Africans Call for Voluntary Medical Male Circumcision

Energy was high at the “Call to Action for Voluntary Medical Male Circumcision” session convened by AVAC, Champions for an HIV-Free Generation, PEPFAR, UNAIDS and the WHO. Leaders from across Africa emphasized the potential for VMMC to dramatically reduce infections and save significant treatment and care costs.

Former Tanzanian President Benjamin Mkapa said, “Scaling up this intervention is an urgent priority. Although it means an upfront investment, the results are significant long-term cost savings.” Former Ugandan Vice President Specioza Wandira stressed the need to involve women in every step of VMMC rollout and scale-up: “Women, in their role as sisters, mothers, wives and partners also play a pivotal role in supporting men to make this decision.” Zimbabwean parliamentarian Blessing Chebundo told the moving tale of his decision to get circumcised along with 43 other Zimbabwean lawmakers: “At first I was scared, but later I found out it was almost painless. Every man should consider getting circumcised.” Zambian Chief, Jonathan Mumena XI, the leader of the Kaonde ethnic group which does not practice traditional male circumcision, challenged other leaders to ensure that traditional practices don’t get in the way of saving lives. “What is a culture without a people?,” he asked. AVAC’s Angelo Kaggwa also gave his experience of getting circumcised in Kisumu, Kenya. He challenged the participants to join a coalition of Africans advocating for the accelerated scale-up of VMMC as part of combination HIV prevention. The event also highlighted a new publication by AVAC, UNASO (Uganda), Sonke Gender Justice Network (South Africa) and NEPHAK (Kenya) that is a “Call to Action” on VMMC. Notable African leaders including former Zambian President Kenneth Kaunda and former Botswana President Festus Mogae were among the packed room of participants.

PowerPoint presentations from the session are available on the AIDS 2012 website. Learn more about the importance of VMMC as an HIV prevention tool at www.avac.org/malecircumcision and www.malecircumcision.org. For more information on and to join a coalition of Africans advocating for VMMC scale-up visit www.truthaboutVMMC.org.

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The Role of Vaccines in Ending the Pandemic

AVAC and a broad array of AIDS vaccine partners convened an interactive session made up of a panel and Q&A session with researchers, funders and local advocates to discuss the latest in AIDS vaccine research and explore how AIDS vaccine research remains a critical and integral part of ending the epidemic. Chaired by Margaret McCluskey of USAID and moderated by Mitchell Warren of AVAC, panelists included Rainer Engelhardt, Public Health Agency of Canada; Glenda Gray, Perinatal HIV Research Unit; Kevin Moody, GNP+; Chidi Nweneka, African AIDS Vaccine Partnership; Punnee Pitisuttithum, Mahidol University; Nina Russell, Bill and Melinda Gates Foundation; and Bill Snow, Global HIV Vaccine Enterprise.

The lively question and answer session touched on many issues including the impact that new strategies like PrEP or a microbicide could have on trial design. As additional prevention strategies are introduced, trial population incidence should fall. This could mean larger trial sizes. Panelists agreed that this will be an issue that needs close attention in the years to come. Bill Snow noted that if trials must be larger because the prevention is more effective and incidence is declining, that is something to be celebrated. One audience member who described his ongoing work with treatment literacy and community education said the question he is asked most often is, “When will we have an AIDS vaccine?” Nina Russell gave a best-case scenario answer based on the timeline for trials designed to follow up on the Thai RV144 result. A coalition dubbed the Pox-Protein Public Private Partnership, or P5, has a South African trial planned of ALVAC plus a protein boost, similar to the regimen tested in RV144. The P5 is comprised of the Gates Foundation, the US Military HIV Research Program, the HIV Vaccine Trials Network, Sanofi and Novartis. Russell said that if this research confirms the Thai RV144 trial, the candidate could potentially move toward licensure by 2022.

Mitchell Warren reminded the audience that history has shown that AIDS vaccine advocacy cannot predict with any certainty when we will finally have a vaccine available for use. Rather researchers, advocates and funders must all work to ensure none of the steps in the timeline take any longer than absolutely necessary.

PrEP for Women — What’s the Plan?

Just days before the start of the International AIDS Conference, the US Food and Drug Administration announced its approval of TDF/FTC for pre-exposure prophylaxis (PrEP). This development has raised hopes, questions and concerns on many fronts. A session in the Global Village at AIDS 2012, “How can ARVs as prevention work for HIV-negative women?”, looked specifically at women’s views on this potential new prevention tool. Over 30 participants, most of whom were women, discussed current and future options for using ARVs for prevention in HIV-negative women. The session was co-facilitated by Lisa Diane White of SisterLove (and a PxROAR member) and Manju Chatani-Gada of AVAC.

The animated dialogue started with a presentation on HPTN 064, also known as ISIS, a US government-funded study designed to estimate the overall new HIV infection rate for women at risk in the US. Through focus groups and in-depth interviews, this research identified a number of barriers to HIV prevention and risk factors affecting these women. The discussion then shifted to one potential new prevention tool for women—daily oral TDF/FTC as PrEP. After a review of the data and current regulatory developments, the audience discussed what PrEP might mean for US women. Participants raised many questions including who would pay, how much PrEP would cost, what types of programs would offer PrEP to HIV-negative women and what kinds of testing would be required.

Similar questions apply internationally. Look out for more opportunities to join the US and international-based conversations led by AVAC and its partners.

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GPP Activities Gain Momentum in Thailand

Implementation of the Good Participatory Practice (GPP) guidelines continues to move forward in Thailand. The Thai NGO Coalition on AIDS led trainings for research organizations including the Thai Red Cross AIDS Research Center, the Research Institute for Health Sciences from Chiang Mai University and the Armed Forces Research Institute for Medical Sciences. These groups represent key networks in the HIV prevention research field including the HPTN, ACTG, IMPAACT and MTN.

Thailand has a long history of community engagement in HIV research. The GPP trainings, however, highlight some key challenges and issues not unlike those experienced in other areas of the world. One ongoing need in Thailand and around the world is to map out processes for promoting and institutionalizing GPP at national levels (e.g. via official adopting by institutional review boards). There is also a gap in terms of systems for monitoring and evaluating GPP implementation where it is being implemented. Other enduring challenges involve dependence on community advisory boards as the primary mechanism for stakeholder engagement (GPP suggests using multiple channels to reach impacted communities), and the limited budgets available for stakeholder engagement.

Open, frank discussion about these issues between community and researchers represents a true shift in practice in Thailand, and key researchers are becoming both more accepting of full GPP implementation and aware of its positive impact on the research process. For instance, the director of the AIDS Research Center at the Thai Red Cross, stayed and engaged in almost the full day of the training, even though he had only committed to coming and opening the session.

Moving forward, potential plans include additional trainings for new protocol/trial teams, piloting of GPP in a “test and treat” study in MSM and follow-on studies from RV 144, and continued sharing of lessons and practices between institutions.

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PxROAR Europe in Action

HIV prevention research took the stage at the 110th “jubilee congress” of the German STI Society (DSTIG) in Berlin last week. At the invitation of the organisers, AVAC and HIV Europe co-hosted a symposium—Modern Prevention Strategies—where panelists and audience members discussed the state of the art in HIV prevention and what modern prevention strategies mean for different affected communities in the region.

Members of PxROAR Europe were among those leading the discussions. Harriet Langanke, of the German Sexuality and Health Foundation (GSSG), led a session focusing largely on some of the highly affected communities in the region—migrant women and gay men and men who have sex with men (MSM)—and the potential opportunities for members of these communities to access to new all HIV prevention options.

Wezi Thamm, Chair of the international network WECARe+ (Women in Europe and Central Asia Regions Living with HIV) and a migrant from Zambia herself, made clear that legal conditions, language barriers and lack of insurance too often hinder migrant women from accessing HIV prevention and care. She demanded not only the development of new prevention options but that the prevention field focus on and address issues that may limit access.

During a special “poster walk” exploring the featured poster area at the conference, Harriet presented an abstract (co-authored by other PxROAR Europe members): Modern HIV Prevention Strategies: What are the implications for German populations? Community perspectives (click to download).

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Activists Strategize in Peru

In May, AVAC partner Epicentro led a civil society meeting, Activism, Access to Health Services for LGBT and Biomedical HIV Prevention, to develop a plan for engaging with biomedical HIV prevention research occurring in Peru. Local advocates, including MSM sex workers and people living with HIV, participated in the two-day conference. (Download the agenda: English and Spanish.) The objectives were to promote a common understanding of the PrEP and rectal microbicide research taking place in the country and to identify strategies for community mobilization on these issues, HIV treatment and prevention, and LGBT health in general. The resulting advocacy agenda articulated a demand for access to affordable TDF/FTC for treatment of HIV-positive people—an issue that must be addressed before oral PrEP using TDF/FTC in HIV-negative people can be fully explored. It also identified the need for journalist training, sensitization of health workers on LGBT health issues, and general awareness-raising on biomedical HIV prevention.

Communities of gay men, other men who have sex with men, and transgender women have some of the highest rates of HIV in Peru. Yet access to HIV testing, care and treatment is limited—due to many factors including stigma, lack of gay-friendly services, and lack of awareness of health care rights among affected communities. Advocacy also includes continued support for ARV-based prevention research— the iPrEx OLE open-label extension PrEP study; MTN 017, the first phase II rectal microbicide trial; and early phase vaccine studies. For example, in March, Epicentro, AVAC, IRMA, IMPACTA and MTN organized a community consultation for the pending MTN 017 trial. Most meeting attendees were Lima locals, but there was representation from elsewhere in Peru as well as Paraguay and Argentina.

The next steps are to prioritize and operationalize the objectives generated at the meeting. To join the burgeoning network of local and regional Latin American advocates spearheaded by Epicentro, contact Steve Miralles at [email protected] or join the group directly at [email protected].

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Testimony at the FDA Advisory Committee Hearing on daily oral TDF/FTC as PrEP

On May 10, a US Food and Drug Administration (FDA) advisory committee met to discuss whether to recommend that oral TDF/FTC (brand name Truvada) be approved for HIV prevention in HIV-negative adults. The committee ultimately decided to recommend approval, and an FDA decision is expected by June 15. The twelve-hour day included an array of presentations, questions and testimony from the public.

For many people who attended the proceedings or watched online, some of the most memorable remarks were made by Matthew Rose, a member of AVAC’s PxROAR program. “I ask you to give my community another option. I do not believe that a single drug or strategy will be what ends this epidemic. But give people options and choices that will work for them, things science tells us will give us a chance.” Copies of Matthew’s full remarks and those from other advocates—including AVAC Executive Director Mitchell Warren, amfAR’s Chris Collins, and others—are available at www.prepwatch.org. Visit PrEP Watch for continuing coverage of this issue.

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Africans telling the truth about voluntary medical male circumcision

AVAC team member Angelo Kaggwa is now partnering with other African advocates and AVAC partners, including Simon K’Ondiek at the Nyanza Reproductive Health Society in Kenya and Richard Hasunira at HEPS-Uganda, to lead an initiative called Africans telling the truth about voluntary medical male circumcision. These advocates urge for a speedy and accelerated scale-up of VMMC and other proven HIV prevention interventions across Africa to begin to end the AIDS epidemic. The campaign webpage will be a space for African men, women and allies to voice their support for VMMC, ask questions and voice their concerns.

Angelo himself underwent voluntary medical male circumcision almost a year ago and published an essay about his experience in the April 15 edition of Uganda’s Sunday Vision. The essay, Circumcision: My Experience, discusses Angelo’s decision to get circumcised, details every part of the procedure and healing process and talks about his enthusiasm to see other “busy” young African men get circumcised to reduce their risk of HIV infection.

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Shining a Spotlight on an AVAC Fellow

Kenyan activist Lucy Ghati is a 2012 Advocacy Fellow housed at the National Empowerment Network of People Living with HIV/AIDS in Kenya (NEPHAK). Her work is focused on building an informed civil society base for influencing the Kenyan AIDS response. As the country prepares for an election Lucy and her close collaborator, AVAC Fellow Jacque Wambui (Health GAP-NEPHAK), are conducting nationwide dialogues about treatment as prevention with Kenyans living with HIV. They’re using feedback from these conversations to shape an AIDS “manifesto” that they hope to have adopted by all of the presidential candidates. The activism has also moved to the streets. In April, Lucy, Jacque and collaborators organized a march aimed at the US PEPFAR Program, demanding greater civil society engagement and allocation of the $500 million as yet undispersed PEPFAR funds. A memorandum was drafted to present civil society demands to the government of Kenya.

Lucy also sits on a global steering group that provides oversight on the implementation of the “The Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive”. In May, Lucy was at the first annual face-to-face gathering of representatives from the 22 focus countries since the launch of the Global Plan in 2011 in Geneva. She was quoted in a UNAIDS report noting the importance of community engagement in implementing the Global Plan.

While in Sydney for the International Microbicides 2012 Conference, Lucy was interviewed by Australian TV to talk about the importance of HIV prevention in women and also about her experience living positively with HIV in Kenya. Watch her interview as part of a feature on Sunrise TV.

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Fellows’ work highlighted at WHO-UNAIDS-UNFPA consultation

On May 7-8, WHO, UNAIDS and UNFPA convened a stakeholder consultation in Montreux, Switzerland, to discuss next steps for implementing the WHO technical note on hormonal contraceptives and HIV risk. Civil society was well represented at the meeting, and included AVAC collaborators from the ATHENA Network, Bar Hostess Empowerment Project (host of 2011 Fellow Grace Kamau), the International Community of Women Living with HIV/AIDS East Africa (the host of Lydia Mukombe, 2012 Fellow) and AIDS-Free World.

In March and April, Lydia conducted a series of interviews with reproductive health providers in Uganda to find out what they were doing to implement the WHO technical note recommendation that women at risk of HIV using injectable progestogen-only contraceptive be strongly counseled to use condoms. The answer: Nothing new. As ICW EA director Lillian Mworeko reported at the Montreux meeting, five of Uganda’s largest service providers said that they didn’t see the note as a reason to change their programming. This report back was a key part of the discussion about the need to implement a well-structured communications strategy to reach service providers and other stakeholders. A guidance document is expected from this consultation, and advocates will be providing input and tracking the process to ensure that the convening agencies make good on their commitments.