Today UNAIDS hosted a webinar to describe and discuss its proposed prevention targets. These have been developed to complement the 90-90-90 target which seeks to have 90 percent of people with HIV know their status, access antiretroviral therapy (ART) and achieve virologic suppression by 2020. 90-90-90 is, of course, a combination treatment and prevention target since virologic suppression reduces the risk of HIV transmission. But AIDS advocates have been asking for targets with similar specificity and ambition for non-ART prevention—including attention to stigma, discrimination and criminalization, since rights-based delivery of services is absolutely essential.

UNAIDS has released both a prevention target draft and a draft of non-discrimination targets. Together, these two documents are the beginning of what a comprehensive response, complementing 90-90-90 could look like. But, as we describe below, there is still a pressing need to review and clearly articulate the rationale for the specific targets being laid out—particularly in the HIV prevention target draft. This is because the prevention target draft has a narrower set of possible objective than the non-discrimination target draft, which lays out two broad approaches to setting these targets—and invites input on the overall strategy.

AVAC and partners have reviewed both draft documents; you can read the composite feedback from Stop AIDS Now and the International HIV/AIDS Alliance on the draft non-discrimination target here. In this post, we focus on the prevention target draft.

The overall prevention goal is to reduce the number of new HIV infections to below 500,000 per year by 2020. There are two population specific sub-goals:

1. By 2020, new infections in key populations will be reduced by 75%
2. By 2020, new infections in young women and girls will be reduced by 75%

As UNAIDS’ Karl Dehne presented on today’s webinar, the over-arching target was selected for the following reasons.

These overarching goals are ambitious, and it is both necessary and exciting to envision how they could be achieved. The prevention targets document begins to map out what Dehne calls the “programmatic targets” that could contribute to these overarching objectives. The proposed “results” framework for these programmatic targets as presented today looks like this:

AVAC and partners who have reviewed the document and the results framework feel that urgent attention and discussion is warranted to ensure that the eventual finished product has the impact that’s needed. We have submitted a letter and a mark-up of the targets document itself that articulate a range of concerns. UNAIDS has also posted shared Google documents of both the prevention and non-discrimination target drafts, and they can be viewed here:

The comment period for both documents closed yesterday (November 12, 2014). However, on today’s webinar, UNAIDS’ Chris Collins said that there was still a narrow window for weighing in—but that feedback did need to come in “as soon as possible.” The above Google Docs remain available. You may also reach out to [email protected].

We will be working with partners to amplify questions and priorities in the coming days—and welcome feedback and input on the documents, our analysis and the overall process for developing these goals. Please be in touch and watch this blog for more updates!

Chris Collins is Chief of the Community Mobilization Division at UNAIDS. Thoughts expressed are his own.

All the recent scientific advances in the response to AIDS present the world with a stark choice: accelerate delivery of HIV treatment and prevention and drive down HIV infection and mortality, or settle for the status quo and accept a grave, avoidable AIDS epidemic for decades to come.

New targets from UNAIDS make this clear. They are based on a modeling exercise that asked where HIV service levels need to be in six years (by 2020) if we want to be on a path so that by 2030 HIV infection and death are down to a tenth of where they were in 2010, and HIV-related discrimination is also dramatically reduced.

We can debate the details of any analysis, but the bottom line is inescapable. Without ramped up delivery of lifesaving treatment and targeted prevention in the next five years, along with advances in non-discrimination and human rights that make these services possible, the AIDS epidemic will remain a serious global health threat as far as we can see. We have the chance to change that outcome—but will we seize it?

Ambitious targets are critical now because the health of the global AIDS response is in question. Funding has slowed; stigma and discrimination continue to magnify vulnerability and have worsened in some places. The world needs ambitious targets that will drive new resources based on the evidence and human rights.

Today’s targets need to be different than those of the past. The “3 by 5 Initiative” and “15 by 15” set our sights on reaching millions with lifesaving HIV treatment. As powerful as these initiatives were, it is time for bold targets that do not close coverage gaps alone—new targets should address the interconnection of treatment, prevention and human rights, as well as the quality of service delivery, in making accelerated progress.

In July UNAIDS announced a new HIV treatment target, “90 90 90,” that calls for, by 2020, 90% of people living with HIV to know their HIV status, 90% of them to be receiving sustained antiretroviral therapy, and 90% of them to have achieved viral suppression. Taken together, the three 90s would mean that 73% of people living with HIV have achieved viral suppression by 2020, a threefold increase from current estimates. (In September President Zuma of South Africa, U.S. Secretary of State Kerry, and others endorsed 90 90 90.)

UNAIDS is now consulting with partners to develop prevention and non-discrimination targets that will promote action alongside the new treatment targets. In September, UNAIDS announced one aspect of the prevention target: to reduce annual new HIV infections to 500,000 or lower by 2020, a 75% decrease from 2010 levels.

The targets represent a new phase in goal setting for the global AIDS response. The viral suppression treatment target puts a premium on quality healthcare outcomes for people living with HIV, in addition to the total number of people reached. In July, over 40 AIDS advocacy groups called for the opportunity for viral suppression for all treatment eligible people by 2020 (here). As they emphasized, respect for human rights must underpin this effort, with respect for personal choice and vigilance against coercion in health services.

The new targets also emphasize equity. The treatment target report (here) points out that key population groups need to realize the same levels of coverage and quality treatment outcomes as everyone else. The prevention target will also highlight the need for major reductions in HIV incidence among key populations, including people who inject drugs, sex workers, gay men and other men who have sex with men, transgender people, and young women and girls.

There is no doubt the new targets are very ambitious. They assert that countries and populations all over the world should be able, in the next six years, to achieve what model programs have achieved – or are near achieving – today. For example, it is estimated that in Latin America 70% of people living with HIV know their status; in Botswana 69% of people living with HIV (PLWH) are receiving lifesaving treatment; in Chile and Venezuela retention rates in treatment are at 90% or above; in Rwanda 83% of PLWH on ART have achieved viral suppression.

Targets are about making change: pushing for new money, strategic investments, and advances in human rights. The targets need to be used as a tool for confronting barriers like drug pricing, discrimination, failing health systems, and underfinancing. They need to be a means for dramatically advancing the response among key population groups and promoting the critical enablers that make services possible, including much greater emphasis on community-provided services and treatment and rights literacy.

The next step is to put the targets to work in financing and national planning. UNAIDS is now working on a Fast Track initiative that will analyze where countries stand in implementing bold targets and help advocates and policy makers fill the gaps.

The next five years are crucial in the trajectory of the AIDS epidemic. A decade ago the “3 by 5” target galvanized advocates, funders and policy makers and changed our conception of what was possible. Today we need that kind of ambition for dramatic advances in HIV treatment reach and quality, prevention and human rights.

Last month, nearly 1,400 researchers, advocates, policy makers and journalists gathered in Cape Town for HIV Research for Prevention (HIV R4P)—the first meeting to gather all the fields of biomedical prevention research under one roof. From broadly-neutralizing antibodies to building trust between trial participants and research teams—R4P had it all.

As part of the continuing coverage of and discussion of key issues and questions raised at HIV R4P, AVAC hosted a webinar, “The State of the HIV Prevention Union: The Road from R4P” on November 6. On it, advocates and researchers alike proposed, explored and debated some of the areas where prevention research and implementation is well coordinated—and places where more union is needed. Missed the conversation? Download the slides and recording here.

Looking to read up on the conference highlights? AVAC covered many of the sessions of interest to advocates in daily “snapshot” summaries from Cape Town.

There is also a lot of great coverage on WhatsUpHIV, a “live blog” set up to report developments from the conference. Over 50 entries were published from advocates, community journalists and researchers—check out the posts here.

These various summaries make reference to webcasts of sessions—all of which are now available on the conference website.

And save the date for HIV R4P 2016, which will take place 18-21 October, 2016 in Chicago!

Greetings from the fourth and final day of the HIV R4P conference in Cape Town. As with the previous days’ summaries—all of which can be found at www.avac.org/hivr4p—this is a selective, whirlwind tour through some of the highlights of a meeting that reflected tremendous momentum, energy and excitement across the HIV prevention research spectrum. Webcasts of all the sessions are available 24 hours after they take place. The live blog, What’sUpHIV, has nearly 50 posts from advocates, African journalists and researchers. It is definitely worth taking a look. And Twitter, at #HIVR4P, has great images of many sessions describe below—and much more. 

Although the conference ended today, the work together is just beginning. We hope you’ll register now for a webinar next Thursday, November 6, that will look at key themes and action items emerging from this meeting. 

Morning Sessions
No such thing as a failed trial
This, for many years, has been a mantra in the biomedical prevention field. If the trial recruited and retained participants, and got a clear answer about a product—then it could in no way be called a failure. But what about when participants don’t use the product often enough to get a clear answer—what do you call that trial? One of the themes throughout the week has been how much the prevention research field has learned from VOICE—which had low rates of adherence across oral and gel tenofovir prevention arms. It was not the outcome anyone would have wished for. But the wealth of insight into the gaps in communication, context and motivation that can exist between women and research is incredibly rich—and might not have emerged, had VOICE not provided a “wake-up call” to look closely at difficult issues. 

Two talks in the session Challenges of Biomedical HIV Prevention Trials [SY10], reflected on lessons learned from trials that didn’t go as hoped or planned. Jeanne Marrazzo (University of Washington) [SY10.01] reviewed many of the challenges—“life is messy,” she said—and showed a really useful slide summarizing the ways that the VOICE result had changed the model for future trials. She ended her talk with a quote from Winston Churchill, “Success is not final. Failure is not fatal. It is the courage to continue that counts.” 

“The trial becomes the protagonist in a story about its life,” said Jonathan Stadler (Wits Reproductive Health & HIV Institute, South Africa) [SY10.04] in a presentation that delved into the ways that myths and rumors about the trial and its experimental products can circulate in waiting rooms and outside the clinic, impacting on womens’ decisions to use the products while in the trial. 

Meeting women’s many needs
A session on multi-purpose prevention technologies [RT05] provided a glimpse of the future, as multiple presenters discussed the pipeline, regulatory considerations and potential study designs for combination prevention tools that would provide contraception as well as protection against HIV and/or other STIs. 

Beyond basic science—antibodies enter the clinic
Differential use of Antibodies in Prevention [SY12] continued the discussion of the possible ways that broadly neutralizing antibodies could be harnessed and induced as HIV prevention tools—another key theme of the conference. Barney Graham (NIH Vaccine Research Center) [SY11.01] provided an update on clinical development of VRC01, a broadly neutralizing antibody developed by the VRC, describing two ongoing studies to establish the safety of this product. One is taking place in people with HIV, the other is enrolling HIV-negative individuals. He reviewed the slate of future trials planned to explore different doses, routes and schedules—a sequence that could eventually lead to efficacy evaluations of VRC01 as a prevention tool for HIV-negative infants and high-risk adults. Even as VRC01 moves through clinical trials, there are efforts underway to engineer the BNAb to be even more potent. Neal Padte (Aaron Diamond AIDS Research Center) [SY12.02] described work, in collaboration with David Ho, also designed to engineer potent BNAbs—including clinical trials with one candidate and several more that are in preclinical development, with the goal of selecting one to bring into human evaluations. While all of these concepts are still in their early phases, the session—and the conference as whole—gave a sense of the concrete, if incremental, steps that are moving this critical field forward. 

Closing Plenary Session 
Getting it right
Douglas Shaffer (US Office of the US Global AIDS Coordinator) continued the theme of safeguarding human rights as part of an effective HIV response in a talk that also highlighted the evidence—from models—that combination prevention incorporating ART, VMMC, condoms, PrEP and other strategies is key to achieving an end to the AIDS epidemic. Continuing with a “status quo” response won’t achieve these results. To frame its work and change the paradigm, the US PEPFAR program has adopted a “Right Things, Right Places, Right Time” approach to guide spending and program design, which he presented in a slide at the end of his talk. 

P-Values
A p-value is a statistical term used to indicate the probability that a research result is a coincidence, rather than an actual finding. There was plenty of actual truth—and an alliterative festival with the letter “P”—in the talk by Alex Coutinho (Founding Director of the Infectious Disease Institute, Uganda) about what’s needed to scale up HIV prevention science from the laboratory to the village. In the move from policy to practice, Coutinho highlighted the need for “Partnerships; planning and processes; pesa, pula, pound and pennies; push and pull approaches; providers’ perspectives; population preferences; and pressure from activities.” (This was just the one of the “P”-value laden slides…watch the webcast for more.) “We are far more credible when we combine science with activism,” he said—a refrain that has been echoing through this conference, and that will be exciting to reevaluate at HIV R4P 2016. (Wondering where it will be? Read on!) 

Walk the walk
Glenda Gray (Perinatal HIV Research Unit, South Africa) used her talk on antiretrovirals for prevention to highlight the compelling science supporting their efficacy and the considerable challenges to translating that efficacy into clinical benefit. She said that much of the billions of dollars spent on research has been wasted due to failures in dissemination. “All breakthrough and no follow-through,” in a succinct formulation that she borrowed from a colleague. This isn’t for lack of cost-effectiveness, either. PrEP, Gray showed, can be cost effective when targeted to the highest risk populations. Lest this seem improbable, consider that the early results from demonstration projects show that individuals at highest risk are selecting PrEP and using it consistently—suggesting that, when provided with the right information and unbiased access, will make the choices that are best for them. The issue of bias and stigma is another huge issue in health care settings—and a major obstacle. Gray made a strong case for how the health and legal systems have failed sex workers, citing astronomical rates of abuse, violence and discrimination reported at the hands of both the police and health providers. She cited a systematic review showing that decriminalization of sex work could avert roughly 30-45 percent of new HIV infections worldwide over the next ten years. Biomedical prevention doesn’t often engage with legislative issues—but, combining Shaffer’s, Gray’s and Coutinho’s messages, it’s clear that this community needs to find and harness its activist energy and challenge the laws that undermine public health. 

Honoring heroes lost too soon
Manju Chatani-Gada (AVAC) presented the Omololu Falobi Award, a biennial honor given in memory of a tireless activist, organizer and journalist who, “lived life in a hurry as a young visionary leader.” Falobi co-founded NHVMAS, the Nigerian HIV Vaccine Microbicide Advocacy Society, as well as helping to lead the Nigerian group Journalists Against AIDS, before his untimely death in 2006. Chatani-Gada explained that this year the award recipient was another Nigerian activist and hero who shared many similarities with Falobi, including a tragic, untimely death earlier this year. Oyelakin Taiwo Oladayo, known as “Taiwo”, was killed in a car accident just six days after his wedding. His life was remarkable for its bravery, commitment and action. Chatani-Gada said, “Taiwo was a passionate advocate for the rights of young people living with and affected by HIV and AIDS with a special focus on the rights and dignity of those who are most marginalized. He was a true son of Africa—championing other African advocates and developing a mentorship program to nurture others. While he focused his efforts in Nigeria, he was also part of the global community of activists who aspired to end the epidemic. As a young person living with HIV himself, he never let that—or anything—get in his way. He had many dreams and many aspirations for the future, as an international activist, as a photo documentarian, as a politician…. Like Omololu, he lived his life in a hurry. And like him, he left his mark on all those who met him.” 

Deliver, Demonstrate, Develop—Tools to end the epidemic 
The Honourable Minister of Health for South Africa, Aaron Motsoaledi, received a warm welcome from conference co-chair Helen Rees, and provided a galvanizing vote of confidence in the role of HIV prevention research in ending the epidemic. He highlighted South Africa’s role in HIV prevention research, including its ongoing leadership in trials of microbicide gels and rings and vaccines that build on the positive results of the RV144 trial. He also looked beyond the continent, hailing the results of the PROUD and IPERGAY trials of PrEP in MSM—both trials stopped early after overwhelming evidence of benefit—and said that South Africa needed to expand PrEP access, particularly in female sex workers, young women and MSM. He also highlighted the need to address human rights issues as part of an effective AIDS response—a key theme for the meeting, and a great issue for a South African leader to raise from the podium. Amandla! 

Optimism and obstacles
Conference co-chair Robin Shattock (Imperial College, London) gave closing remarks, on behalf of his colleagues, that summed up the key themes and great sense of shared purpose at the meeting. Shattock spoke of the optimism that the meeting had generated. “Why optimistic? Because the science is outstanding and this is a key moment of change in the field.” He spoke of the “new and achievable” goals across interventions—from broadly neutralizing antibodies to microbicides to PrEP—and of the exciting engagement of new young researchers, the “lifeblood” of the field. But, he noted, it is both the best and the worst of times, as research funding is falling (see the most recent trends from a report from the HIV Vaccines and Microbicides Resource Tracking Working Group) at the moment when significant change is possible, and breakthroughs within reach. 

From the “Mother City” to the “Windy City” 
HIV R4P 2016 will be held in Chicago, US—which is nicknamed the Windy City, just as Cape Town is known as the Mother City. Nelly Mugo (University of Nairobi) accepted the hand-over as one of the four conference co-chairs for that meeting—which will take place in a country with hot-spot epidemics among MSM that are equivalent, in incidence and prevalence, to the most severe in sub-Saharan Africa. The other co-chairs for the 2016 meeting are Thomas Hope (Northwestern University, US), Lynn Morris (National Institute for Communicable Diseases, South Africa) and Jeanne Marrazzo (University of Washington). 

All of us on the AVAC team want to thank you! It’s been energizing and exciting to work with so many partners in Cape Town, and to hear from so many more who’ve followed R4P from abroad. We will see you in Chicago in 2016 and many times before, we hope, as we continue to plan, prioritize and act for effective change. Don’t forget to register for the post-R4P webinar to continue this work.