Controlling the HIV epidemic with ARV: From Consensus to Implementation

The TasP PrEP evidence Summit organised by the International Association of Providers of AIDS Care (IAPAC) opens in London with a welcomed tone that departs from the usual HIV Grand Masses.

There is something in the annual IAPAC conference in London that is not often found in any other HIV/AIDS conference and that makes it stand out as an event to look for. Maybe it is the feeling that this is the time and place where participants and panellists feel free to talk, unconstrained by the dogma, hubris and “langue de bois” that pervade so many other such-like events.

This year’s opening was no exception with UNAIDS Director Michel Sidibé reminding the audience of the looming milestone re-affirmed in 2013 of having 15 million people on ART by 2015, and that despite the many successes of the recent years there was still a lot of work ahead; the job was not done yet. How far were we from recent exhilarating statements that the HIV epidemic was over?

A Change in Leadership?

Thought the fight against HIV/AIDS started and was initially led by “The West” or “The North”, Sidibé emphasised that ending the epidemic was now a shared responsibility. Further, Africa was now leading the fight having successfully increased by more than 800% the number of people put on ART in the past 6 or 7 years; something that was thought unachievable at the turn of the century. Interestingly, Uganda’s past successes have been relegated to history and it is now Malawi which is leading the way.

Malawi’s MoH Catherine Gotani Hara explained that her country’s success was in part down to successful task shifting and an ability to get closer to the people in need. The Minister was echoing Sidibe’s comments that there is a need for HIV guidelines that are relevant at community level. However, the “capital trap” was still depriving remote and difficult areas from qualified workers and despite successes, the biggest obstacle to more successes remained resources. Support from development partners is still needed.

There was no shame reminding “The West/North” that despite being more economically advanced or more liberal, the UK still did not have a National Strategy for addressing the epidemic and the US government’s position on clean needles and syringes exchange was leaving Lord Fowler “bemused”.

Rethinking and re-engineering Health Systems

Sidibé suggested that the failure of the developed world and the struggle of the developing world are calling for a re-engineering of the HIV care system and beyond of health systems in general. This is already happening in the UK where it is raising concerns: the health system, and HIV prevention and care, has been thrown up into the air with the expectation that it will all fall back into place nicely.

Could it be, as CDC’s Deborah Birx puts it that “all that is standing between us and the end of the HIV epidemic is ‘us’”? A proposition that Jorge Saavedra from AHF would later explore and that was clearly a barrier to future success. As noted by Julio Montaner, pioneer of TasP amongst IDUs in British Columbia, the lack of federal leadership led to lack of progress in controlling the HIV epidemic in Canada.

Clearly, it is no longer all down to science only. We may have the tools to end the epidemic but do we have the will? Montaner added that if we were to implement the 2013 WHO guidelines we will have at least 9% less mortality & transmission in the next decade.

What role for science in tomorrow’s prevention?

The translation of scientific progresses is now hindered by both politics and logistics. Kenly Sikwese from the African Community Advisory Board noted that biomedical approaches have reached their capacity to make changes in some settings, leading to new problems that needed urgent addressing. There is now a need for a real debate about science’s contribution to the future management of the HIV epidemic.

Sikwese raises the interesting question of how much science really contributed to changes in policy, asking us to ponder how much had been down to leadership in the face of lacking or contradictory evidence, political risk and opportunism. Of note was the lack of interest to provide evidence to support improving the cascade of care, a task that was therefore down to political will and whims.

Yet, Africa is still lacking the political will to address the needs of vulnerable groups such as People Who Inject Drugs (PWIDs), Men who have Sex with Men (MSM) and Sex Workers. This is a thorny issue that needs a “careful approach because of local beliefs towards these groups” said Minister Gotani Hara, lest we are prepared to face a backlash that could challenge current success. Maybe “we [just] need to be more sophisticated about the information we give about these groups” to politicians suggested Sidibé.

Joorge Saavedra humoured the audience noting that if we were managing air traffic control as we manage the HIV epidemic we would have planes crashing every 10 mins and that if you have HIV in Russia you better ask for asylum in Uganda or Haiti, as you will have more chance to access treatment.

Seeing and acting beyond HIV and ABC

But there was also the recognition that HIV does not just affect women in sub-Saharan Africa (SSA) and that there is more to HIV than just a viral infection. Frederick Altice reported that 33% of HIV infections outside SSA occur amongst PWIDs and Keith King that mental health issues are key contributors to new HIV infections, poor access to prevention and care services, treatment uptake, adherence and overall treatment success.

Altice presented data showing that the now famous “cascade of care” was much worse amongst PWIDs compared to other group. Ken Mayer noted that we have to think about how we address coexisting syndemics such as mental health, TB, Hepatitis C, Malaria, etc.

If needed, this confirmed that one size does not fit all and that there is a need for multipurpose prevention. Thought “Multipurpose prevention” is an extension or rewording of “Combination Prevention”, many developed countries including the UK continue to focus their prevention effort on condom promotion and HIV testing because the promotion of TasP creates unmanageable tensions with traditional HIV prevention messaging. When THT former Chief Executive Sir Nick Partridge was asked by a community advocate when the organisation leading HIV prevention in the UK will open up to all HIV prevention technologies, minding those who do not want to use condoms, Sir Nick ignored the question, but referred to the THT website where condoms in different sizes can be bought.

Models have been at the heart of much discussion about what to do and how to do it (though not so often at the heart of policy changes as an audience member noted). WHO Reuben Granich presented a series of such models lamenting that we were too slow cycling through the OODA loop, an old-new concept that you can be sure you will hear a lot about in the future.

It is Alan Whiteside who had the last word emphasising that “We are preaching to each other” and that “we need to make a case for HIV treatment outside this room and it is not that simple”. It is about convincing finance ministers first of the benefit of treatment. The “exceptionality” of HIV is over claimed Whiteside, the HIV prevention and treatment fields are now in a fierce competition; different interest groups about HIV, AIDS, TB, Malaria are competing for the same pot of money.

Something Malawi’s MoH Gotani Hara seems to be very successful at. Africa leading the way?

~rjt

note: this is written rather late, expect some editing in the coming days as time permits

UPDATE: On the 23rd of September, a small group of UK “leading HIV charities” finally acknowledge the existence of PrEP as a prevention option beside and beyond condoms. It will have taken 3 years since the announcement of the iPrEX results