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Another international AIDS conference in South Africa is over, ending on a higher note than the last international meeting in Durban in 2000.
At that conference activists were still fighting to get patients antiretrovirals to save their lives. Now about 600 000 people in South Africa are on the life-saving drugs.
But the battles are far from over. Drugs are running out. Global funding is being cut. Resistance is emerging.
Yet treatment is widely available and many of the conferences presentations – particularly under the new Operations Research track – reviewed how to provide it in the most timely, efficient, cost effective and safest way.
The DART results were an outstanding example of this.
The final plenary heard how scaling up ARV programmes had not robbed health systems, but had boosted other health priorities, for instance, preventing new TB infections in the Western Cape and saving the lives of babies in KwaZulu-Natal.
The debate about immediate ARV treatment – offered through voluntary universal counselling and testing – for HIV prevention is also on the agenda.
Maybe at the next IAS conference in Rome researchers will discuss studies implementing this model and will have a clearer idea whether the world has a chance at eliminating HIV, by 2050 or beyond.
Risky and violent sexual practices, from transactional sex to many casual partners, are common among men who perpetrate intimate partner violence– and lay the groundwork for HIV to spread.
Dr Rachel Jewkes,head of the MRC’s Gender and Health Research Unit, told IAS 2009 today that building gender equity was essential in preventing HIV.
She also raised the need to overturn female complicity and subservience, to challenge male dominance that rules in much of South Africa.
She reported how intimate partner violence, physical and sexual, seemed to be an even greater problem when it came to HIV transmission in South Africa than rape – which is also shockingly common.
A quarter of men in an MRC study reported ever raping a woman or a girl.
Jewkes referred to the Stepping Stones study, which her team conducted in the Eastern Cape, to illustrate her points.
This intervention did not impact on HIV rates but did reduce herpes rates (HSV-2) and influence behaviour.
“Gender inequity is very linked to HIV,” said Jewkes, stating that large prevention efforts had failed because they didn’t tackle the gender context.
“Gender equity is possible and will extend human rights and human development,” she said, adding however that their resources were severely and disproportionately limited.
“This conference should be to one to say thank you very much d4T (Stavudine), goodbye and never come back again,” Dr Pedro Cahn, a past president of the International AIDS Society, told IAS 209 today.
D4T, 3TC and Nevirapine are the drugs (triple therapy) provided to patients starting antiretroviral treatment in South Africa, and most developing countries.
But d4T has problems with toxicity and lipoatrophy that discourage patients from starting treatment, said Cahn. Back in 2004, the World Health Organisation recommended it be phased out in favour of less toxic drugs.
Cahn said HIV/AIDS is the first disease in history to overcome the “too complex-too costly” paradigm in public health.
In 7 years, some four million people have been put on antiretroviral treatment – leading to a remarkable reversal in disease and death.
But at least six million more people need treatment.
Cahn said the time had come for changes in treatment, including:
DART RESULTS ENCOURAGING
The encouraging results of the major DART (Development of Antiretroviral Therapy in Africa) trial were released today at IAS 2009 by James Hakim on behalf of the trial team. The partners are based in Uganda, Zimbabwe and UK.
Hakim reported that : “Overall survival at 5 years in 3316 participants with advanced HIV pre-antiretroviral therapy was excellent.”
The DART trial, the biggest antiretroviral therapy trial in Africa, showed that these drugs could be given safely with clinically driven, rather than routine, laboratory monitoring — with major cost savings.
Hakim stated survival was better than predicted, retention was very high and the study showed “ART can be given wherever people live.”
I don’t like having my photo taken but today I overcome that barrier to join the Infected & Affected project, a cool anti-stigma project running at IAS 2009.
With the sutitle Portraits of a Community Combating Stigma, this is a photographic project to capture people’s feelings – individually and collectively – about HIV/AIDS stigma and take a stand against it.
The photographer Joan L. Brown took portraits of nearly 600 people from 67 countries as the 12th International AIDS Conference in Mexico City last year and she has taken hundreds more in South Africa on this trip – both at IAS and at a Crossroads Clinic and Groote Schuur Hospital.
She said it was very intense for her.
Carol Metcalf – a South African epidemiologist at the HSRC who was waiting to have her photo taken – said her research including studies on men having sex with men and serodiscordant couples had demonstrated to her what a problem stigma still was.
The magazine POZ is supporting the project.
NO AIDS conference in South Africa would be complete without a protest, an imperative that started with the huge demonstrations at the International AIDS conference in Durban 2000. Activists are the conscience of a conference, reminding delegates how far from their goals – like universal treatment – the world falls.
Today activist treatment groups Medecins Sans Frontieres, ACT-UP Paris and the Treatment Action Camp joined forces at IAS 2009, marching through the conference centre with placards demanding an end to drug stock outs and cheaper second line antiretroviral drugs.
MSF and TAC also demonstrated against the antiretroviral shortages that are harming patients and public health, before the conference even opened on Sunday night.
South Africa’s TB and HIV situation “can be likened to a twin tornado…that together has results that are catastrophic”, Dr Prashini Moodley, head of Infection Prevention and Control at the University of KwaZulu-Natal, told IAS 2009 today.
She said: “The overall load of bacterial cells in the population is increasing exponentially and the number of mutants is also increasing exponentially.”
Moodley said the high HIV prevalence, increased incidence of smear positive and smear negative cases, high prevalence of resistant TB (MDR and XDR), rate of hospital-acquired transmission and presence of successful strains were all fuelling the current TB epidemic.
She proposed three important steps to reign in TB: rapid diagnostic tests for smear negative and resistant TB; accelerating the antiretroviral roll out and offering the drugs above 200 CD4 counts; and improved infection prevention measures in wards and outpatient clinics.
“We need less AIDS for the money and more money for AIDS,” declared Dr Stefano Bertozzi, the executive director of a UNAIDS collaborating centre in Mexico, at the plenary on the second day of IAS 2009 in Cape Town.
Bertozzi made a strong case for implementing HIV prevention strategies that are strategic, focused, effective and have a long-term vision.
“It is time to stop implementing large-scale interventions of uncertain value without measured effectiveness,” he said, pointing out, for example, that nobody has measured the efficacy of abstinence education.
In 2007 an estimated 2.7million people were newly-infected, only one sign that prevention on a large-scale is not yet working.
Bertozzi suggested that delegates visit aids2031.org to contribute to the long-term vision to stop HIV.
The 1st day of IAS 2009 in Cape Town was marked by much (though not exclusively) good news– and by how far South Africa and the rest of the world have progressed from the International AIDS conference in 2000 in Durban.
*For a start, conference co-chairman Dr Jerry Coovadia told me how the attendance of high-ranking politicians (deputy president, minister of health and director general) at the opening ceremony showed how the relationship between scientists and the state in South Africa had crossed a threshold and reached an “equable level”.
*At the plenary Dr Louise Kuhn reported how much prevention of mother-to-child-transmission had advanced since 1994 in saving infant lives, improving regimens, integrated care of mother and infants and lactation support.
But she said still only about 30% of the women who need it are covered and often by sub-optimal regimens.
*Dr Wafaa El-Sadr reported on a dramatic decrease in mortality among HIV-positive patients since 1996. The majority of these patients are growing old on antiretroviral treatment, but what’s discouraging is that they are dying of non-AIDS related diseases, such as cardiovascular, renal and hepatic complications. Inflammation associated with HIV (not the drugs) is thought to be contributing to this.
El-Sadr challenged the concept that people with HIV have a long period of “clinical latency”. She suggested instead that there is ongoing morbidity from HIV during this time, and argued that treatment needs to be initiated earlier for patients than the current system (CD4 counts of 250 and below in the public health system).
*Dr Gavin Churchyard, CEO of Aurum Health, reported exciting developments in the TB vaccine field, describing this as a time of “great promise’, with the release of new drugs, new vaccines and new diagnostic tools.
*Jerald Sadoff, president of the Aeras Global TB Vaccine Foundation, agreed that there was resurgence in the TB field – which is hugely significant for South Africa given that it has the greatest number of HIV infected patients with TB.
*Tony Fauci, director of the National Institute of Allergy and Infectious Diseases in the US, said that President Barack Obama was committed to make sure that PEPFAR funding stayed high and that conditions for the funding – like abstinence promotion and restrictions on needle programmes – were being removed. He also said the US would be removing restrictions affecting people with HIV travelling to the States.
*The newly-appointed US Global AIDS co-ordinator Ambassador Eric Goosby said they were committed “not to give up on excellence or quality or urgency”.
*Dr Francois Venter, president of the HIV Clinicians Society of Southern Africa, said the model of universal voluntary testing and immediate antiretroviral treatment was one of the most exciting new ideas on prevention” (Story in The Times tomorrow).
*But underlying all these positive reports were two significant concerns: a crisis in global funding and the failure of world leaders to fulfil their promises; and the persistent failure to fully involve people living with HIV/AIDS in conferences like these – as pointed out by activist Paula Akugizibwe
HIV patients in SA – and at least five more African countries – who need antiretroviral drugs are at risk of dying before they can get the tablets, Medecins San Frontieres declared today on the eve of the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009).
“All around us, clinics are stopping enrolling patients because there are just not enough ARV supplies,” Eric Goemaere, MSF Head of Mission in South Africa stated in a release on the problems with drug funding and supplies.
“The waiting lists are growing by the day, risking that patients die before they start ARVs. It’s unbelievable that a relatively well-functioning ARV programme has been allowed to be crippled in the space of just a few weeks.”
A cut in SA’s health budget has severely worsened existing problems.
MSF warned that shortfalls in funding and disruption to supplies or stockouts have led to the “delay, suspension, or risk of suspension of the supply of life-saving HIV drugs” in South Africa, Malawi, Zimbabwe, Uganda, the Democratic Republic of Congo and Guinea — and that this could be catastrophic.
MSF appealed governments, donors and their partners “to take urgent and concrete measures” to end the crisis.