And I would celebrate that day. I hope it comes in my lifetime.
But it's an extraordinarily tricky virus. And I think cure, in the sense of hepatitis cure-- as in the virus goes away-- is probably going to be very difficult. I think what they call a functional cure, which would actually be that you would still have reservoirs of the virus, but it would be so controlled and undetectable that you were virtually cured, that's probably more possible than physically erradicating the virus. Because it's phenomenally tricky.
Even on the business model over the longer-lasting treatment, for example, how are you modelling that? I mean, is one injection every four weeks four times the price of daily pills, for example?
Our strategy, as an organisation-- let's talk broadly about GSK. But Viiv's part of that. The last six medicines that we've launched have been at or below the price of the existing therapy, even if we've demonstrated significant additional beneficy [INAUDIBLE] efficacy. So for me, I would love to see that long-acting injectible reach the market. I can guarantee that it will be priced sensibly.
I think, for treatment, that's absolutely a given. My big question-- and we talked about this earlier-- is how do you price the same medicine for prevention? Because actually, we are currently doing large studies in women and men who have sex with men to see whether the same long-acting injectable can prevent you from actually getting the virus in the first place. And that's where the economic modelling becomes more difficult.
And we'll have to think that through. It's four five years away. But still, that's top to my mind at the moment, in terms of, how do we sort of manage that? I mean, what are your thoughts?
Well, it's ringing off a bell. Because I was involved in the process around PrEP in the UK, which is, of course, the use of actually one of the main drugs used for the treatment of people with HIV, but instead to prevent HIV-- people getting HIV in the first place. And I was on the NHS England working group that was kind of looking through this very long process, looking at cost effectiveness, and what have you.
But what was striking was there was no system within NHS England, or really within when you talk to pharma, to consider the preventive use differently from the treatment use. And one of the problems in the way-- and interesting, then it went about looking at PrEP-- was that they were applying their cost-effective models as if it were a treatment for people who are ill, which didn't work.
And so you probably know the story, that they tried to walk away from this, in terms of claiming they didn't have the legal power to commission PrEP. And we got them back to the table through a court case. And now there is a big implementation trial and a commitment to commissioning in the long term.
But it was a lesson to me about the importance of thinking differently and thinking about different economic models, depending on what whether you're talking about prevention or treatment. So it's a very similar scenario from that. So it rang off the bells when you talked about that.
Yeah, and the key now is that, instead of trying-- so we've got five years to sort of get to a point where we've prepared the market in the appropriate way. I don't mean in a commercial sense prepare the market. I mean, helped the NHS or whichever country we're working in, they'll sort of have a model that can allow this regulation in treatment and prevention to be appropriately introduced. So it takes a long time to change the system. And I think that's what we've learned from what's happened with the current PrEP treatment.
And in the UK, is there still any concern of access, both prescribing within the NHS, or, indeed, kind of the costs otherwise for individual patients or those at risk?
Access to what kind of treatment, or PrEP?
Well, I mean, there are issues. And again, we've talked about this chatting earlier. One of the interesting things that's happening is some of the main drugs that are being used are now coming off patent, becoming generic. So what that has meant is that some of the combination single pills, one of the elements has become generic, while the others are on patent.
And NHS England is asking patients to, therefore, migrate from a single very convenient pill to taking two-- possibly more-- so they can save money. And that is not uncontroversial, in terms of convenience, compliance, and what have you. I mean, there is some evidence that's the main issue around compliance isn't the number of pills you take, but the number of doses in the day.
So it may not impact on adherence. But it certainly impacts on convenience, amongst other things. And so there is a question of what value our health system places on that, in terms of the patients' welfare. So I think generics is-- and there have been other instances previously where that seems to have been an encouragement for people to migrate from one regimen they're perfectly happy to another, because the generic version is cheaper.
So I think there are issues around consent. There are issues around treatment information. And there are issues around kind of quality of life that need to be looked at very carefully. I mean, sometimes the generic version may be better than the one on patent. It's not, you know--
No, I agree.
But we need to think quite carefully about that process. In terms of PrEP, one of the facts about the implementation trial is that, because it's a trial, NHS England can use generic drug in law in the UK. So the trial is meant to be for 10,000 people for three years. If the clinic doors opened for people to get PrEP on the NHS three weeks ago, I expect 10,000 places to be filled full within a few months.
So I don't think it's acceptable for, then, NHS England to pull down the shutters and say, no more PrEP. So we'll have, then, to face again the issue of NHS England paying for PrEP routinely for people who need it. So that issue of access remains, I think, not completely solved.
I know it's not your core focus, but can we just switch a little bit to the kind of lower-income countries as well and your perspective there on the access issue-- obviously, still a huge gap.
Well, I was looking-- 17 million people living with HIV globally who are not on antiretrovirals.
It's about 47% of all people living with HIV. And we should continue to think that's a scandal. But I mean, Deborah is right, in terms of voluntary licencing. I mean, the greater part of the people who are not on treatment are not on treatment because they're not diagnosed.
And it raises the issue. There are still issues around treatment pricing. And don't get me wrong. But it raises the issue about how access to treatment is not only about treatment pricing. It's about stigma and discrimination. It's about health systems. It's an awful lot of other things as well, which we need to get right if we're going to maximise the benefit of all these scientific advances for patients.
Just to build on that-- so I actually spent the last three days at a paediatric HIV conference with UNAIDS, and PEPFAR, and a number of other key bodies that are really trying to tackle the issue of paediatrics who are living with HIV, 99% of whom are in Africa and the developing world. And it goes way beyond treatment, way beyond the sort of the availability of medicine. So actually, what happens is, your family, you may suspect that you're HIV positive. But you're not going to admit this because the consequences that, for you and your community, are really significant. And the last thing you're going to do is get your kids tested.
If one of your children starts to become ill, there is no way you're going to test your child. Because actually, as a result of that child being diagnosed with HIV, then actually the whole family is outed. And then as a result of that, the stigma that the whole family has to experience through their community's response to them is so horrendous, that actually the ARVs could be there. But you're not going to take advantage of that until your child is really and you've got no choice.
So it's a very complicated situation. And I think one of the main things that we spend a lot of time tackling through our community-based programmes is really that of stigma. Because if you can tackle stigma, actually, the medicines are there for the children and the rest of the family to take. So it's a complicated stigma-based disease where we have to tackle all the different elements of it.
Are you concerned-- obviously, a lot of the funding for low and middle income countries is coming from donors, in parts from governments, which aren't always necessarily meeting the necessary investment in their own health system. So we've got kind of something of an economic crunch in the middle income. We've got a bit more of a-- how should we put it-- a more nationalistic tone in the US, even the UK to some degree. Does that raise some concerns about future funding, both domestically and internationally for a lot of access to HIV medication?
The US are the big contributors to the treatment of HIV in the developing world. And despite some of the rhetoric that you may hear, PEPFAR's funding remains in place. Bill and Melinda Gates Foundation is clearly a different model of funding. Elizabeth Glase Paediatric AIDS Fund is a different funding model. UNAIDS is a different funding model.
So actually, so far, the stream of funding into developing countries remains steady. And the big question is, how do you use that funding most effectively? So adults is a population where we've made huge progress.
Paediatrics remains a real issue. And that is the next frontier where we have to, all of us as a global community, show up differently. Because the mortality rates are still extraordinarily high. And the whole stigma piece is a massive barrier to getting kids treated.
So that, for me, is the area that we now need to focus our energy on. And I think that's an area where there's a lot of consistency in us believing the same thing. So I think, luckily, the funding is still there. We just need to direct it.
Any concerns, Yusef, with development aid, particularly, and domestic resources elsewhere to support--
Well, some of the noises are not that encouraging. But, as Deborah said, kind of the big funds still seem to be in place. In terms of the kind of world political environment, I kind of think we have to acknowledge that some of the communities most affected by HIV, gay men, trans women, migrants, people who are inject drugs, are facing, in many countries, a wave of hostility, which may not all go well for the HIV response.
So you know, we have a single development goal of eliminating HIV as a public health threat. It's an epidemic it by 2030. And let's hope we get that. But I think we're at a kind of tipping point, I think, in terms of choices we make as a global community and whether we're all going to carry on working together using that combination of pharma development, national government resources, global resources to get there, or whether the sort of world is kind of going to split in two with some countries carrying on with this ambition and others going backwards.
It's striking that a country that many rich people, Russia-- Eastern Europe and Central Asia, with Russia is the main contributor. It's the only region in the world where the rate of HIV infection is increasing. And it has one of the lowest rates of antiretroviral coverage. And it goes back to the point that you can't divorce the technological from the political.
I was very heartened by Deborah talking about paediatric formulations, which I think are really important. I really have a question myself. I've read about the issue of access to second and third line therapies in developing countries. And it'd be interesting to know about where we are on that. Because that's been something in the past that people have worried about. The first line is there. But what happens when--
Actually, the second and third is an area of significant progress at the moment, and not just the medicines themselves, but in formulations that kids can kind of take. So if you think about-- if any of you guys got kids in the audience. I've got two. If you ever tried to feed them vegetables that they didn't like-- I don't know if you'd been at that kind of, come on, [STRUGGLING].
So imagine trying to get them to take an incredibly bitter syrup which just got their HIV medicine in it. They just won't swallow it. Nothing you can do can get it down their neck.
And so what we have to do is to make sure that we focus not just on second and third lines, but in formulations that they will actually be able to take-- so sprinkled on food and taste masked formulations. Because children are not kind of the most logical creatures when they're particularly very small. And as a result, you have to make it so they'll take the medication.
We are a global community. So as you said about Russia Nigeria have got a massive HIV issue. Infection rates are going up. And you could say to yourself, well, the Nigerian government has a very specific perspective on what it's like to be gay, and blah, blah, blah. But fundamentally, Nigeria is not a country that you can isolate. Russia is not a country you can isolate.
The global community travels everywhere and goes everywhere. And so as a world community, we have to tackle this together. We can't just decide, well, in the UK, we're doing pretty well. Let's leave others to sort themselves out. That's not the way it works.
Yeah. We [INAUDIBLE]. Obviously, Russia is taking a bit more of an initiative, which is evidence-based. But they're sort of-- I don't know. I suppose you would call it moralistic component that is still a big factor in a number of countries.
Yeah, very much so.
[INAUDIBLE] progress or evidence-based policy.
Yeah, no, absolutely. And that's a real worry, I think. And so if we're going to get to the sustainable development goal, we have to get back to evidence-based policy, harm reduction with the epidemic amongst injection drug users, and carry on, I guess, advocating for-- I mean, the thing we haven't talked about. There's also the right to health.
UNAIDS' focus this World AIDS Day is the right to health. They just produced a report on it. And the concept of accessible and affordable treatment is within the context of the right to the highest attainable standard of physical and mental health, which is one of the UN covenants.
So it certainly is an activist and community organisation. All of our thinking begins with that, a version of what Deborah said about beginning with the patient. It begins with the right to the highest attainable standard of heath. And that's what we have to fight for.
Just for a second, because we touched on the politics, as it were, and the dreaded word of Brexit, obviously, rather topical yesterday with the decision to relocate the European Medicines Agency. I wondered, Deborah, both on that and more generally in the sort of the possible fragmentation or decoupling, as it were, of the UK from Europe, what implications for the company, perhaps, around regulation, around trials, around more broader cooperation, what the implications will be and how you're planning or responding to it?
So because GSK is one of the country's largest employers and is in the sort of FTSE top 10, we have been consulted quite extensively on what a good Brexit-- if there is such a thing-- would look like. So it's great to have a seat at the table and to have the opportunity to contribute. For me, it doesn't really matter where the EMA is based, actually, as long as the EMA continues to be clear about the evidence that it requires to secure regulatory approval for medicines as quickly as possible.
So the location of the EMA isn't such an issue. I think what we need to make sure is that no barriers get in the way of us securing the broad regulatory approval at a global level for the medicines that we have in our pipeline. And we are particularly, at the moment, in a very exciting but nerve-wracking position where we've got a licence application with the FDA, which is due to come through any day now on two drug regimens.
So this is, again, another advance in treatment, where, traditionally, you've taken three or four medicines to keep your virus suppressed. We've got sort of a two-drug regimen pipeline that's coming through. We've applied to the EMA. We've applied to the FDA.
It doesn't matter so much geographically where that entity takes place. But for the sake of patients, obviously, getting as speedy an approval as we possibly can is sort of very much at the front of our mind. So Brexit, if you believe it's going to happen-- which it looks like it will-- we need to make it as patient-friendly as we possibly can.
And from an employee-based perspective, I worry. Because I have a lot of people from all over the world working in our organisation. And I just worry that the bureaucracy could tie us up a bit, in terms of times of regulatory approval, which is what hurts patients.
Any concern, so far, in terms of [INAUDIBLE] the best, for example? Are you seeing people reluctant now to come [INAUDIBLE]?
Not at the moment. We've got some employees who are highly talented individuals who are probably bit nervous about what's going to happen.
Non-UK, European individuals. But luckily for us, they're so committed to the purpose of leaving no person living with HIV behind, they kind of swallow those concerns, and just leave it to fate, and hope that it works out in a positive way.
And Yusef, what about you? The Brexit perspective, obviously, there's a lot of collaborative research programmes, and funding, epidemiological support, and so on. Do you see any fractures opening up, as it were, as a result of this whole debate [INAUDIBLE]?
I think it's a risk. Full disclosure, we've got a contract at the moment with the European Centre for Disease Control for surveying the whole of the WHO European region on their response to the Dublin Declaration, which is the European commitments around HIV. So we're working with the CDC on that, and working with colleagues across the whole European region finding out what the HIV response looks like, drafting a questionnaire, et cetera.
We will not be able to bid for that contract after Brexit. Now there are work-arounds possibly. But I think there is a concern in the academic community. I mean, the UK is full of great expertise around HIV, epidemiological, [INAUDIBLE], academic and research. And we have very strong links with European institutions.
I was the chair for three years of the European Commission's Civil Society Forum on HIV. It's like a big family, really. And I'm sure there are ways to surmount the challenges. But there's no doubt there will be challenges, in terms of law, common legal space, in terms of academic research, and being able to be part of joint European projects, et cetera. So it's something that we're monitoring, we're concerned about.
I mean, we could go on a legion. But why don't we open it up a little bit? Who might in the audience like to raise a question or reflect a little bit on where we're up to? [INAUDIBLE] yeah, please, there's a mic coming. Do just briefly introduce yourself, as well.
My name is Miles [INAUDIBLE]. And we organise platforms that bring together stakeholders looking at issues around assertive access to medicines, particularly in Africa. I was just interested to ask Yusef a little bit on the politics, as you put it, Andrew. So obviously, I think the global governance, structures around HIV and AIDS policy, has been built up over many, many years, including a number of different [INAUDIBLE] pharmaceutical companies, patient organisations, civil society, and so forth, and so forth.
I was just interested to find out whether you feel that this governance structure that has been built up will change, if it will, and how it will change, and how those tensions that you mentioned around countries that feel maybe there is an impact on their sovereignty and how they want to sort of take their own policy issue like and how that will impact progress on the STG targets, if you like?
You want to have a go?
One thing we haven't talked about, in terms of treatment access, is the role that activism and the community has played in getting us where we are, which isn't to, in any sense, kind of question or decry the commitment of Viiv and pharmas to the patient. But it's been a dynamic relationship, in which the patients' activism, I think, has been key in getting people to the table and getting the kind of accessible treatment at affordable prices. So I think that, in terms of the politics, that a lot will remain related to the degree to which there's treatment activism in particular countries and globally.
I think there was also interesting-- I think in terms of what the agenda is around medicines and medicine's access-- I'll be interested in Deborah's thoughts on it. But the Stop AIDS and the Global Health Network produced a report recently called Pills and Profit, which got quite a lot of media coverage, looking at pricing and the role of initially publicly-funded research in the overall pricing of medicines and also the need, they said, for a greater transparency in how pricing works. I can already kind of hear the arguments the other way. But I'd be quite interested to know what the thoughts are on that.
Yeah, so I guess two parts to the question. So I think sovereignty is a hugely important issue to recognise. So you'll know yourself how the Democratic Republic of Congo want to manage the situation, versus what Nigeria wants to do, versus Botswana, versus Namibia is actually incredibly different. And no foreign intervention from PEPFAR or UNAIDS, or whoever is actually going to take that away.
That's where, I think, each country has to find its own solution. Sometimes countries make challenging choices for the people who are living with HIV. And I'm, therefore, with Yusef. I think activism is absolutely key. And my big concern at the moment is that a lot of the activists are getting more mature. And we need the youth to come through and actually be the activists of the future.
And we were in South Africa as a team last week. And we were in the [INAUDIBLE] a few weeks before that. And what we are starting to see is a groundswell of young people now wanting to step into the space and demand more. Because actually, adolescence and early 20s is where people become infected with HIV.
And those guys need to step in, and want to step in more, and demand more of their governments. And I think that's going to be phenomenally important moving forward. Because PEPFAR, and UNAIDS, and the like can never take away the sovereign power of a government. So that will be my first choice.
Pricing is a very interesting kind of topic. I think I touched earlier on, we have a three-tiered approach to pricing. So we will charge an appropriate but profitable amount of money for our medicine to the developed world, of which Europe, Australia, Canada, the US are the main markets in which we operate. And then we run tenders in middle-income countries.
But in the least-developed countries, we either sell our own medicines at cost, or cost plus distribution, or we work very hard to hand over our intellectual property to companies who are locally-based and can-- whether they're in South Africa, Nigeria, or wherever-- can actually produce locally, high-quality medicines that enable access to broad populations. So that's the way we approach it. Because I think you've got to be able to deliver a return to shareholders. Because inevitably, we're commercial entities. But you have to do it in a very thoughtful and careful way, a clear, transparent, and tiered manner.
And so at Viiv, we're very transparent about the prices we charge in the developed world. We do tender-based approach in the middle-income countries. And then, as I say, in the least-developed, we will charge cost of goods, which we're very transparent about, plus distribution costs.
But mainly, we'd like to enable generic manufacturers. Because they can do things much cheaper than us. That's our approach. And I think that transparency is totally crucial.
On another point, I think on sovereignty is, on the whole, governments, nations want to be quite proud of what they're doing. And so I think they try to avoid being-- this is a generalisation-- try to avoid being seen as kind of at the bottom of the pile or kind of failing in some way. And it's partly how the conversation works.
And going back to the project we're not currently doing with European Centre for Disease Control, every two years, there's this kind of European survey, this kind of family of nations as to what's going on, how we're doing. And the last time it happened, one of the bits of information that at what point people initiate treatment, what the CD4 count is.
And there was one country where it was still at 200. And as soon as the report was published, they changed their-- because they were embarrassed [INAUDIBLE]. And it wasn't a question of someone coming in and having to whack. It was actually interesting. It was about transparency. And it was about people understanding and knowing what good looks like, and simply sharing that.
Now, I'm not naive. There are certain countries and governments where that's more problematic. But that seemed to be quite an effective approach to addressing sovereignty and respecting it, whilst at the same time, leveraging up the quality of response.
In terms of activism, I agree about maturity point. And but what's been great-- I thought HIV activism was over in the UK. And PrEP completely changed my mind.
And when I was going into an NHS meeting, having to walk through kind of people demonstrating, and kind of chaining themselves to railings, and what have you-- and a doctor said to me, ah, it reminds me of the 1980s. And activism was actually really key in making it impossible for NHS England not to provide PrEP in some form or other. So activism isn't dead. We're back in an activist phase, I think, certainly, in the UK at the moment, which is very heartening.
Who else would like to ask? One at the front, yeah, please. Oh, OK. And then we'll do one here. Yeah, go ahead.
OK. Hello, my name is Sophia Patai. I'm a global medical lead within the HUMIRA franchise [INAUDIBLE] AbbVie. I'm also an ophthalmologist.
So in my former life, I was an academic. And I investigated HIV and accelerated ageing in South Africa. So I'd really like to ask your insights about co-morbidities, which I think you touched upon, but also the hypothesis that HIV does cause accelerated ageing.
So for example, within ophthalmology, we looked at patients of ophthalmic parameters. We found that patients had an earlier a need for reading glasses, increased cataracts at a earlier age, and changes in macular degeneration. So how do you think we manage this in a resource setting, but also in less well-resources settings? Because I think the paradigm is changing now. And we're talking about the future of medicine. So I'd love to know your insights about this.
So you've picked on one of the hot topics at the moment. So there is growing evidence that having the HIV virus and then taking antiretrovirals throughout your life does accelerate ageing. And we're doing a lot of work on this at the moment. I'm digging into something called Telomeres, which are basically signals of how your body is ageing over time a great deal more than I ever thought I would.
So we looked at Telomere lengths in Cape Town. And we found that patients with HIV were, on average, 10 years biologically older--
So that's totally in line with our findings, actually. So if you're 60, you've got kind of a sort of a profile of a 70-year-old-- not necessarily how you look on the outside, but how things are on the inside. So that's what led us to start to investigate whether or not you could actually suppress the virus with two versus three or four medicines, which is what we've been doing over the last kind of 10 or 12 years. And it's on the basis of this co-morbidity.
So obviously, as you get older, you take various medications. And how that interacts with your HIV meds can sometimes be quite negative. And then actually, we're trying to stop this kind of accelerated ageing process, which, again, leaves you with a quality as well as a quantity of life. So ageing is a hot topic.
For us, that's exactly why we are approaching this next phase of treatment with two drugs, not three. And we're lucky enough to have a product that we have, which is such a powerful. Yet, it's well-characterized, got a very good safety profile that is the cornerstone of two-drug regimens. It might offer benefits moving forward.
So I'm not here to promote anything tonight here. That's not my job. But I'm just describing our thinking around ageing. Less is more. Can you actually help the human body manage that ageing piece through taking less drugs over a lifetime? And that's not been proven yet. That's the scientific hypothesis that we're exploring.
Yes, and I defer to you and Deborah on the actual kind of clinical. I've heard some people, I think, still might have some debate. But there does seem to be evidence around this accelerated ageing point.
But the other point is, we're all getting older, as it were. And the HIV cohort is getting older. 38% in the UK of people with HIV are over 50. And in another few years, it's going to be over 50%.
And you're right, even putting aside the accelerated ageing point, what's certainly clear is at a younger age there is a higher burden of co-morbidity and multi-morbidity amongst people living with HIV compared with the general population. And this, then, links to what we've already been talking about, about the fact-- there are the three 90s, which is the UNAIDS big target, of 90% of people with HIV diagnosed, 90% of them on treatment, 90% of them having an undetectable viral load. But there is a campaign now.
People living with HIV talk about the fourth 90, as it were, which is, what about the rest of my life? Is there going to be effective linkage in other secondary care specialties? Is my GP going to actually be willing and interested in managing my care pathway across the health care system? When I go to another health care specialty, can they not ask me how I got HIV or double glove before they touch me?
I mean, so there are all sorts of both issues of clinical expertise and competence, as other bits of the health service have to become HIV literate and also issues of, again, of stigma and discrimination. So I think that it's absolutely the kind of frontier issue at the moment, is how we support people living with HIV getting older. And the risk, in terms of the trajectory of the epidemic, is, if we do see that this kind of biomedical revolution and prevention really working and the number of people getting HIV diminishing massively, the risk is we think, job done.
And there will still be 40 million plus people living with HIV. We can't neglect their needs. We can't neglect their quality of life. We can't neglect issues of stigma. We can't neglect the prompt and effective treatment co-morbidities and AIDS-related issues.
Gentleman at the front of me, please, sure.
Thank you. I'm a consultant for a global pharmaceutical branding. And so I'm quite interested in how people's attitudes change towards things. And what you've all described is a really interesting and it's quite specific, it sounds, to HIV. But there have been, I guess, some aspects of the business become acquainted with doing business differently. So the generic companies you talk about are now comfortable with you sharing your secrets openly.
In the area of attitude and social beliefs towards things, that's probably also changing. What learnings are we are we finding from the HIV experience that you're seeing affecting other therapeutic areas outside of HIV? Do you see the issue of proprietary drugs and generics becoming-- are they now demanding other companies do this in maybe less severe diseases? Are we learning things about how to change the perception of societies that we're finding we're applying to other different therapeutic areas? Are there any learnings from outside?
I mean, HIV is very unusual, because of where the burden sits, in terms of people living with the disease. So it's very skewed towards the developing world, as opposed to a being a problem of the developed world. So diabetes or whatever, actually, is moving more to be a developing world issue. But traditionally, it's been a disease of the developed world.
So I think HIV is a little bit unique, because of the epidemiology of the disease. I think it's a little bit unique, because of the community that's constructed itself around the disease, in terms of putting the patient at the heart of everything we do together. So I think that community approach is actually very valuable.
And I see that now replicated around TB, around malaria, and actually, to a certain extent, just starting around some have hepatitis. So I think where the epidemiology is similar, I see learning from HIV and actually an accelerated approach to solving the issue. I don't necessarily see that in the same way with-- and vaccines, as well, is actually quite similar, in terms of supranational groups ensuring that vaccination is available where those who most need it are not able to afford it.
In other disease areas, I don't see the same thing. Because the epidemiology is different, whether it's [INAUDIBLE], or diabetes, or cardiovascular, or whatever. I don't see that same kind of approach. But I don't know if you've got any observations to make on that.
I agree, basically. I think there's some-- in my experience, which is limited outside HIV, but obviously from the [INAUDIBLE] infection perspective, there is some crossover with hepatitis, and hepatitis C, especially. But the patient voice is much weaker, if I can use that word.
There really is, yeah.
Yeah, and it's strikingly so. And the strength of the HIV patient voice kind of perversely came out of the extraordinary adversity and prejudice, the clinical adversity, and the kind of social adversity, the adversity of the early years. And that hasn't really been replicated elsewhere.
But there is some learning I see in the way the hepatitis C community is now kind of getting alliances and developing. And I've been interested also from a stigma perspective at seeing how mental health--
Very good point.
--has in the UK-- disease-related stigma, really first became a subject of kind of focus with the work Susan Sontag. And she talked about cancer, but then really talked about AIDS and HIV. But I think it's interesting to see some of the learning around how to address clinical conditions and the stigma now being replicated and actually leveraged to much greater scale in relation to mental health.
Yeah, I agree.
Hepatitis H is very interesting, isn't it, as you leapfrog to a cure, so extraordinarily quickly, but at the same time, creating expectations very much, perhaps, from the HIV community of affordable access to all. I mean, it's really put strains, I think, on the system.
It has, yeah.
In a very short space of time. Who else has a question? Anybody else? Yeah, there's one here, please.
My name is [INAUDIBLE]. And I'm a communicator in the life sciences. Do you see that there's going to be any sort of problem with resistance to the drugs, as the same problem that we've seen with super-bugs and resistance to antibiotics?
Yes, that's a good question. The answer is yes. So what we see in various parts of the world is, a while ago, when you were initially infected, you didn't really have resistance to the various medicines that were available. And you took those medicines. And that gave you sort of the longevity of life that you were able to secure.
Actually, what you're seeing now is at the point of infection-- and actually, as the journey goes along, people are carrying with them greater levels of resistance. So that's why our job is never done. So just a sort of a small example, you eventually come to the end of the journey, in terms of the medication that you're taking. You may have no more regimens left that will keep the virus suppressed.
So what we need to do is to investigate new mechanisms of action that sort of block different pathways, so that the virus isn't able to replicate when all of your other options are already used up. So we've got a number of product coming through our pipeline that will kind of allow more options to be available. But it is an area of constant vigilance.
And that's why adherence is very important. Because what happens is if you take your medication, the virus stays suppressed. If you become lacking in adherence-- so you take it one day, you don't take it next, the virus finds a way of mutating around the medicines. So that's why we're all obsessed with adherence.
But that in adolescence, particularly, is extraordinarily difficult to get them to do. And if you become resistant when you're kind of in your teens and your early 20s, then you blow a lot of options later on in your life. So that's why a lot of the work that many support groups and peer-to-peer support, particularly, is important in those adolescents when you need to keep them taking the meds every day, even if they absolutely don't want to.
So it's a real risk. And it's a constant kind of battle against different resistant strains of the virus. It's such a tricky virus. And so we need to be continually vigilant.
And Yusef, it has been an issue that's been raised sometimes in the context of PrEP, hasn't it? [INAUDIBLE]
It has. But the striking thing-- Deborah is absolutely right. Thing adherence issue is particularly acute amongst adolescents, amongst children who were born with HIV. And that's a matter of real concern. There can be high resistance.
But what is striking-- I remember when the kind of roll out of antiretrovirals was spoken of in developing countries. Because, oh, people won't be able to adhere. And they'll be immense resistance. But people adhere.
Yeah, they do.
They really do. They adhere to-- putting aside adolescents and to adults, The vast majority adhere. And they do so on PrEP, as well. The adherence rates on PrEP are very high. So I think the balance what Deborah said is absolutely right.
The HIV virus mutates at a great rate. And there do need to be drugs in the pipeline. And there does need to be vigilance. But I think the worry is we now have about antiretrovirals are a very different order of seriousness and urgency compared with the kind of good housekeeping, as it were, that we have with HIV.
I remember, a decade ago, this was something people talked about a lot. We don't want to sound complacent. But I think, as long as we have that vigilance and things coming along in the pipeline, people do adhere. And it's something that we are, at the moment, managing.
OK, who else? Does anybody else want to raise a question? Yeah, Clive?
I'd be interested to know, how much exciting scientific innovation is coming out of smaller biotech companies and universities in this field, or whether it's really dominated by the big four companies that you mentioned earlier, Deborah? And if there is exciting stuff coming, what is it?
Oh, that's a good question. So there is a lot of exciting scientific research coming out of academic groups, both across Europe and the US. And for example, our cure work is actually done in partnership with the University of North Carolina. So we've set kind of a group where we collaborate very strongly using their academic expertise, but applying sort of the resource and the fast-track methodology that we've got for drug development ourselves.
We very originally called it Qura. So whoever's the branding consultant probably could have given us some great advice on that. But come on. You might as well name it as you see it. But actually, that's a great example. And most of our sort of more advanced scientific work is in collaboration with academic institutions, whether it's in Liverpool here, and London School of Tropical Medicine, where we were this morning, whether it's a US-based entities.
And then you have got quite a lot of small biotechs, actually, who are looking at delivery devices, who are looking at kind of what I would call real-world evidence generation. So they're not just looking at the medicines that would treat the disease, but how you wrap things around is the disease that will help people live with it, or adhere better, or get better support on their journey. So there is a very vibrant biotech kind of community out there looking at all sorts of different things. There's a very vibrant academic community. But in terms of where the market sits today, it is mainly with the big sort of know HIV companies.
I was going to ask you just one more. It's a strike in GSK, of course, now has become a very feminised company at the top, as it were, two CEOS, I think, unique in the world, if I can think of it.
It is unique.
I mean, there's been a few biotechs, but certainly in terms of larger players. What does that say? Is that changing the internal culture of the organisations, do you think?
Oh, that's a very good question. So I would say that you want to make sure that whatever company you lead, you've always got the best leaders, whether they're male or female. What I would say is, through my 20 years of working at GSK is, I have never had any experiences where I felt my gender counted against me. I've had every possible opportunity to kind of work flexibly and work globally. And anything has always been open and possible to me.
And so I don't know whether it's that culture of inclusion and diversity that's really encouraged many female leaders, as well as male leaders, to do well within the organisation. But we are at an in important moment in time when you've got the CEO of GSK and the CEO of Viiv both female. So I don't know if it makes any difference from a cultural perspective.
But what it certainly sends a very strong signal of is that anything is possible when you work for an organisation that supports you whether you're ethnically or gender diverse, and that you want to have a successful and fulfilling career. So I'd give GSK and Viiv a big plug for diverse employees of any description. If you want to find a fabulous place to work, then we are it. So come on down.
And Yusef, maybe a final question just on the biggest challenges that you see, perhaps, particularly in the UK going forwards, in terms of development of HIV? And we talked earlier about-- actually, there were some very significant progress, particularly in London, compared to a few years ago, despite these challenges, including of disinhibition and so on. But what do you see as the roadblocks ahead?
Yes, what's Andrew's referring to is the fact that, for the first time in 30 years, last year, we saw a drop in the number of gay men diagnosed with HIV. And it wasn't just a sort of slight decline. It was a 21% drop. In London, it was a 29% drop. And in the five major clinics, it was a 35% drop.
Dean Street, in the middle 2017, set the scene of further 40% drop in HIV diagnoses amongst gay men. There is a revolution going on, particularly in the urban centres, London, Manchester, Brighton, and amongst gay men. We went on for so many years about combination prevention. And this could change things.
It's great to see that we were actually right. And because you can kind of know it in theory, but then it's actually happening. With continued condom use-- I think one can over-egg the disinhibition point, actually. Gay men have a much higher rate of condom use than heterosexual men and women in the UK still.
Much higher rates of testing and repeat testing amongst men, that has historically been the case. When you are diagnosed, if you're diagnosed positive, getting on treatment within a matter of days. So you become noninfectious very, very quickly. And now PrEP-- and though we talked about PrEP only just beginning on the NHS, thousands of gay men have been buying PrEP online from overseas and using it. And thus, not only preventing themselves getting HIV, but also not passing it on before they were diagnosed inadvertently.
So we have proof of concept about the possible elimination if we continue down this path of HIV amongst gay men. So I think the challenges are, one, we have to continue that. And current public health cuts are just to the point where we see it all working, we risk tearing it all up by restricting access to testing, because local councils are not getting enough funding for public health. So that's a matter of great concern.
But the other thing is that we cannot be content with simply seeing success amongst gay men. There are heterosexual men and women. There are particular communities-- African communities, there are higher rates of HIV-- where we have to replicate that success. And it can't be replicated in exactly the same way. Because circumstances, cultures, and dynamics of the virus saw are different.
So the overall message is, this is a time of great hope, actually, in terms of where we could get to, in terms of the HIV epidemic. But we absolutely have to ensure we keep on working and investing in what we now see works, and making sure that we extend it equitably across everybody affected by HIV, not just one community.
Deborah, hope but also challenges ahead for you.
Oh, no, I'm going to end on hope. So let's just talk about the UK. Because that's where we're sitting today. So I was at the European AIDS Conference a few weeks ago. And I was sitting having a cup of coffee with one of the leading clinicians in the UK. And we don't have anybody here today. So I'm going to end on their voice.
And I've known this guy for 17 years now. And he said, in the UK this year, around about 2,000 people will become infected with HIV, which is actually an amazingly low number. And he said, and by the time we get to 2020, I think that will be down to 1,000. And I'm looking forward to putting you out of business. And we were laughing.
And I look forward to that day. I want to end on kind of the hopeful note that we will see transmission rates falling. We will see prevention. And ultimately, we will see that cure.
And that will be a triumph of human collaboration and science over what is a really hideous disease. And so I think that's where we should end, on a very positive note, on our partnership.
I just read the formal part. I mean, there's some more wine, and so on here. I think both our guests could stay for a little bit. So reminder, Clive, as well as Sarah, and Darren are amongst our colleagues here still. So do please enjoy. Relax informally. Reminder, you can sign up for FT Health, the newsletter, and read it online, and follow our Twitter feed, and so on. And keep in touch. Formally, we're always open to your ideas, and thoughts, and feedback for the future. So it only remains for me to thank Yusef and Deborah for being here tonight.