The fifth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention was attended by almost 6 000 mostly scientists and researchers eager to deliver their latest studies to a predominantly American and European audience ‘wanting to hear about new science and future interventions.
While the audience was predominantly from the so-called north, IAS president Dr Julio Montaner set the tone at the opening ceremony when he delivered a sobering reminder that the world knew what needed to be done, yet implementation floundered, costing thousands of lives each day.
‘The gap between evidence and implementation is particularly apparent between North and South. In the North we have virtually eliminated vertical (mother to child) transmission of HIV infection with the use of Highly Active Antiretroviral Therapy (HAART). We have unrestricted access to drug combinations, and new, highly-potent, and safer drugs that are easier to adhere to. We also have highly effective second and third line regimens, as well as point of care testing, and routine viral load and resistance testing.
‘In contrast, in the South people living with HIV are often stuck in a therapeutic corner with a paucity of first line treatment options, typically selected based on cost rather than safety and efficacy considerations. While this was acceptable as a means to jump start the roll-out of antiretroviral therapy, this is no longer the case: short-term savings will come back to haunt us in the form of toxicities and tolerability challenges, which will ultimately compromise adherence and in turn effectiveness,’ warned Montaner, who is Director of the BC Centre for Excellence in HIV/AIDS in Vancouver, Canada.
One of the most talked about presentations was that of Robert Granich of the World Health Organisation, who presented further details on a paper him and others had published in The Lancet journal a couple of months ago, claiming that HIV could theoretically be eliminated if all people were tested each year and given antiretrovirals straight away if they tested positive, regardless of whether they were sick.
Granich and his four co-authors said their mathematical model, using universal voluntary HIV testing and immediate treatment with antiretrovirals (ARVs), showed a reduction in HIV incidence and drop in mortality to less than one case per 1 000 people per year by 2016, or within 10 years of full implementation of the strategy. They predicted that it would also reduce the prevalence of HIV to less than 1% within 50 years.
Their model, using data from Malawi and South Africa, is based on scientific evidence that a person newly infected with HIV is most infectious. When placed on ARV treatment soon after infection (even within multiple concurrent sexual relationships and without correct and consistent condom use) the chances of infecting their partners is reduced to almost zero.
The use of ARVs for prevention is established in the prevention of mother-to-child (vertical transmission) programmes and through post-exposure prophylaxis for sexual assault and needle-stick injuries.
Latest figures reveal that roughly three million people worldwide were receiving ARV therapy at the end of last year, but an estimated 6,7-million were still in need of treatment and a further 2,7-million became infected with HIV in 2007.
A costing exercise revealed that the staggering funding needed to implement the theoretical strategy for an epidemic of South African-type severity peaks in 2015 at U$3,4-billion per year.
However, Granich argued that in the long term costs could reduce to very low amounts as progress towards elimination is achieved.
Activists have questioned how viable annual, universal HIV testing is, and how acceptable would it be to populations.
Questions were also posed whether there wouldn’t be similar outcomes if the same kind of effort was invested in programmes we currently have.
IAS 2009 delivered very little good news on the prevention front, other than the need to scale-up male circumcision which has shown to reduce by 60% the chance of the male being infected with HIV.
Zambia, Zimbabwe. Botswana and Swaziland reported back on male circumcision projects where they were struggling to cope with the demand, even in communities where circumcision is not a cultural practice. Scientists and activists have questioned the South African government’s lack of urgency to release a policy position on male circumcision ‘ although there are indications that they are in the process of formulating a directive.
A trial site in Orange Farm outside Johannesburg has circumcised over 9 000 men since January 2008, but it is unable to assist men coming from outside their catchment area because of restrictions on the trial conditions.
Delegates and organisers used the IAS 2009 platform to call the G8 countries to account for failure to recommit themselves to universal access for prevention and treatment and excuses that they didn’t have money to fund AIDS programmes.
Paula Akugizibwe of the AIDS and Rights Alliance of South Africa said that the money was available, but that it was not being spent on people’s health. ‘The African Union has estimated that U$148-billion has been lost to corruption, that’s pretty much the funding gap we face.’
‘If you limit the money you spend on health, you are prescribing how many people get to live. If you are pitting one Millennium Development Goal against another, you are prescribing how they die. It may be different MDGs, but it’s the same people,’ she said.
Akugizibwe handed out fake dollar notes calling to ‘Show us the money for Health’ with pictures of African and American leaders on the flip side and the money they have wasted. Uganda President Yoweri Museveni is accused of spending U$48-million on a private jet which is more than his country spends on HIV/AIDS.
Zimbabwe President Robert Mugabe is called to task for spending U$250 000 on his birthday bash ‘ enough for 10 501 treatment courses for TB.