A Conversation with Andrew Talal, MD

Issue: January 2016

In this issue, HCV Next asks five questions of Andrew Talal, MD, Professor of Medicine and Director of the Center for Clinical Care and Research in Liver Disease at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo in New York.

Talal came to Buffalo by way of New York City and Weill Cornell Medical College where he rose through the ranks and established himself internationally in both the research and clinical sides of hepatology, especially hepatitis C virus and its need for translational research and integration into addiction medicine care.

Andrew Talal

Today, 3 years after arriving in Buffalo, Talal and his team have tripled the capacity of Erie County Medical Clinic in terms of the evaluation of patients with viral hepatitis and other hepatology needs, established a comprehensive liver clinic at Buffalo General Medical Center, provide ongoing clinical support to the Buffalo VA Medical Center and run a robust research facility at the Clinical and Translational Research Center.

What was the defining moment that led you to your field?

After my GI fellowship, I worked 3 years in the lab of David D. Ho, MD, the Aaron Diamond AIDS Research Center at The Rockefeller University where I witnessed the transformative activities of the introduction of highly active antiretroviral therapy — as we called it at the time. As a research associate, David encouraged me to pursue investigation on the pathogenesis and treatment implications of HIV in the gut and specifically the gut associated lymphoid tissue.

That initial work in HIV introduced me to the use of biopsy as a mechanism by which to understand how viral infections affect certain organs, which we are now employing in the liver.

When I finished at the Aaron Diamond, Ira M. Jacobson, MD, hired me at Weill Cornell when the Center for the Study of Hepatitis C was just forming.

Additionally, receiving the 2006 Clinton Global Initiative was my entrée to the world of addiction medicine. Receiving that award was transformative in that it introduced me to the concept that individuals with substance use disorders have a very high prevalence of hepatitis C but these individuals have largely been excluded from treatment. I think that this population is going to be remain a “special population” from the standpoint of HCV treatment for quite a while, although we are developing telemedicine-based interventions that can bring HCV treatment to the substance use treatment facility. If in general medicine clinics we have a 6-month backlog of physician referrals for individuals seeking HCV care, what about those patients, such as those with substance use disorders, who never go to the doctor?

Have you ever been fortunate enough to witness or to been part of medical history in the making?

The first time I was part of medical history was in 1996 when Dr. David Ho was on Time magazine as Time Man of the Year and I was working in his lab. That honor was primarily bestowed due to the advent of highly active antiretroviral therapy and the realization that it would likely make HIV a controllable disease.

Fifteen years later with direct-acting antivirals for HCV, we saw the beginning of the same thing with the entry of HCV-specific agents. You can ask if it was a specific drug that was approved that was transformative, , but it’s really the whole class of drugs acting directly on the virus. Each drug that is developed leads to progressive improvements in the therapeutic efficacy, reduction in side effects, and shorter treatment duration.

What area of hepatology interests you most now, and why?

My research involves two broad areas within hepatology. The first is translational applications of disease progression, so we are beginning to understanding what’s happening in the liver. I’ve pioneered the technique of fine needle aspiration for measurement of liver levels of the virus as well as liver drug concentrations. We are now using that technology to understand what’s happening in the liver from a variety of different perspectives including immunologic, genetic, proteomic, etc.

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The other research area is development of treatment modalities for engagement of disenfranchised and marginalized populations, particularly individuals with substance use, either active or former. We are accomplishing this through the development of telemedicine-based treatments for HCV that bring HCV care directly into the substance use treatment facility.

What advice would you offer a student in medical school today?

The advice emanates from the kind of environment we’re creating within the liver centers here at Buffalo, which is one where we are fostering the career of physician scientists with the seamless integration of research and clinical care and how one feeds the other in multiple ways.

The opportunity to conduct research can lead to more efficient practice patterns, can lead to novel therapies being embraced and available to those who might be in desperate need for treatment through clinical trials. Research requires an infrastructure, of course, but it also expands the educational opportunities for physicians in training.

What’s up next for you?

Basically, 2016 is going to be a very busy year as we continue to integrate improved care, new technology and ongoing research into the community in Buffalo.

I didn’t realize how fortunate we are to be a part of NY State and at the forefront of expenditure on health care right now because of the tremendous amount of money that is being invested in health care and in making it an economic driver of the city. These expenditures are driving the building that’s happening here. The types of programs we’ve been describing with liver disease are what the institution, the city and, ultimately, the state government want to see as a microcosm. The work we’re doing on a day-by-day level has ripple effects by increasing the overall economic condition of the city.

What’s next is to continue the momentum we’ve built and to continue its growth because without continued action, it’s empty words.