Progress and pitfalls in prevention at AIDS 2016
Stagnating incidence and growing epidemics in key populations saw the optimism of other recent conferences give way to an embattled air in Durban, South Africa.
Progress The return of the International AIDS Conference to Durban led to much reflection on and comparison with the situation 16 years earlier when the meeting was last held there. AIDS 2000 is now seen as a watershed in the fight against HIV/AIDS, when the human face of the crisis in Africa was recognised inspiring the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President’s Emergency Plan for AIDS Relief.
Enormous progress has been made since 2000 in terms of treatment options and roll-out of life saving therapy. Of an estimated 38 million people living with HIV, 17 million are receiving treatment—3 million of them in South Africa, which has the largest HIV burden but also the largest treatment programme of any country. But despite this great progress, the mood at the conference was neither celebratory nor congratulatory. New estimates from both UNAIDS and the Global Burden of Diseases Study suggest that HIV incidence has not declined substantially in the past 5 years. When the 18 000 or so delegates reflect on the 2016 conference in 2030—when global targets aim to have ended AIDS—it will be remembered as the point when the global HIV/AIDS community realised just how much of an uphill struggle that target represents. “Why haven’t we beaten this epidemic?” asked Charlize Theron (whose Africa Outreach Project works to combat HIV/AIDS among young people) in an impassioned and rousing speech at the opening session. “Too expensive, too daunting, too politicised: these are not answers, just excuses. The real answer is we value some lives more than others. We value men more than women, straight love more than gay love, white skin more than black skin, the rich more than the poor, and adults more than adolescents.”
Equality and opportunity were recurring themes at the conference and the programme was remarkable in two regards: for the first time, more than half of the speakers were women and a third of the abstracts had African first authors.
ASPIRE to HOPE One of the great unmet needs in HIV prevention is an effective and usable approach for women—dapivirine impregnated vaginal rings previously showed promise in helping to prevent infection in the ASPIRE trial, in which risk of HIV was reduced by 27% in women using the ring. Elizabeth Brown (Fred Hutchinson Cancer Research Center, USA) and colleagues reported an exploratory analysis of adherence in 2359 of the 2629 women from sub-Saharan Africa aged 18–45 years in the ASPIRE trial. Protection was 65% (95% CI 23–84) in women who had high adherence (≤22 mg drug in returned rings); there was no evidence for protection in those women with partial or low adherence (>22 mg in returned rings). In the HOPE study, women who participated in the ASPIRE study will be given the opportunity to continue to the use the ring with the knowledge that it can be effective. The goal of the open-label HOPE study, which will not have a placebo arm, is to better understand the factors associated with protection, adherence, and usability of the vaginal rings.
Expanding PrEP use
In 2015, following the International AIDS Society meeting in Vancouver (BC, Canada), WHO recommendations were revised to propose preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine in people at substantial risk of HIV. “Despite strong science, implementation has been limited mostly due to availability”, said Linda-Gail Bekker (Desmond Tutu HIV Center, South Africa) about the PrEP roll-out.
Scott McCallister (Gilead) presented figures on PrEP use in the USA in 2013–15. The number of prescriptions increased substantially from 3746 in 2013 to 30 967 in 2015—a 738% increase from the fourth quarter of 2012 to the fourth quarter of 2015.
87·5% of prescriptions were for men, and uptake was highest in New York, San Francisco, and Chicago. McCallister pointed out that uptake was low in Washington, DC, and in Baltimore, MD, the cities with the highest lifetime risk, and the increase in use by women had not matched the high uptake in men who have sex with men.
Funding under threat Not for the first time, the conference was alive with talk of cuts to funding in the global fight against HIV/AIDS. Just ahead of the meeting, the Kaiser Family Foundation reported that contributions from donor governments fell in 2015 for the first time in 5 years, from US$8·6 billion in 2014 to $7·5 billion. In a stirring Thursday morning plenary, Alessandra Nilo (from Brazilian sexual health organisation Gestos) called on all countries to enact financial transaction taxes to ensure funding for the fight against HIV.
And during protests calling for ongoing funding support, banners called on countries to “Brexit on the Global Fund”, showing how in some people’s view Britain’s vote to leave the European Union has quickly become synonymous with reneging on commitment.
