Michael Harney, The Rubberman, is an HIV/AIDS/STD/Hepatitis prevention educator and street outreach worker at the Western North Carolina AIDS Project (WNCAP), and separately operates the Needle Exchange Program of Asheville (NEPA). He recently attended the sixth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Rome, Italy July 17-21 (ias2011.org).
“Treatment is Prevention” was a major theme of this science-based conference. Highlighted were amazing additions to the armamentarium in the battle against HIV, stemming from research and clinical trials on:
- topical vaginal microbicides for HIV negative women
- rectal microbicides for women and men
- medical male circumcision for the reduction of HIV transmission from female to male heterosexuals
- pre-exposure prophylaxis (PrEP) especially shown effective for men who have sex with men and transgender women who have sex with men
- therapeutic vaccines for HIV positive people to stimulate the immune system
- boosted antiretroviral (ARV) regimens
- medication delivery strategies with the potential for long-acting slow-release injectable nanoparticles, and
- •pdates on activating and treating latent HIV from anatomical reservoirs in hopes of eliminating 100% of an infected person’s virus – a potential cure.
Rounding out the three days of plenary and breakout sessions, poster presentations, and satellite meetings, numerous well-known HIV researchers addressed the 7,000 attendees, among them: Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases (NIAID); Elly Katabira, IAS president and professor of medicine at Makerere University Kampala, Uganda; Françoise Barré-Sinoussi, Nobel laureate and chair of the seventh IAS Conference on HIV Pathogenesis, Treatment and Prevention to be held in Kuala Lumpur, Malaysia in 2013; Nora Volkow, director of the National Institute on Drug Abuse (NIDA); Joseph Eron and Adaora Adimora, from the University of North Carolina at Chapel Hill.
Dr. Peter Leone, medical director of the North Carolina HIV/STD Prevention and Control Branch presented a research poster on the importance of diagnosing acute HIV infection, and Stella Kirkendale of Family Health International (FHI) based in Durham, had a poster about assuring follow-up care for HIV patients in Africa who are disenrolled while participating in U.S.-sponsored clinical trials.
Many more HIV heavyweights brought high-end perspectives and expertise to this conference. Dr. Peter Piot, director of the London School of Hygiene & Tropical Medicine, reminded delegates that even when a disease is totally curable and preventable like syphilis, eradication has proven impossible; so even under the best of circumstances such as a vaccine or cure, we will need to mobilize immense resources to battle HIV/AIDS for generations to come.
The conference had a consensus goal: “15 by 15” – that is, to have 15 million of the estimated 33 million HIV infected people worldwide taking highly active antiretroviral therapy (HAART) by 2015. It means scaling up to treat some 9 million more people than are on ARVs currently in developing nations around the world. For this reason, at least one big pharmaceutical company – Gilead – announced it has licensed competitive generic production of some of its most popular and effective medications that are still protected by patents, and even those in development once approved by the FDA, so that the lowest-income countries can afford and have access to the same treatments as high and some middle-income countries use now. For example, Truvada could become available outside the U.S. for 28 cents a day, compared to its brand-name full retail price of $28 a day.
The proof of concept that antiretroviral treatment is effective for prevention includes a Prevention Trials Network study, HPTN 052 (niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspxpepfar.gov) published last spring and much discussed at the conference. It showed a 96 percent decrease in HIV transmission in “discordant” couples where one partner is positive and appropriately treated, and suggests that a lower community viral load resulting from expanded treatment worldwide would substantially reduce overall HIV infections, as fewer viral particles would be available for transmission. As Dr. Fauci observed, “Every new infection occurs in a discordant couple.”
Financial considerations for all aspects of this battle are high on the priority list. Demonstrators called on Italy’s government to fully fund its pledged obligations to the Global Fund to Fight HIV, Tuberculosis and Malaria (theglobalfund.org). The U.S. has been a major contributor to the fund having provided over $21 billion to date through the President’s Emergency Plan For AIDS Relief (PEPFAR) (pepfar.gov).
Other protesters called attention to continuing barriers to prevention and treatment, including harassment and prosecutions in Eastern Europe and the U.S. of injection drug users and those seeking to serve them through harm reduction and needle exchange. Women’s rights, as well as stigma regarding gay men and AIDS itself, were identified as areas that must still be addressed if the epidemic is to be overcome.
In the long run, high-cost ARV therapy is likely to become economically unsustainable, especially as people are living so much longer with HIV, thus increasing the cumulative demand for drugs and diagnostics. In that regard, portable instruments have been developed to check CD4 and viral counts even in remote locations without basic facilities; good news for clinical management, but it will also increase detection of HIV resistance and the need for expensive second and third line therapies.
This has added urgency to the all-out research effort to find biomedical, human genome, and behavioral answers to the mysteries and complexities surrounding HIV/AIDS. Among emerging technological breakthroughs presented in Rome was a plenary report by Dr. Gary Nabel of the US National Institutes of Health (pag.ias2011.org/session.aspx?s=97) on discovery of immutable segments of the virus, to which antibodies can now be cloned for a realistic prospect of a preventative vaccine and immune therapy.
There are co-morbidities too, including the aforementioned TB and Malaria, which kill millions of people annually around the world. Hepatitis C is another co-morbidity often found on a back-burner due to the lack of research and funding. The Treatment Action Group (TAG) has published, and distributed at the conference their 2011 Pipeline Report on HIV, Hepatitis C Virus, and Tuberculosis Drugs, Diagnostics, Vaccines, and Preventive Technologies in Development (i-base.info/files/2011/07/2011-pipeline-report-FINAL.pdf). It is a comprehensive and unbeatable overview well worth reading.
So, there is hope for a better and healthier future, but it will require refocusing our priorities and redoubling our efforts. One more very important note is that we, the U.S. will host the XIXth International AIDS Conference, July 22-27, 2012 in Washington D.C. It has been over 22 years since the conference has been here because of a ban, only recently lifted, on travel to this country by persons living with HIV/AIDS.
We now know that “Treatment is Prevention,” but education is just as vital. The Western North Carolina AIDS Project and similar community-based agencies everywhere try within their means to provide this essential service. Please find out more at any of the websites below: