Council Commentary

Invigorated by the science, resolute in the work ahead: Reflections from IAS 2017

Each day, approximately 4600 people around the world are newly infected with HIV, and more than 2500 die of HIV related causes each year.1  Substantial progress has been made to combat the epidemic, but the need for rigorous research and scientific breakthrough to achieve an AIDS-free world has never been more pressing. 

Last month, as scientists, researchers, programmers, activists, and policymakers gathered together in Paris for the International AIDS Society Conference, many encouraging advances arose, including:

  • Promising steps toward an HIV vaccine and long-acting HIV treatment regimens;
  • The Council’s own pre-clinical work around multiple prevention technology to avoid HIV, HSV, and HPV;
  • The continued evidence of PrEP efficacy to prevent acquisition;
  • The use of national surveys to assess changes in HIV incidence;
  • Discussion of programs to successfully assess and support how to retain key populations in the HIV cascade (test to treat to viral suppression); and
  • Keen attention to provision of client-centered care in improving quality care and support health systems.

Despite this promising science and much success in getting people living with HIV on treatment, the fact remains nearly 50% of the adults living with HIV worldwide are still not on HIV treatment. While HIV incidence has declined globally over the last five years, a large increase in the global youth population means that the number of people living with HIV will remain the same without drastic and concerted efforts.

In this light, notably limited in the discussions at this science conference was an emphasis on

  1. Proven prevention technologies;
  2. Social and structural factors that influence prevention and care behaviors;
  3. Research to elucidate how and under what conditions prevention and care programs can be successful in real-world settings.

The omission of these topics from the current scientific discourse represents limited attention to existing solutions, social and behavioral science research, and linking evidence to decision-making and programming that can accelerate progress towards eliminating HIV.

There is need for continued investment – by donors and countries – in proven prevention strategies, such as prevention of mother to child transmission (PMTCT) and voluntary medical male circumcision (VMMC), to continue to curb the epidemic. For instance, the Council’s work in Kenya and Zambia with young women of reproductive age who live in areas of high HIV risk shows that less than half are even aware of the PMTCT prevention strategy. This does not bode well for the continued success of PMTCT programs or for preventing a new generation from being afflicted with HIV. 

Similarly, while the HIV incidence rate reduction in Swaziland has decreased remarkably over the last five years, VMMC rates remain low at 28 percent. The Council’s collaboration with MEASURE Evaluation and IHM in Swaziland (with a national-level HIV prevalence of  27 percent among 15-49 year olds) shows that men frequently have multiple partners who are younger them, most report inconsistent condom use with their last female sexual partner, and men who were uncircumcised were not even considering it. There was a noticeable lack of discussion at the conference on how to successfully reach and engage men in HIV prevention and treatment services. More work is needed to better understand and address the factors that deter men from using this effective HIV prevention technology in this setting.

Finally, while important advances were noted around the introduction of pre-exposure prophylaxis (PrEP)2, limited attention has been given to the role of community-level influences and country-level decision-makers in effective roll-out of oral PrEP. Similar to the learnings from the national-level roll-out of PrEP in Kenya, the Council’s formative work in Tanzania is highlighting the importance of contextually-relevant messaging around PrEP and the importance of engaging policy-makers, parents, and partners in effective uptake and use of oral PrEP among adolescent girls and young women at-risk of HIV.

In this era of shrinking resources, we will need to work smarter and harder to end this epidemic once and for all. Effectively reaching the end of the epidemic will require an expanded science and technology toolkit. I find myself encouraged in the global commitments to end AIDS and the innovations in the biomedical sciences, and resolute in the tough work ahead to sustain prevention efforts while expanding equitable access to quality health care for all affected by HIV and AIDS.

 

 

1. http://www.unaids.org/en/resources/campaigns/globalAIDSupdate2017
2. PrEP is the use of anti-retroviral drugs used by an HIV-negative person as a means of preventing against HIV infection.