Announcing the 2018 AVAC Advocacy Fellows

AVAC is delighted to announce the 2018 AVAC Advocacy Fellows—the ninth class of Fellows! Please join us in congratulating these seven talented advocates.

The 2018 Advocacy Fellows were selected from a pool of over 125 applicants from over 26 countries across the globe. We thank all of the applicants and their proposed host organizations for the time and effort put into this process. We’re also grateful to the independent review committee of advocates, scientists and former Fellows and Hosts who guided our decision-making.

The 2018 Advocacy Fellows are:

The 2018 Fellows’ year begins in April against a backdrop of promise and challenge. Long-acting injectable PrEP and vaccines are both in large-scale trials. Rates of new HIV diagnoses are falling in some places, and not in others. Key primary interventions, like VMMC, compete for funding in the context of finite country budgets; as does programming for newer strategies, like PrEP.

The 2018 Fellows join a fantastic group of 56 current Advocacy Fellows and Alumni from eight sub-Saharan African countries and China who have participated in the program since its inception in 2010. Please visit the Advocacy Fellows page to learn more about the new Fellows’ planned work for the year. We hope you’ll find ways to collaborate with them in 2018 and beyond.

A Call for Applications for the 2019 Fellows Program will be announced this June with an application deadline in August. If you would like to be notified of the 2019 Call for Applications or have any questions, please email us at [email protected].

Did the South African Government Waste R127 Million on a Condom No One Wanted?

Johannesburg’s Bhekisisa Centre for Health Journalism has published this article by Tian Johnson on how South Africa can make smart investments in the female condom. Read on for details on the difference demand creation and counseling can make.

Real Women Don’t Look Like Models: What the latest paper on hormonal contraception and HIV risk leaves out

Emily Bass is AVAC’s Director of Strategy & Content.

The incomparable activist and writer Kenyon Farrow used to write a blog called Non-Shock of the Week, and it came to mind when I read yet another analysis of the interplay between hormonal contraception (HC), HIV, and the long-term impact on women’s health in Africa.

This paper, published by the journal Global Health: Science and Practice, uses models to explore what would happen if the injectable contraceptive DMPA, or Depo-Provera, was withdrawn from the parts of the world where it is most widely used.

Why ask this question? Because there is a possibility that DMPA (and other injectable contraceptives that contain the same synthetic hormone) could increase women’s risk of HIV. The World Health Organization (WHO) identifies this “theoretical or possible risk” in its current classification of three products: DMPA, NET-EN (another injectable that uses a different hormone from DMPA) and DMPA-SC, also known as Sayana Press, which is the same hormone as Depo but uses a different, simpler delivery method. (More background information is available here.)

DMPA is the mostly widely used contraceptive in East and Southern Africa, so my non-shock of the week was its key finding: Taking away DMPA without offering a comparable method would increase women’s risk of dying from pregnancy-related outcomes (e.g., unsafe abortions, complications from pregnancy), and that more women would die than would be protected from HIV.

Well, yes. That’s not news. Various models have drawn the same conclusion, and an updated systematic review of epidemiological evidence on hormonal contraceptive methods and HIV acquisition was published in 2016. At least one of the authors of the recent analysis knows this, having participated in forums where civil society have implored “experts” to stop promoting these false choices. No responsible funder, government, activist or advocate would ever suggest that DMPA should be pulled off the shelf without a replacement. Maternal mortality claims too many lives; contraceptives are essential; and DMPA is the right one for many women.

So why do we keep on being told how bad it would be if DMPA were to vanish, in the event it turns out to increase women’s risk of HIV? A cynical analysis is that these publications are preparing the ground in advance of data due in 2019 from the ECHO trial, which is expected to yield an answer to these questions. (ECHO is measuring whether DMPA administered through an intramuscular injection (IM) and two other HC methods-the Jadelle implant and the non-hormonal copper intrauterine device (IUD)-impact women’s risk of HIV.)

The ECHO trial is designed to provide clarity where there hasn’t been any-by using a randomized clinical trial design that aims to eliminate the potential for bias, which could be influencing observational data available thus far. If DMPA does increase women’s risk of HIV, there will be an imperative to change the status quo and do things that are costly, hard and largely avoided by many countries for many years. Things like: increasing the number of choices that women have for contraception; integrating HIV prevention and contraceptive provision services into one clinic; and providing oral PrEP as part of comprehensive HIV prevention options.

Does this sound far-fetched? Consider this:

The article concludes, “In countries with the highest maternal mortality rates, an unrealistically large proportion of the women would need to transition from progestin-only injectables to another effective method in order to reach net neutral mortality thresholds.” (Emphasis added)

In fact, the authors found (except in South Africa) 80 to 90 percent of women now using DMPA would need to switch to something just as effective to net more lives saved than lost. This calculation seems to be borne out by the available facts, but it also puts the problem in a vacuum. If a contraceptive method impacts a woman’s HIV risk she should be given the option to switch methods; she should be provided the means to make different choices about HIV prevention.

The modeling paper could have suggested that now is a moment to intensify efforts to give African women access to oral PrEP along with other methods of HIV prevention-at the same places where they choose their contraceptives. This has been the refrain of advocates working on this issue all along: Women must be able to protect themselves from HIV and access safe and effective contraception. There is no time for programs or modeling papers that, however inadvertently, put forward a false dichotomy between women’s HIV prevention needs and their contraceptive needs.

Instead of issuing papers and arguments about how hard and risky it will be to change anything if ECHO does indeed find that a given method impacts risk, global and national decision makers need to send the message: This is an opportunity to advance women’s health via integration of HIV prevention and contraceptive programs and expanding the method mix of both. There’s consistent evidence that women want this and that it’s good for individual and community health. So why not do it at scale now, irrespective of the ECHO trial? Send money with the message. Fill the shelves with options for women to choose from and provide counselors skilled in explaining the risks and benefits of different methods. This is not impossible.

Another article published recently, which sits behind a paywall, looked at possible explanations for why DMPA might increase women’s risk of HIV. It’s dense, but the bottom line is that the specific progestin in DMPA acts differently than other progestins. Some of those differences could increase women’s risk of HIV. It’s all inference-there’s no direct measurements of DMPA use and HIV risk. The authors looked at the available data: different kinds of cells, immune substances, other markers that the body produces and how DMPA affects them. The authors say that there could be a rational explanation for why DMPA may increase women’s risk and other methods don’t. But their research doesn’t supply an answer, just more information in a murky space that might-or might not-be cleared up by the ECHO result.

In the meantime:

  • WHO should clarify their course of action if the ECHO study shows that DMPA does impact HIV risk, including how they will engage stakeholders and convene a guidelines review. WHO should contribute further models, other literature and resources that will lead to clear communication and policy guidance.
  • All stakeholders working in both HIV and reproductive health need to plan, ideally together and not in silos, now for the range of potential results from the ECHO trial.
  • Programs, policies and messages need to be developed and evaluated to understand how best to honor and uphold women’s right to know all available information on the contraceptive method(s) they are being offered.
  • Investment is needed now in programs that provide women with broader choices in contraception and HIV prevention.
  • Ongoing engagement with women affected by these issues is essential. Their perspectives and experiences must guide policy, programs and messaging.

Additional Information

The January Episode of Px Pulse is Up!

As the new year gets into full swing, we at AVAC look forward to assessing, untangling, confronting and calling on all of us to commit to HIV prevention in all its complexity. Building on the advocacy agenda we lay out in AVAC Report 2017, and a corresponding December episode of our Px Pulse podcast, our January episode expands on what we’re looking forward to in the year ahead.

Find Px Pulse on iTunes or listen at AVAC.org to hear AVAC Executive Director Mitchell Warren explore more of what’s got our attention—it’s no small list.

  • Major new vaccine and long-acting injectable PrEP trials are launching.
  • The dapivirine ring is under regulatory review, and could be the world’s next biomedical prevention option since oral PrEP.
  • Recent findings from the Rakai Community Cohort Study in Uganda confirmed what models predicted—bringing combinations of existing interventions, such as voluntary medical male circumcision and antiretroviral treatment, to scale slashes new HIV diagnoses. How can we leverage these findings to maximize prevention at the global level?
  • What will advocates need to do this year to prepare for results—anticipated in 2019—of a key trial called ECHO that’s looking at whether contraceptive methods affect HIV risk?

Hear all this and more in the January episode of Px Pulse, AVAC’s podcast on HIV prevention research today. Tell us what you think!

Our New Year’s Resolution for 2018: Speak up, act up loud and clear

Released a few weeks ago, AVAC’s annual state-of-the-field report calls for an end to mixed messages about key issues affecting HIV prevention research and implementation. As we come to the end of a year that has been filled with challenges and moments of resilience, collaboration and progress, we want to be clear once more: we cannot give up, and we cannot do this alone.

Over the past several days in the US, a law has passed that many analysts say will increase taxes for poor and middle-class people, and make life even easier for the richest of the rich. There’s also been a flurry of news and action triggered by the report that the US government directed the Centers for Disease Control and Prevention (CDC) not to use seven words in its budget requests: diversity, entitlement, evidence-based, fetus, science-based and transgender.

CDC denied the ban, but this hardly matters. A valuable analysis of the last four CDC budget requests—lengthy documents that lay out the agency’s annual plans, priorities and funding needs—shows a dramatic decrease in the number of times CDC used some of the words on the alleged list in its budget requests. In particular, transgender and evidence-based were both nearly erased from these documents, which run hundreds of pages long. This signals worrying programmatic and policy shifts.

Income inequality is a global scourge; censorship is an insidious practice. They are also two facets of the structural violence that drives HIV worldwide. You cannot be an advocate for HIV prevention and accept wealth disparities or any form of silencing as the state of the world.

And so we don’t.

Not today and not ever.

In the past months, AVAC has launched a new program with African transgender rights defenders and activists, and has begun work on a dynamic new phase of coalition-based action aimed at ensuring that people most affected by HIV are at the frontlines of decisions about the HIV response in their communities. Stay tuned for updates about these and all of our activities in the New Year.

In 2018, we’ll keep on working with our partners in these and many other initiatives to speak up, act up and fight back against all of the drivers of the epidemic. Our lives depend on it, and we depend on you as partners in this fight.

In that spirit, we send our great thanks for your partnership and wish you all a holiday season of rest, respite and recharging.

The Weekly NewsDigest will return January 5

There will be no issue next week. The NewsDigest will return on January 5, 2017. Our best wishes for happy holidays and a peaceful new year, and our thanks for reading!

Untangling Mixed Messages in the Newest Episode of AVAC’s Px Pulse!

Last month, AVAC released our annual, opinionated state-of-the-field report—Mixed Messages and How to Untangle Them. It’s filled with information, graphics and in-depth analysis and definitely worth a read! This month, we’re also pleased to offer highlights of the report in the December episode of our podcast Px Pulse, which is now up. Find it on iTunes or click here for Px Pulse on avac.org.

Hear AVAC’s Director of Strategy and Content, Emily Bass—who’s been writing for the AVAC Report for nearly 15 years—give short, sharp summaries of the key “mixed messages” that the report untangles, and review AVAC’s advocacy agenda for the year ahead. In conversation with AVAC’s Web Editor, Jeanne Baron, Bass describes critical issues in the research landscape, the evolving field of PrEP rollout and the unfinished work of scaling up effective HIV prevention worldwide. Tune in to hear what AVAC thinks needs to happen—now and in the year to come.

We can’t wait to hear what you think!

US Agency for International Development/Bureau for Global Health/Office of HIV/AIDS/Research Division, Microbicide Branch (GH/OHA/RES) is recruiting to fill the following position: Senior Advisor for Development of Biomedical HIV Prevention Technologies

For more information, please click here.

African Advocates Build Platforms and Networks to Push for HIV Prevention Access and Ethical Research Conduct in Africa

Morenike Oluwatoyin Folayan is an Associate Professor at Obafemi Awolowo University and Coordinator of the New HIV Vaccine and Microbicide Advocacy Society (NHVMAS) in Ife, Nigeria. This post first appeared in News Proof.

It was a beautiful sight to behold – the coming together of African advocates for HIV prevention access and conduct of biomedical HIV prevention research that respects the rights and welfare of participants. Acronyms like NHVMAS, AfNHI, VARG, AAVVi.net, APHA, WACIHealth were a delight to hear.

The New HIV Vaccine and Microbicide Advocacy Society (NHVMAS) was the oldest of the pack. It was formed by Advocates in Nigeria to push for the access of Nigerians to biomedical HIV prevention tools as soon as they were available way back in 2004. It is expanding its scope of work to West Africa and liasing with other networks to expand its work to Africa.

One of its chief liaison is WACIHealth. WACIHealth is focused on promoting increased domestic funding for health in Africa. It expanded its scope of work to include advocacy for HIV prevention commodity access, including promoting domestic investment for biomedical HIV prevention research, in 2011 just ahead of the Abuja+12 conference. Its partnership with NHVMAS led to the successful implementation of the biennial Biomedical HIV Prevention Forum since 2013. The forum serves as a platform for networking, sharing, providing updates and motivating for new action to promote access to HIV prevention tools and investment in ethical conduct of biomedical HIV prevention in Africa.

AfNHI is a birth product of the WACIHealth and NHVMAS with ample midwifery from AVAC. AfNHI envisons seeing Africa free of New HIV Infection. It is led by Africans for Africa and largely marries the vision of both WACIHealth and NHVMAS for the purpose of prevention new HIV infection in Africa. The network was launched during the 2017 Biomedical HIV Prevention pre-conference that held on the 3rd of December 2017 in Abidjan.

Also launched was the Vaccine Advocacy Resource Group (VARG). The Group is more global in outlook with members from beyond Africa. The lead of the Group – Tian Johnson – shared the goals and aspiration of the group at the meeting one of which was to be the voice of community advisory boards. The group is largely focused on promoting HIV vaccine research that respects the rights of study participants, and future end users. It tries to address the complex relationship between race, gender, rights and research. One of its most astounding work is the shift it accomplished with respect to PrEP access for all and by all study participants enrolled for HIV vaccine research in South Africa. This landmark shift in the context of designing and implementing HIV prevention research is historical and a huge success worthy of celebration – a proof that the VARG through its members – the VARGers – has the potential to make landmark changes in the way HIV prevention research is designed and implemented in Africa.

Also present at the meeting was Ntando Yola, a founding member of APHA – a group of HIV prevention advocates working in South Africa; and Prince Bahati, a member of AAVVi.net – a group of researchers and advocates who are set to shape the science of HIV vaccine research in Africa.

While it is so heartening to see the evolution of these groups on the continent the hosts the highest number of HIV prevention research, it was clear that more work needs to be done to breed new and many young advocates on the continent. You find the same set of people belonging to the groups. This comes with its challenges – how novel and distinct can the concepts and ideas of these groups be? How do they deal with conflicts of interest? How do the organisations handle the financial resources from funders?

The AVAC Fellowship and PxROAR Africa programmes and the NHVMAS LeNNiB Champion project may be one of the many ways to address this time-limited challenge. Let’s look forward optimistically to what these networks, platforms, organisations, programmes and project is set to do for HIV epidemic on the sub-Saharan continent.

Setting the Standard: New prevention trials in the era of oral PrEP

There’s a lot going on in the world of HIV prevention research right now. The HIV vaccine field has launched a second efficacy trial—HVTN 705/HPX 2008—investigating a mosaic vaccine that could protect against clades of HIV from around the world. HPTN 084, a second trial comparing injectable cabotegravir to oral PrEP as prevention, this one among women, also recently launched across Southern and East Africa. These two trials join five other efficacy trials currently looking to expand the range of new prevention options.

At AVAC, we came out with our annual AVAC Report on December 1–our attempt at trying to untangle the mixed messages that have been circulating, and offer solutions to confront them head on.

The report touches upon an issue that has gained a lot of attention: how participants might access oral PrEP as part of HIV prevention trials. In the midst of all this activity, we thought it necessary to dive deeper into this issue. It may seem simple: trial participants have the right to the highest standard of HIV prevention and care as part of participation. Both the WHO/UNAIDS ethics guidance and the UNAIDS/AVAC Good Participatory Practice Guidelines for biomedical HIV prevention trials clearly outline this point. But the ethics, trial design issues and the mechanisms by which interventions are provided as standard of care are quite complex. Opinions differ and politics abound.

On November 2-3, the South African Medical Research Council (SAMRC) held a summit in Cape Town to discuss this very issue of standard of care in prevention and treatment trials in Southern Africa. Before the summit, members of the Vaccine Advocacy Resource Group (VARG) convened an Imbizo—a South African term for a gathering led by a traditional leader to discuss policy issues—to develop their position on what standard of care should be in prevention trials, and the role that communities and advocates should have in these decisions. AVAC attended both the Imbizo and summit to support the VARG and engage in the discussions.

The topic and tensions–and, for the most part, the players—are not new. Standard of care, and particularly when and how to integrate new interventions into the prevention package, has been discussed and debated for nearly as long as the research itself. What is new is stakeholders across prevention research coming together to reach consensus on not only the package, but on how it should be delivered. Traditionally, these conversations have been siloed. Ethicists made decisions based on their guidelines, statisticians based on trial design considerations, researchers on national context and available resources. Excitingly, there is a way forward from the summit that integrates the different interests of a broad range stakeholders. This is Good Participatory Practice in action!

The summit arrived at some concrete next steps. The SAMRC and the Fred Hutchinson Cancer Research Center (FHCRC and home of the HIV Vaccine Trials Network) will establish a trial-agnostic fund to cover the cost of oral PrEP and HIV testing for HIV prevention trial participants for the duration of the trial; trial sites and their communities will decide how to provide PrEP at their site—and this will likely look different at different sites; sites will be encouraged to work with implementing partners to optimize PrEP access and to support adherence; and South Africa researchers will work with the National Department of Health’s (NDOH) PrEP Technical Working Group to support establishment of demonstration projects closer to trial sites.

These are commendable and essential steps—and advocates, AVAC included, will be following them closely. As we continue to reflect, these are the questions and issues that remain at the fore for AVAC.

How ‘standard’ can standard of care be?

Decisions about provision of oral PrEP in clinical trials as standard of prevention, in particular, are happening as PrEP is being rolled out with great variability in the very countries in which the trials are happening. This creates operational and ethical complications—as well as exciting opportunities. Is there undue incentive if participants are offered PrEP in the trial, but PrEP is not available in the communities? Are researchers filling for the role of government—which is responsible for setting and improving the national standards of care? Within the same country, South Africa being an example, availability of PrEP can differ even between trial sites, potentially creating inequality in how participants in the same trials and in the same country get access.

The consensus from the summit is that rigid standardization is likely impossible; community and trial context have to be taken into account. Some sites do not have the capacity to provide PrEP on site, while some do. Some are close in proximity to demonstration projects and implementation sites and can create efficient linkages, while others cannot. The agreement is that trial sites, in collaboration with communities and local and national advocates, will work together to define a model of provision that ensures all participants who want PrEP can access it. This variability presents an exciting opportunity for sites to be innovative, and for the field to learn from different models of PrEP provision in real time.

But researchers, regulators and communities must also monitor execution of the PrEP plans to ensure that variation does not lead to inequality in access—and stakeholders at all levels must be linked and coordinated so there is constant learning and more efficient collaboration.

How should coordination look different moving forward?

As we move from discussion to action, partnerships are a must. Meaningful coordination will be especially critical among:

  • Advocates and researchers: Civil society is key to the HIV response at national levels. They can, and should, play a concrete role in how to connect prevention programs to trials. As both the ethical guidance and the GPP guidelines highlight, advocates and civil society should have voice in these decisions, and it was good to see that happen in the summit. True engagement, though, doesn’t just mean one meeting. It means a comprehensive, transparent plan for the ongoing role for advocates.
  • Trial sites and governments: Science does not happen in a vacuum; national policies have great impact on trial conduct, and as we have seen with HVTN’s proactive and progressive stance with regards to treatment in HIV prevention trials in 2003—researchers can also have an impact on national policy. SAMRC has committed to working with the South African National Department of Health to set up demonstration projects closer to trial sites.
  • Trial sites and local and national PrEP implementation and research activities: If PrEP cannot be provided onsite, mechanisms must be developed to connect participants to PrEP delivery programs and initiatives. Data and existing capacity from the research and implementation activities should also inform messaging and enhance counseling and adherence support.
  • National advocates and community advisory boards (CABs): To ensure PrEP plans are developed with meaningful and inclusive engagement, that CABs need to be linked to national advocacy agendas, and national advocates, in turn, to the clinical trial objectives and activities. VARG members are planning to follow up with CABs and community engagement personnel to ensure coordination and synergy across sites and communities in South Africa.
  • Regulators, ethics review bodies and funders: The decisions from the summit stand to impact trials happening across Southern and East Africa and those being implemented by multiple clinical trial networks. To promote equity and ensure adherence to core ethical and scientific values, regulators, funders and ethicists need to be coordinated across geographies and networks.

So, what?

AVAC’s position, as we outlined in our new report, is clear: while one research organization, product developer or funder cannot reverse global inequities in HIV prevention or care, researchers have an obligation—and an opportunity—to try to narrow the equity gap. Trialists must grapple with PrEP provision in clinical trials head-on; they should work with program implementers and communities to develop, implement and assess high-quality prevention and treatment models for participants in research programs, and can encourage the development of sustainable community access to good quality, comprehensive HIV prevention.

The summit was a good starting place. As advocates we will be following the implementation of the plans set out by MRC and HVTN—we will be making sure that stakeholders involved and affected by the decisions (from advocates to regulators to trial site staff) are engaged in a sustained manner, that trial sites are communicating with PrEP programs in their contexts, and that there is equity in access across trial sites and across countries.

As we anticipate how the next generation of PrEP products and other HIV prevention modalities will further complicate standard of care conversations, it is partnerships and transparency that will make research smoother and more relevant to the real-world context.

Further resources