2016 amfAR HIV Scholars Program Announcement

amfAR, The Foundation for AIDS Research and the Center for LGBT Health Research at the University of Pittsburgh Graduate School of Public Health are announcing continuation of the amfAR HIV Scholars Program: a training program for junior investigators from low- and middle-income countries who are interested in conducting HIV research among gay men, other men who have sex with men (MSM), and/or transgender individuals (collectively, GMT). Applications due date is 17 September 2015 at 5:00 PM EDT.

Funding opportunity: ethical, legal and policy issues in HIV research with key populations

This announcement encourages empirical and conceptual research projects in relation to research studies or program implementation for HIV or associated co-morbidities affecting one or more of the following: men who have sex with men; people who inject drugs; people in prisons and other closed settings; sex workers; transgender people or adolescent girls and young women at high risk of HIV acquisition or who are living with HIV.

#TargetsMatter

Devex recently published Right things, right places, right targets — right now, an article by policy staff at amfAR, AVAC, Elizabeth Glaser Pediatric AIDS Foundation, IDSA and ONE, calling on the US President’s Emergency Plan for AIDS Relief (PEPFAR) to set new treatment and prevention targets. The article notes that the last PEPFAR targets, which were met ahead of schedule, expired in 2013.

Why is this important, when UNAIDS just announced that 15 million people are now on life-saving antiretroviral treatment? Isn’t the global response getting there? Although many things contributed, it is not insignificant that “15 million people on ART by 2015” was a target. Just as it is not insignificant that targets supported two biomedical prevention methods— voluntary medical male circumcision and prevention of mother-to-child transmission of HIV. Without these targets, it is highly unlikely that PEPFAR would have quadrupled the number of medical circumcision procedures it supported or been able to announce the millionth baby born HIV-free.

As AVAC said earlier this year targets matter, particularly prevention targets, which too often lack precision. Targets need to be resourced, audacious, achievable, measurable, accountable, politically supported and a collective priority—see Prevention on the Line for our “Anatomy of A Target” infographic and an analysis of targets that have worked in the past.

Right things, right places, right targets— right now makes the point that the time for new targets is now with the upcoming adoption of the new Sustainable Development Goals (SDGs) in September—Transforming Our World: The 2030 Agenda for Sustainable Development. The Devex article warns:

  • For PEPFAR targets to be absent from these discussions is a glaring omission and a missed opportunity — particularly in light of the program’s transformative role in improving the global health landscape and how integral it will be to any future HIV and AIDS successes.
  • There is still time to fix this problem, but the clock is ticking. It is time for PEPFAR and the White House to establish new treatment and prevention targets to guide the years ahead. These targets should be announced ahead of September’s UN meetings, so that PEPFAR’s vision can be included in and help shape the global dialogue. Every week and every month that goes by, we risk losing momentum. And in the fight against AIDS, we have no time to lose.

As world leaders meet in New York in September, it would be inspiring and powerful if PEPFAR provided the leadership it so often has provided in leading the way.

Injectable Options and Preventable Confusion: An update on the pipeline of antibodies, long-acting ARVS and vaccines

On July 19, AVAC convened a satellite session, Injectable Options and Preventable Confusion: An Update and Interactive Discussion on the Pipeline of Antibodies, Long-acting ARVS and Vaccines. This session, part of the IAS Conference on HIV Pathogenesis, Treatment and Prevention, featured presentations on trials of long-acting injectable PrEP agents by Mike Cohen (HPTN and UNC), Larry Corey (HVTN) gave an update on HIV vaccine research and John Mascola (NIAID Vaccine Research Center) reviewed the state of passive antibody infusions for prevention. The presentations were then discussed by a panel that included Brian Kanyemba (Desmond Tutu HIV Foundation), Veronica Noseda (Sidaction) and Jerome Singh (CAPRISA).

The session provided a moment to consider what might be coming for HIV prevention. The speakers provided a guide to the prevention pipeline. The three approaches that the speakers highlighted—injectable PrEP, an HIV vaccine and passive antibodies—are in trials now. All three approaches, even if they show efficacy, are years from being implemented. But the HIV field must be ready, and must prepare now.

These updates were particularly relevant at a conference that was focused heavily on ART—whether the START results establishing the health benefits of early treatment, or the expanding implementation of daily oral PrEP globally and in different populations.

The lessons from and, ideally, successes of implementation of early treatment and PrEP that will emerge in the months and years after this discussion will provide a roadmap for these new options if they become available. Speakers emphasized the challenge of success. As Glenda Gray said at the session “We are used to failure in HIV prevention but market failure for effective interventions is the thing that worries me the most.”

A Pill That Prevents HIV

Micheal Ighodaro is an AVAC staff member.

Over the past few months I have spent a lot of time talking to LGBT people about PrEP. I have been at meetings that were specifically focused on HIV and meetings where HIV was a very, very small part of the agenda. And while it’s clear that PrEP is needed for LGBT people, it’s also clear that we have a lot of work to do.

Many members of the LGBT community are still struggling with the idea of PrEP, and many do not know about it or how it works. For example, I was at a conference this past June that brought together LGBT and sex worker activists from east Africa and around the continent. HIV was a very small part of the conference agenda. In fact, AVAC, amfAR and IAVI hosted the only HIV-related panel in the conference. I spoke about this new pill that prevents HIV. To some, this was a totally new concept, but to others PrEP sounded good. Others asked whether it would take away ARVs from people living with HIV who still can’t always access them?

But before I answered the questions, one of the panelists who was openly living with HIV as a gay man in Africa—a very brave individual—stood up and said that if there was a pill that could help prevent other members of his community from having to go through the same experience he has had to face as a gay man living with HIV in Africa, he wanted to make sure every member of his community knew about this pill and advocated for it.

But all these concerns are very valid. When the WHO’s recommendation for PrEP as a prevention option for gay men and other men who have sex with men came out in 2014, many LGBT activists around the world had mixed reactions. Some didn’t know very much about PrEP and didn’t pay much attention. For others the recommendation singling out MSM just proved the point that the LGBT community is viewed by many stakeholders primarily as the “carriers of HIV.” To get away from this perception, many LGBT Africans I know don’t want to work on HIV at all anymore. And so they weren’t excited when the WHO recommended this new pill just for gay men.

Now that the WHO seems likely to issue broader recommendations for all people at substantial risk, there is a chance that access efforts will focus on other populations.

Last week when I was in Thailand for several meetings with transgender groups, a very close friend of mine who is transgender asked me, “Why can’t people just use condoms? Why do we have to take this pill?” My answer was short and quick, “Condoms are great but not everyone can use them all the time, just like not everyone will use PrEP all the time. PrEP is just an added HIV prevention option.”

In contrast to my sense of the how gay men in Africa are viewing PrEP, which based on recent conversations is with some skepticism, the question for most gay men I met in Thailand was whether or not to start taking PrEP. Dialogues are happening in Thailand that are moving beyond whether this strategy is a good idea or whether it is stigmatizing a specific community. The Thai LGBT community is talking about this medication and what it can do for them and that should continue, not just in Thailand but in Africa and Europe.

US National HIV/AIDS Strategy Gets A Reboot

Kevin Fisher is an AVAC staff member.

When the Obama administration released first US National HIV/AIDS Strategy (NHAS) in 2010 it was an overdue step forward and the product of years of advocacy. How could the US—with the eighth highest number of people living with HIV (PLWA)—have no strategy for getting more PLWA into care and reducing infections and health disparities?

Now on the fifth anniversary of the first NHAS, under the leadership of the Office of National AIDS Policy (ONAP), the NHAS is getting a reboot. The updated NHAS has renewed the focus on those most affected by HIV: gay and bisexual men of all races, but especially black men, heterosexual black women and men, young people, people who inject drugs and transgender women. There will be prioritization on places, like the southern US—where nationally 50 percent of new infections now occur—and key metropolitan areas. It takes responsibility for improving viral suppression and access to care in the US treatment cascade, which now lags behind many European, and some African countries. While not explicitly linked to the UNAIDS 90-90-90 goal, this new US strategy does align with the global focus on improving diagnosis, linkage to care and viral suppression. And, happily, this strategy puts the treatment cascade into the more comprehensive needs of primary prevention and addressing stigma and discrimination.

Even if the overall goals of the original NHAS—reducing infections, improving outcomes, eliminating disparities and a coordinated response—remain the same in the revised version, much has changed since 2010. In 2010 the iPrEx trial results first showed that pre-exposure prophylaxis (PrEP) is an effective HIV prevention option. In 2011 the HPTN 052 trial showed treatment and viral suppression can reduce risk of transmitting the virus and just recently, in 2015, data from both 052 and START showed that early treatment improves health outcomes for people living with HIV. The revised NHAS embraces these scientific advances adding new goals to improve the US treatment cascade, and making full access to PrEP services a cornerstone of the strategy. The full-throated endorsement of PrEP is welcome, needed, and will hopefully have impact.

The NHAS also importantly acknowledges the essential role of research in providing new tools and methods of achieving the goals of the strategy. The NHAS is unabashedly positive about research, with particular emphasis on research priorities for PrEP and innovative approaches to preventing new infections, importantly strengthening the case that now is not the time to scale back.

The updated strategy does make an important change from its predecessor, which raises some concern. The revised NHAS abandons incidence in favor of HIV diagnosis as a measure of the impact of prevention. ONAP believes it does not have the data to measure incidence, particularly in the context of increased testing. Do the data reflect higher rates of infection, or are more people being tested? This makes methodological sense but raises the question of how the impact of specific prevention interventions, or combination prevention, can be measured and assessed. The HIV field needs a tool to measure incidence to judge impact.

There will be more detail of the revised NHAS to come. A federal action plan for the revised NHAS is expected on Dec 1, 2015 and will operationalize the strategy. Now is the time for advocates and civil society to weigh in with ONAP on how these goals might be achieved in communities across the US.

Have a question about NHAS? Join the conversation on social media via #HIV2020 or Tweet your questions to @AIDSgov.

Visit aids.gov for more and download one-page infographics on “what you need to know” regarding the updated NHAS and one that outlines the five major changes since 2010.

How Would Bob Say It?

Emily Bass is an AVAC staff member.

The first AIDS conference I attended was the 1999 Conference on Retroviruses and Opportunistic Infections. This annual meeting happens in the northern hemisphere’s winter time, and this particular gathering was in Chicago. It was cold on many levels. Chunks of ice floated in the river that ran between the hotel and the conference center. There was no consensus that AIDS drugs should be made available to poor people in developing countries. The scientists, activists (and hyphenate scientist-activist-journalist types that AIDS work breeds) all seemed fluent in a language I didn’t speak and was just beginning to understand.

The colleague who I’d traveled with said that activists met daily to discuss what they had learned and so at the end of the first day I hovered by an indoor water feature and waited. Slowly people began to arrive—there were men and women, nurses and educators and writers. And we sat down and everyone went around and said what they had seen that was most interesting about the day. There was tremendous warmth in that circle. Commitment, wisdom, frustration and, as I recall, a man with a beautiful smile. That circle is where I met Bob Munk for the first time.

Bob, who passed away earlier this month, has been on my mind as I have watched the events from IAS 2015 in Vancouver unfold. I have thought about him because he was a familiar, friendly face that I saw at AIDS conferences, and because so much of the road that lies ahead depends on the work that Bob, who founded and wrote for AIDS InfoNet, did better than anyone I have ever known.

The final day of the Vancouver meeting, July 22, the international NGO Medecins Sans Frontieres (Doctors without Borders) released a statement that the successful global HIV response will depend on a much greater emphasis on adherence. Adherence is just one of the many words that has crept from public health jargon into widespread use within the community of people living with and working on HIV. But even though it has crossed over, it hasn’t lost its scientific veneer.

Bob Munk’s genius lay, in part, in his ability to explain the most complicated terms in simple language. His black-and-white fact sheets, all designed to be read by someone who hadn’t completed secondary education, were and are unequaled in their accuracy and accessibility. There has not been a year in the two decades that I have done this work that I haven’t suggested that a colleague “see how Bob would say it” or contact him for advice on how to word something. The day that he got in touch with AVAC in recent years to look at the AIDS InfoNet PrEP fact sheet draft, was the day that I realized this intervention would “take off” in the US and around the world.

Adherence is critical, so is saying what that actually is: sticking to the plan. And going forward, it’s not just adherence by people living with HIV or people at risk who receive PrEP—it’s also adherence by the global leaders who promise so much at these meetings and hear so much and present so much of what might be possible, if only action is taken.

Sticking to the plan is only possible if you understand why you’re doing what you’re doing. For a whole generation of AIDS writers and activists and treatment educators, Bob Munk set the gold standard for this understanding. With so much work to be done, we’ll miss him dearly and carry on, as clearly as we can, in his name.

AVAC sends wishes for peace and ease to Bob’s family, friends and husband.

Snapshot from IAS 2015

Several members of the AVAC team attended the meeting of the International AIDS Society in Vancouver which just completed. Along the way we presented our “take” on key conference events.

We invite you to learn more about:

In addition we held a post conference webinar, IAS 2015: What was presented and what it means on the road to Durban 2016. Slides, audio and a Flash presentation are available.

Traversing the AIDS Vaccine Terrain in Vancouver

Amid the excitement in Vancouver over the START and PrEP results, conference-goers did hear several specific updates on progress in HIV vaccines. Here are a few highlights advocates seeking to track the vaccine field should check out.

One great place to start is with the slides from a presentation on delivered by Dr. Anthony Fauci, head of the US National Institute of Allergy and Infectious Diseases. The slide set, with Dr. Fauci’s instantly-recognizable font size and simple layout, has some familiar images from previous presentations—including the always-useful depiction of the HIV prevention continuum—but also provides crystal-clear explanations of the “empirical/intuitive” and “rational” pathways of vaccine development focused on producing antibodies against the virus. In the former category is the RV144-like regimen moving ahead in trials in southern Africa. In the latter are broadly neutralizing antibodies being studied in passive immunization and preclinical work. A commentary in Science published just after the conference by Dr. Facui and Dr. Hilary Marston provides additional perspective and depth to the discussion. 

RV144 was the name of the 16,000 person trial that took place in Thailand and found evidence of modest protection in data released in 2009. Just before Vancouver got underway, the research team involved with the trial published new data on why this protection might have occurred. Every person has a distinct genetic make-up that affects how our immune systems function. In analyzing volunteers’ HLA gentoypes (these contain the “instructions” for proteins that help regulate the immune system), the investigators identified specific genetic signatures associated with vaccine efficacy. This type of research can help scientists figure out how to make vaccines work even more effectively in the future.

The rational pathways also got attention at a Wednesday session, “Advances in B-cells and Antibodies,”” including an update from Joseph Jardine of Scripps Research Institute, on upstream work aimed at increasing the potency of the VRC-01 broadly neutralizing antibody. VRC-01 is a purified form of a potent antibody isolated from an individual living with HIV; it is in Phase I trials in adults and, as described at a cure satellite symposium, a safety and pharmacokinetic trial in infants is now enrolling.

Vaccine science is heady stuff and presentations of the hill-and-valley contours of antibodies can seem very far from the rural and urban landscapes where people live, work, encounter HIV and perhaps enroll in trials. A presentation on hypothetical willingness to participate in vaccine trials from the Perinatal HIV Research Unit in Soweto, South Africa, focused on that terrain. Pointing out the urgent need for HIV prevention strategies in 15-24 year olds, particularly young women, the research team asked people in this age group whether they would enroll in a trial. About half would, saying altruism would motivate them. About a quarter said that they wouldn’t, because they were worried about “becoming ill.”

Bridging the gap between landscapes of molecules and townships has always been the work of AIDS vaccine research. This bridging was highlighted by Glenda Gray, president of the South African Medical Research Council, in her Wednesday plenary on Advancing HIV Vaccines into Efficacy Studies—and though it was a quiet year, we can clearly expect more updates in Durban 2016 as the South African trials continue and basic science also proceeds.

Follow the Money

AIDS is inextricably linked to inequitable distribution of resources—money, medications, legal protections, education and more. AIDS activism has long been dedicated to redistribution of all of the above in ways that would make the world a more just place. But does this extend to actually giving people money or other compensation (a gift card, food and so on to change their behavior or get circumcised or keep coming to their clinic visits?)

The answer isn’t exactly clear. For many activists and people on the frontlines, especially those who are well-versed in the potential coercive impact of financial compensation for trial participation, the idea of offering people money to change behavior is a finger in the dike or a band-aid on the problem of major inequities that need reform at the level of international trade, governance and accountability.

Nevertheless, the issue bears exploration and yesterday’s presentations at IAS 2015 added information that will undoubtedly fuel discussions and programming going forward.

NAM provided an excellent summary of data on cash compensation for men coming for VMMC and for women living with HIV attending antenatal services and, in a different write up, a summary of data presented on the use of cash transfers for young women to remain in school (in a study called HPTN 068) and for young men and women conditional on life skills training, educational attainment and HIV testing (a study called CAPRISA 007).

The very brief summary of these findings is that cash offers improved uptake of VMMC and clinic attendance for women in antenatal care, but that it didn’t reduce HIV incidence among young women who received the contributions to stay in school—compared to their age-matched counterparts who were also in school but didn’t receive cash bonuses. The CAPRISA 007 study found a reduction in HSV-2 incidence associated with individuals who received cash, but did not find an impact on HIV incidence.

These are not the first studies to investigate the use of such structural interventions on reducing HIV incidence—Julia Kim and colleagues are one of many teams that did groundbreaking work on this topic over a decade ago in rural South Africa (summaries of some work by Kim and others can be found here and here.) And as Helen Rees has eloquently stated in her discussion of the full spectrum of strategies needed for an effective AIDS response, structural strategies such as girls’ education, economic empowerment for women and effective programming to reduce gender-based violence are essential, whether or not they turn up a statistically significant result in a randomized trial.

But these newest data come at a time when cash transfers are getting increasing attention from global leadership seeking to define the package of interventions needed to “end AIDS.” And for this reason, it’s important to track the findings carefully as they may inform what gets rolled out or called for in the near future.

Most specifically, it’s quite possible that cash transfers will turn up in an expanded set of Fast Track goals from UNAIDS. Regular readers of AVAC materials over the past six-plus months are well aware that we’ve been calling on UNAIDS to release comprehensive targets for prevention and non-discrimination, and that we’ve also been urging that these targets—which are available in draft/unofficial form—are defined in ways that match the intervention. So, for example, VMMC lends itself to numerical and coverage targets—a certain number of men reached by a specific deadline. Newer strategies like PrEP need targets that reflect how much still needs to be learned about delivery for maximum impact. That’s even more true for cash transfers for young women—an intervention that has turned up in official UNAIDS documents since World AIDS Day, and that has been included—based on data from World Bank-funded research—in the modeling that underpins the 90-90-90 goals.

As we stated in AVAC Report 2014/15, the term “cash transfers for young women” isn’t nearly specific enough to be operationalized. All sorts of variables are in play—from the amount of money, to the conditions for receiving it, to the recipient—whether communities or individuals. And we’ve clearly stated that defining these variables needs to be part of any target-setting for such an intervention (e.g., the target would be having a clear definition of the intervention, based on evidence, by a specified deadline).

With the new data, and with work we’ve done over the recent months related to both VMMC and women’s access to ART, we want to add a few more questions to this discussion.

  • Could—or should—cash transfers “for” young women include cash transfers uptake of VMMC?
    VMMC programs face funding shortfalls in some places and, in others, are looking for ways to reach men who did not take up the strategy during early, successful roll-out. VMMC is a one-off strategy that reduces individual risk and population level incidence. As Audrey Pettifor, one of the investigators who led the cash transfer study in South African young women observed, it’s important to think about the terms of “conditional” cash transfers. VMMC may be suited to this type of offer, since it is a single procedure. Conditional transfers tied to ongoing behavior change could be less successful, she suggested. This doesn’t mean that conditional transfers can’t work for women, but achieving saturation coverage of VMMC will reduce women’s incidence, along with men’s. In early versions of at least one PEPFAR Country Operational Plan, money from the DREAMS initiative for reducing incidence in adolescents and young women was earmarked for VMMC. With scant resources for adolescent women and young girls, no one wants to see resources earmarked for women going to young men. But the data on VMMC, including the cash transfer study, are a reminder that both men and women need to be involved and reached to impact women’s risk of HIV.

  • What is the need for additional research/interventions that focus on pregnant women from third trimester through immediate post-partum—versus those that encompass many stages of the lifecycle?
    A study in the Democratic Republic of Congo found that incrementally increasing cash transfers (starting at USD$5 and adding one dollar at subsequent intervals) significantly increased pregnant women’s attendance at clinic visits from roughly 32 weeks pregnant through six weeks post partum. As Option B-plus programs grow, there is also an expanding body of evidence of when and how women are lost to follow up and, arguably, any intervention that improves retention should be considered. But the question should be raised by review committees funding trials, advocates asked to consult on protocols, and agenda-setters at every level working on women’s sexual and reproductive health: given all that is known about the complexities of reaching and keeping women in care, should research continue to have a narrow focus on third trimester and early antenatal periods?

  • Education reduces HIV incidence. What are UNAIDS, PEPFAR, WHO, GFATM and national governments going to do about it?
    In the South African study that didn’t find a link between cash transfers and HIV risk, there was a clear link between staying in school and staying HIV negative. This echoes trends detected in Botswana, Zambia and other countries—where additional years of education are protective in terms of reducing young women’s incidence. The structures that need to be in place to support a functioning free and/or accessible secondary education system are quite different from those that need to be in place to deliver cash transfers to selected adolescents and young women. The global and national stakeholders don’t need to forgo cash transfers for large-scale structural work on education for girls—but they ought not imagine that the former will do away with need for the latter.

Finally, on the subject of money, one of the most striking images from activist actions at this conference came from a gathering of women living with HIV, holding handmade signs. Jessica Whitbread, an artist, activist and organizer with ICW Global made a lace-trimmed, hand-lettered blanket that reads: “I am glad my AIDS is paying for your mortgage.” AVAC is part of the professional world that now defines much of the response. We work to remind ourselves, our partners and our funders of the very high bar of accountability for all of the resources available in the global fight. And when it comes to eloquence about following the money—this is exactly the kind of reminder that we need.