Setting Advocacy Priorities: PEPFAR Country Operational Plans 2017

This week in Johannesburg, South Africa, MSMGF, Health Gap, and AVAC gathered 15 advocates from Botswana, Cote d’Ivoire, Kenya, Uganda, Unites States, and Tanzania to prepare together to advocate for gay men and other men who have sex with men in their national HIV programs. This workshop came before US President’s Emergency Plan for AIDS Relief (PEPFAR) Country and Regional Operational Plan review meetings where officials from 23 countries will review and finalize PEPFAR-supported programs that will be implemented next year.

PEPFAR is the largest funder of HIV programs for key populations in Africa. The review meetings will be a critical opportunity for activists to voice their concerns and recommendations, and strengthen the way that their countries’ HIV programs respond to the epidemic among gay men and other men who have sex with men and funding to reach the right populations with the right services in the right places, right now. They come at a critical moment as the current US Administration’s proposal could potentially cut PEPFAR’s budget, signaling a dangerous diversion in the global AIDS response that will come at a great cost to human lives.

“The US contribution to PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria grew to $6.81 billion per year in 2016, making the United States the single largest contributor to the global fight to end AIDS. We all need to advocate tirelessly for the US to maintain its budgetary commitments to foreign assistance, the reversal of which could dismantle over a decade of progress,” said Matthew Kavanagh from Health GAP, United States.

“Over the past three years, PEPFAR country programs, have really improved. There are still gaps that we have to address, but we have seen that being involved early on can really strengthen the plans so that they are more effective at reaching men who have sex with men.” said Nana Gleeson from Bonela, Botswana.

Over one and a half days, participants priorities to advocate for in their own Country Operational Plans (COPs). These priorities will be raised in the next two weeks with their respective PEPFAR country teams. In addition, they identified the following common priorities which will be raised with the U.S Office of the Global Aids Coordinator (OGAC):

  • PrEP (Pre-Exposure Prophylaxis) should be included in the minimum package of services for men who have sex with men, and clear targets should be set for PrEP enrollment among this key population.
  • Data that describes the HIV treatment and prevention cascade for key populations should be collected and used in programing. Data should be based on reasonable population size estimates: Where population size estimates are implausibly low or unavailable, an estimate of 2-3 percent of the adult male population should be used in program planning.
  • There should be increased funding for community-led HIV responses among men who have sex with men.
  • Health care professionals should be trained to reduce stigma against gay men and other men who have sex with men, and to provide competent and tailored services to this group.
  • There should be increased engagement and participation of key populations such as men who have sex with men at appropriate entry points in PEPFAR processes.
  • Size estimate and epidemiology studies are critical, but researchers must recognize that in many countries MSM face criminalization and state-sponsored violence. Protecting human rights during research therefore often means avoiding the use of identifiers like biometrics that require MSM to disclose their identities in order to be counted in these contexts.

Over the next two weeks, MSMGF, Health GAP, AVAC and other global, regional and local civil society organizations will participate in PEPFAR regional review meetings, carrying forward the advocacy priorities that were generated in the meeting, and amplifying the voices of communities in the response to HIV. Together with our partners, we will continue to advocate that PEPFAR ensure that global health investments from the US Government to remain responsive to the unique HIV-related needs of gay men and other men who have sex with men living around the world.

Thai HIV Advocates Drop the PrEP Ball

Udom Likhitwonnawut has been working as a consultant for AVAC in Thailand on community engagement on HIV research for the past 5 years. He has been a member of the first community advisory board (CAB) in Thailand from its conception more than 12 years ago. He promotes community participation in HIV research and advocates for the implementation of GPP implementation in Thailand. He is a member of the National Subcommittee on HIV Vaccine Development and the National Subcommittee on Biomedical HIV Prevention representing the Thai NGO Coalition on AIDS (TNCA), the national umbrella organization for HIV/AIDS-related organizations. He is one of the founders of Thailand national CAB (NCAB) on HIV research.

Since the introduction of combination antiretroviral (ARV) therapy almost 30 years ago, antiretroviral drugs have been a key factor in saving lives and restoring the health of millions of people living with HIV throughout the world. In addition to treatment, antiretroviral drugs have been used successfully to prevent HIV transmission from mother to child. Furthermore, over the last five years or so, scientists around the world have shown that a popular ARV drug, Truvada, is safe and effective as pre-exposure prophylaxis (PrEP) to prevent HIV infections. A number of trials, demonstration projects and implementation studies in real world settings have confirmed the findings. As a result, Truvada as PrEP has been approved for prevention of HIV infection in many countries.

Thailand is a well-known poster child in fight against the HIV epidemic. Thailand is credited for being the first country in Asia to eliminate mother to child transmission. Several HIV research institutes in Thailand have been involved in PrEP research from the beginning. Given all this, it could be assumed that PrEP uptake and scale-up in Thailand would be smooth and trouble free. No serious objection was expected, least of all from Thai HIV non-governmental organizations (NGO).

Thai HIV NGOs have been in the forefront of the fight against the HIV epidemic from the early days. They fought for accessible HIV prevention and treatment for marginalized and at-risk populations such as sex workers, injecting drug users, undocumented migrant workers, people living with HIV/AIDS, and women and young people. Thai HIV NGOs were among a core group of civil society organizations that advocated for the establishment of the country’s universal health care program. Because of their advocacy for the universal health care program, ARV treatment and other medical treatment for people living with HIV are free of charge for all Thai citizens as well as migrant workers. With this track record behind them, it is astonishing that strong, albeit subtle, resistance for PrEP scale-up in Thailand comes from a few influential leaders of HIV NGOs. Small in number, these NGOs are vocal and influential. Their opinions are esteemed by government officials and fellow NGOs.

The resistance is not stated in public. Most of the objections to PrEP I have heard from these individuals during backroom talks or various office meetings or private discussions. Concerns, doubts, or cautions against PrEP that are said in public were vague and ambivalent. The objections are couched in cautious, well-intentioned terms such as stigmatization of PrEP users, short and long-term side effects, risk compensation and the possible increase in STI infections, effectiveness in real-world situations, and lastly fairness. At one community meeting on PrEP, I watched as a participant suggested the Thai coalition of AIDS NGOs issue a statement concerning PrEP. A leading PrEP critic, who is a well-known advocate for access to HIV treatment, objected that there was no need since PrEP, in his opinion, was a personal choice. However, he also added that PrEP users should be responsible for the cost and the government should not pay for PrEP. This critic and others are not mentioned by name because they are important figures in the fight against HIV in Thailand. No one wants to jeopardize the response to HIV by alienating them.

Initially, objections centered on concerns that PrEP was a ploy to sell a drug that’s market had plateaued. Then critics shifted their concerns to questions about side effects and risk compensation. They gave voice to a myth that PrEP is a lifelong medication (actually, individuals can choose to use PrEP only during a period of time when the risk of exposure to HIV is high). This purportedly lifelong commitment was contrasted with condoms, which are effective as-needed. Later objections focused on HIV resistance. Finally, the critics talked about fairness and justice. They worried that finite resources would be siphoned off for HIV negative people. People living with HIV need ARV drugs for treatment as a matter of life and death. Wouldn’t they come up short, the thinking goes, while HIV-negative people received Truvada even though condoms would protect them just as well.

Let’s start by addressing this wishful thinking that condoms can do all the work of prevention. PrEP critics are ignoring the fact that some people have no choice; if they insist on using a condom some risk abuse from partners or customers. Some people have to engage in condomless sex in order to earn money for a meal or a place to sleep.

As for costs, the generic version of Truvada (Teno-EM), manufactured by a government agency, is widely available and much cheaper than Gilead’s Truvada. A one-month supply (30 tablets) of Teno-EM is Baht 630 (US$18). Meanwhile, people living with HIV who need ARV drugs for survival get them for free in Thailand, something PrEP critics seem to conveniently disregard. ARV treatment is not only free, it’s available to all people living with HIV at any CD4 level. When it comes to treatment access, the main problem is that a number of people don’t seek treatment due to a variety of reasons or are not aware of their status.

The latest reason cited in objecting to PrEP is that it will lead to HIV drug resistance and HBV drug resistance. Opponents claim that PrEP users will be poorly screened for HIV, will have poor adherence, or that their status will be poorly monitored. Each of these factors could contribute to the development of drug resistance. Finally, the critics assert that PrEP advocates and supporters talk only of the advantages, omitting the damaging effects of Truvada PrEP. Research results on adherence, side effects, and risk compensation, available to the public thru various venues, are snubbed by critics as unsubstantiated or cherry-picked by PrEP advocates.

Instead of Truvada PrEP, critics insist that condom use is the answer to preventing HIV infection. Condoms are cheaper, they say, and suitable to everyone on every occasion. For them, the problem is not that some people don’t or can’t use condoms, the problem is only a shortage of supply. They insist that, with enough condoms, there will be no new HIV infections. Despite their long experience with issues related to the dynamic of the HIV epidemic in the country, they persist in this oversimplified and naïve claim. It verges on chemically-induced hallucination.

They certainly cannot point to a lack of information about PrEP research to justify their apprehension. Information about PrEP research is available in many venues and formats. Though much of it is in English, a substantial amount is available in the Thai language, particularly on a variety of websites and YouTube. Furthermore, many PrEP critics are members of HIV Community Advisory Boards (CAB) and members of a few national committees related to HIV and public health. PrEP critics, if they want, could be well informed about PrEP research.

On several occasions, facts or news about PrEP were reconstructed by PrEP critics to fit their narrative against PrEP. A few examples deserve additional details here.

When the UK National Health Service (NHS) decided not to provide PrEP, the news was celebrated and circulated widely among Thai NGOs. The ensuing discussion never acknowledged that PrEP safety or effectiveness was never challenged by the NHS, only who should pay for it was at issue. Subsequent news, including UK court decisions that NHS can provide PrEP and the launch of a PrEP program that will reach a minimum of 10,000 people over three years, has been ignored by these Thai critics.

When news hit of a rare case of ARV resistant HIV appearing in a PrEP user, critics cited it repeatedly to discredit PrEP. The discussion focused only on one single issue that PrEP could lead to HIV drug resistance and other details were omitted.

A couple months ago, a leading PrEP critic, a well-known HIV activist and human rights advocate, together with a few consumer rights advocates, lodged a formal complaint with the Thai FDA about an educational video on YouTube, produced by an esteemed HIV research institute. They said it was misleading and irresponsible, comparable to false advertising because it explained the benefits of PrEP but not the risks. As a result, the video was removed from YouTube.

PrEP critics are determined to employ any means or tactics to derail PrEP uptake and scale-up. A few prominent PrEP critics who are also members of key national committees related to HIV or public health have declared they will oppose any government plan or HIV prevention budget that includes PrEP delivery.

Could it be that PrEP is guilty only by association? The leading HIV NGOs have been fighting with Gilead and other pharmaceutical companies over access to affordable ARV drugs for many years. The fight still lingers, and it extends beyond ARV drugs to direct acting antivirals for the treatment of hepatitis C infection (HCV) as well. The fight is often confrontational and acrimonious. Gilead, the patent holder and manufacturer of Truvada and several drugs used in HIV and HCV therapies, represents a boogeyman for HIV and hepatitis treatment advocates in Thailand. (It’s worth noting, these PrEP critics stand alongside other critics who had a problem with one PrEP trial in particular, the Bangkok tenofovir study (BTS). BTS was investigating the efficacy of PrEP as HIV prevention among drug users. Advocates for the drug using community had a number concerns about the commitment to harm reduction and the consent process. But the efficacy of PrEP itself was not a chief concern for those criticizing of BTS.)

Then again, maybe a conflict of interest is undermining support for PrEP. A few PrEP critics have been advocating for a national condom fund. PrEP scale-up could weaken or jeopardize their plan. Admitting that PrEP may be an important option for certain populations suggests condoms are not a perfect solution, as they obstinately insist.

Despite the criticism, a number of HIV NGOs have stepped up to support PrEP. Some are involved in demonstration projects or implementation studies. Most of them are less influential NGOs and prefer to remain silent or defer to the more experienced and better-known NGOs on most issues, including PrEP. Some of the silent PrEP supporters are key partners of community-based PrEP projects being implemented in the country now.

It is important to point out that the PrEP critics have done many good works for HIV-affected people and communities. It is unfortunate that they let their prejudice against pharmaceutical companies and their hidden agenda for a national condom fund to override the scientific evidence. Currently, these vocal PrEP critics prefer to throw up obstacles from the sidelines while others to carry the ball forward. It is up to the silent majority to work together with other stakeholders in delivering PrEP to people who need or want additional HIV preventive tools. The discussion related to PrEP should be framed to include PrEP and condoms as well as other prevention options, instead of creating a PrEP-or-condom dichotomy as it is being framed today.

Dear HIV Researchers, To Do Effective Research – Engage Us

The annual Conference on Retroviruses and Opportunistic Infections (CROI) is an annual gathering where advocates and researchers learn where the science on HIV is taking us. The findings can be both grand and granular. They answer questions, raise new ones or both. And not all of those questions are strictly about science. Two of AVAC’s partners have been reflecting on what they took away from the conference, insights that inform our thinking long after the sessions end and results are published.

Julie Patterson is an HIV prevention research advocate and public health professional who lives in Northeast Ohio. She is chair of the Case Western Reserve University/University Hospitals of Cleveland AIDS Clinical Trials Unit’s Community Advisory Board, a member of AVAC’s PxROAR program, and a member of the US Women and PrEP Working Group.

Recently, I had the opportunity to attend the Conference on Retroviruses and Opportunistic Infections (CROI) as a community educator scholar. It was a grand experience – a gathering of brilliant, hard-working research minds at one of the premier HIV scientific meetings that are held each year. It was truly an honor to be among them.

However, I’m not sure my presence was felt.

A cohort of us came to CROI to give voice to community needs and bring new research back to our communities. We see it as a two-way street.

On the first day of CROI, there is a workshop held for newer researchers called, “Program Committee Workshop for New Investigators and Trainees”. People awarded the Young Investigator and International Delegate Scholarship are required to attend in order to get an introductory overview of the conference, what to expect in the days ahead, and a primer on aspects of the science that may be unfamiliar. The attention is on the science and the scientists—new investigators and clinicians who are actively involved in research. The organizers encourage participants to ask questions because lab scientists aren’t always aware of the issues in epidemiologic research, virologists speak a slightly different tongue than immunologists. You get the idea.

Not surprisingly, community educators are also required to attend the workshop for new investigators. This is a great idea; the nature of these talks is more general than others at the conference, and provides a foundation for understanding key results. Unfortunately, the structure often does not allow the presence of community educators to be known. Sure, we ask questions, but mostly we are like ghosts – ethereal beings with messages from the past. Not quite real. Certainly not equals.

This year, in what I perceived as an attempt to turn this CROI norm on its head, one of the crucial lectures included in the workshop was centered on GPP—Good Participatory Practice. It was led by community activists, grounded in the lives of people living with HIV, and aimed squarely at the new investigators, and with this I agree wholeheartedly. The Martin Delaney Lecture honored his legacy and brought the attention back around to the communities who are struggling with HIV, to the people who are at the heart of this epidemic. The message: listen to community stakeholders, and you will hear what you need to know. Ignore them, and your research results will suffer. We will all suffer.

I was disappointed that this vital talk was held during lunch when many left the room to pursue other food options. Most of the awardees of the Young Investigator and International Delegate Scholarship stayed to eat a free box lunch, but the timing appeared to indicate that this lecture wasn’t as important as the others. It would have been easy to miss it and not be held accountable.

Researchers, I’m here to say that you are accountable to us. We need you on our side and to see this through to the end. Our goals are the same—we want to end this HIV epidemic, to roll out a vaccine that will prevent new infections, to find a cure that works for everyone, to lead happy, healthy and long lives full of purpose and meaning, full of love and adventure. We want to see all of it in our lifetimes, just like you.

I tend to follow HIV prevention and public health research closely, so those were the sessions that I attended. Time and again, I sensed the urgency in the tone of the presentations. For that I am grateful. We must continue to push forward. Yet I also heard something else, even from prominent scientists—a scientific expediency that can leave communities behind.

Two significant HIV prevention clinical trials that are currently being conducted under the umbrella name of the “AMP Studies”—HVTN 704/HPTN 085 and HVTN 703/HPTN 081 are a case in point. I sit on the Community Working Group for these trials that are studying the efficacy of antibody mediated prevention. The HVTN 704/HPTN 085 trial is recruiting cisgender heterosexual women at risk in South Africa. In the US, Peru, Brazil and Switzerland, HVTN 703/HPTN 081 is recruiting cisgender men and transgender people who have sex with men.

Unfortunately, on multiple occasions at CROI, when I heard researchers refer to the AMP Trial, they neglected to mention the involvement of transgender people.

This may seem like a small oversight. Surely it is acceptable to use shorthand amongst fellow researchers? Everyone knows that referring to MSM as the target population for recruitment in this situation includes transgender people, right? Wrong. Transgender and gender non-conforming (TGNC) people don’t necessarily assume it. We all need to see ourselves in HIV prevention research.

Will this study collect data in such a way that we can separately analyze findings that are specific to TGNC participants—if not,we will have lost an invaluable opportunity. Will TGNC people at risk for HIV see results from AMP as applicable to their lives? If our experience with PrEP is any indicator, the answer is no, unless the investment continues to be made in TGNC people. AMP has included TGNC stakeholders early in the research process- from choosing research questions to protocol development, from design of informed consent to rollout of marketing materials. Now advocates are watching to ensure that it continues—from interpreting results to follow-on studies and implementation, all the way to the next trial. Every step of the way. Every step.

The AMP Trial has helped to set a new standard for transgender inclusion in HIV prevention research, but it is only one example of how GPP can be utilized. There are so many more. Community stakeholders have to be involved at every step.

In the end, researchers, my message isn’t to watch your step, it’s to walk alongside us. We can’t do it without you, and you can’t do it without us. As community stakeholders, we bring information to the table that you may never know without our voices. Knowing it up front will make the science more efficient, more ethical, and better in the long run.

For over 30 years, HIV research has been on the cutting edge of engaging affected communities and working together with activists. We need to keep that momentum going. I look forward to it.

Editor’s Note: AVAC’s Stacey Hannah led the presentation during the session on Good Participatory Practice (GPP). GPP is a set of guidelines developed by AVAC and UNAIDS in 2007 to engage affected communities and all other stakeholders in the design and conduct of biomedical HIV prevention trials. GPP has been widely adopted and is instrumental to a research process that yields trusted results.

A Steady Hand of Advocacy in Uncertain Times: HIV Vaccine Awareness Day 2017

[UPDATED] This post now includes recordings of previously held webinars.

This year will mark the 20th anniversary of HIV Vaccine Awareness Day (HVAD). On this May 18, as HIV prevention advocates we find ourselves in new terrain when it comes to vaccine research—both in terms of scientific progress and the challenging political environment. We’ll be highlighting these important issues in an HVAD webinar series leading up to and ending on May 18—read on for full information and to register.

As we look back on the 20 years since President Bill Clinton called for accelerating HIV vaccine development, AVAC recognizes that, now more than ever, we need steady hands and supportive voices to back this long-term, challenging, essential endeavor. Can you help us identify the next HIV vaccine champions? Are you one of them?

This year we are celebrating HVAD, not only on May 18, but throughout the month leading up to it (and beyond). We promise not to inundate you! But we recognize the “breadth and potency” of the current research landscape and the many events that will happen around the globe to mark the momentous day. We want to keep you in the loop.

We’ll provide research literacy tools; share AVAC’s take on developments in the field; and host a series of webinars to discuss key issues in vaccine research and advocacy. Please register, mark your calendars, and have your questions ready.

Recordings of previous webinars available here:

  • Ad26 Mosaic Program—Janssen’s Maria Pau discusses preparations for the next efficacy trial
    April 28 – YouTube / Audio / Slides
  • The History—and Future—of the NIH’s Vaccine Research Center with Barney Graham
    May 4 – YouTube / Audio / Slides
  • Building on (and Building!) Success—Status of HVTN 702 with Fatima Laher
    May 8 – YouTube / Audio / Slides
  • “Plan B”-NAb? An Overview of Antibody Research with Lynn Morris
    May 11 – YouTube / Audio / Slides
  • An Overview of Vaccine Development with Julie Ake of MHRP
    May 18 – YouTube / Audio / Slides

We hope you’re looking forward to the month ahead as much as we are! Talk soon.

MTN Annual Meeting: Presentations Available

The Microbicides Trials Network (MTN) held its Annual Meeting on March 20-21, 2017 in Bethesda, MD. You can find slides from the presentations on the Annual Meeting page of the MTN website, http://www.mtnstopshiv.org/2017annualmeeting.

Webinar: CDC and WHO Review Current PrEP Guidelines

In February, hundreds of people tuned in to hear researchers discuss the available data on “time to protection” required for effective oral PrEP with TDF/FTC—i.e., how many doses must be taken to build up protective levels of the drug in the blood? The answer is—it varies. Not surprisingly then, so do the guidelines for PrEP use.

As webinar participants learned, the data are varied and subject to interpretation. The World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) recommend different time frames to reach protection in their respective guidelines for oral PrEP use. Both of these recommendations are based on measurements of the amount of drug that accumulates in blood and/or tissue over a specific period of time. The studies of how drugs are taken into the body and how they leave the body is called “pharmacokinetics” and “pharmacodynamics” or “PK” and “PD” for short, as explained in our primer for advocates. There isn’t a single PK measurement that is associated with PrEP protection—so both WHO and CDC guidelines are based on inference.

In a follow-on webinar presentation and Q&A, representatives from both CDC and WHO reviewed their respective guidance development processes and the role, use, contexts and audience for guidance documents.

The Recording: watch on YouTube, listen to an mp3 version or download the slides. Q&A starts approximately 55 minutes in.

HVTN Regional Meeting – A View from the Outside

This blog is the first in a series of reflections from AVAC staff and members of the Vaccine Advocacy Resource Group (VARG) on the regional meeting of the HIV Vaccine Trials Network (HVTN), which took place in Johannesburg from February 28 to 1 March 2017.

AMP. Licensure. Enrollment targets. Success.

These were a few of the buzz words from the HIV Vaccine Trials Network (HVTN) regional meeting last month. This meeting, the first of three the network will convene in 2017, was held in Johannesburg, highlighting the HVTN’s build out of programs in sub-Saharan Africa—and the significance of an HIV vaccine for this region.

As network meetings go, the audience for this meeting was largely internal; a chance for HVTN core staff and leadership to celebrate key milestones, particularly around the network’s two large efficacy studies—HVTN 702 and the Antibody Mediated Prevention Trials (AMP)—with their clinical site partners.

While advocates are not the primary audience, the HVTN allows us to attend plenaries and other open sessions. AVAC and civil society partners look to these meetings to hear updates, interact with research teams, and continue to build our research literacy and our translation and liaison roles in the HIV vaccine field.

To advocates—both from AVAC and the Vaccine Advocacy Resource Group (VARG), a global team of HIV prevention advocates—looking in from the outside, this meeting underscored the intensity of resources necessary to make clinical trials happen and allowed us to get a sense of how the vaccine field sees itself.

What follows are impressions from AVAC and a few VARG members from our times in meeting rooms—and in hallways.

AMP. The AMP trials are in an exciting place—exceeding enrollment targets across all sites, both in the Americas and Southern Africa, and maintaining high retention and adherence. While we are thrilled about the trials’ current success, and intrigued by passive immunization as a potential prevention strategy, we felt a gap in communication from the trial’s architects about how to situate it in the broader field. AMP is testing a 30-60 minute infusion of an antibody called VRC01 that is administered every two months for just under two years. While there was much discussion about this particular antibody and others in development, it’s not yet clear how researchers will build on the AMP results to deliver a feasible prevention option. We were left with questions about what will happen with VRC01 if the trial shows efficacy, as its dosing schedule makes it hard to imagine as a real world tool. There are also more powerful antibodies and easier methods of administering them that are being explored. We want to be sure that the goals and follow up steps of AMP are well articulated and understood. Watch this space—it is sure to evolve quickly!

HVTN 702. The first vaccine efficacy trial in seven years is now in its 22nd week of enrollment. As 702 sites continue to get started and data from the precursor trials, RV 144 and HVTN 100, continue to provide more clarity on mechanisms of improving immunogenicity, we note a need for cautious optimism. While 702 presents a possibility for moving toward a licensed vaccine, we were a bit concerned about the hopes being raised about this trial, and feel strongly that the messages should convey realistic expectations. Licensure is the ultimate goal, but we have to closely watch, and accurately translate, the data for ourselves and to our communities. If we’ve learned one thing from HIV vaccine research, it’s that we never know what to expect!

PrEP Access. Finally, let’s talk about oral PrEP—researchers certainly did at this meeting. Access to PrEP is (slowly) becoming a reality in trial communities all over the world—and the HVTN, and all trialists, are grappling with how to incorporate PrEP into trials, especially as this context evolves at national, community, and individual levels. As research advocates, we know that the trial context rarely reflects the real world. While we commend the AMP and 702 teams for exploring ways to connect trial participants to mechanisms for PrEP access, we see a necessity for a more rigorous and urgent commitment to link national and local PrEP programs to participants who need and want it.

Note: This is a crucial area that advocates are watching, and where they can and need to help research teams. Without taking PrEP into account and ensuring that communities have input, clinical trials run the risk of being viewed as skirting larger community needs as well as ethical and human rights obligations.

Now that the meeting is wrapped, and we’ve had a couple of weeks to reflect, we’re left with the feeling that the field appears too siloed. The conversations around antibodies and vaccine candidates seem to be happening in isolation from larger dynamism in the field and the very communities where trials are taking place. The rich and rapidly iterating prevention research environment needs an HIV vaccine—and an HIV vaccine needs this exciting environment.

What’s New on AVAC.org

We’ve posted several new resources on AVAC.org that you won’t want to miss.

1) The WHO’s recently released guidance on the use of hormonal contraceptives in women at risk of HIV has prompted a great deal of interest from advocates working in HIV prevention and women’s sexual and reproductive health and rights. We have several new resources that address this complex issue.

2) Advocates continue to work to understand the difference between the US CDC and WHO recommendations about the number of doses that new users of daily oral PrEP need to take to achieve reliable protection. In our webinar, Time to Protection for PrEP, pharmacologists take you through their data. Check out the recording as prelude to our upcoming webinar, Time to Protection Part 2, which follows up on this issue on Tuesday, April 4, 9am US ET / 3pm CET. Tune in to hear representatives from the CDC and WHO review current PrEP guidelines.

3) And on our blog, P-Values, don’t miss Micheal Ighodaro’s post, Building Solidarity Between African American Gay Men and African Gay Men Through PrEP.

Too Little Data and Old Strategy on Prevention for MSM in Africa: Time for change

Despite decades of advances in HIV prevention, HIV continues to burden gay and bisexual men disproportionately, especially younger gay men, and men who have sex with men. This is truly a global health issue—applying equally to the US and to Africa. Vulnerability to HIV exposure is propelled by key structural drivers: antigay stigma laws, poverty and inadequate understanding of how to prevent HIV.

One major difference between the epidemics among men who have sex with men (MSM) in the US vs Africa is the level of information available. In the US, HIV was first diagnosed in gay men and there are decades of data, including on racial disparities. Yet in every report that I read about gay men and HIV in Africa, there is always this disclaimer: “Data on men who have sex with men (MSM) is very limited for sub-Saharan Africa.” This famous line is getting boring!

I remember when I was preparing for my AIDS 2016 plenary presentation and was looking for the most up-to-date data on MSM on the continent. It felt like I was looking for a pin under the ocean! And of course, only a handful of people had information for me, including Chris Beyrer and Linda-Gail Bekker (the immediate past and current presidents of IAS) and Stefan Baral, who I like to call the data guru (Stefan is Associate Professor at John Hopkins) and friends at MSMGF. My good friend Brian Kanyemba (a former fellow of AVAC who now works with the Desmond Tutu HIV Center in South Africa and Advocacy for Prevention of HIV and AIDS-APHA) and I were moved to tears in Zimbabwe during the African AIDS Conference when MSM where not mentioned at all at the opening ceremony by one of our most important allies, Michel Sidibe who is the current Executive Director of UNAIDS.

The very few data that exist give us evidence of emerging HIV epidemics among MSM, often in settings marked by discrimination, homophobia and criminalization. MSM in Africa are understudied, tokenized and then often denied a more meaningful role in advocacy because they are told they lack adequate capacity! High HIV prevalence among MSM in Africa is evidence that prevention strategies are failing to reach this group. Real prevention—prevention that works—demands real engagement with MSM in Africa. This means counting our numbers and supporting the development of leadership among MSM advocates, and sustaining a comprehensive dialogue with the MSM community on the subject of prevention. It’s time to respect gay men in Africa.

What will HIV prevention mean for gay men and other MSM in Africa?

For many of them, that still means using condoms consistently with lubricant that is most times not available! But as we know around the world, HIV prevention has gone far beyond condoms and lubricant, so you might want to ask why Africa isn’t moving along with oral PrEP? In fact, Africa is making some hard-won progress. Activists on the continent are engaging in discussions about HIV prevention through AVAC’s PxROAR Program and more. PxROAR trains US, European and African partners in HIV prevention research and implementation advocacy through mentorship, peer support, networking opportunities and technical and financial assistance.

To go beyond condoms and lubricant, activists are getting involved and learning about prevention research, about PrEP, about cure, about vaccines and long-acting injectables. But is that enough? What else can we do?

It is time to go back the drawing board. We can build on some of the success we’ve had in the past and go further. PEPFAR now has funds directed to key populations (KP), groups such as gay men or sex workers who are considered vulnerable to HIV. These KP funds can be used to build and improve upon programs like PxROAR. We need a targeted effort to inform and work with Africa MSM beyond the known faces. We need to engage with a hidden generation, invite them to conferences like CROI, HIVR4P and IAS, provide direct funding to understand and overcome barriers to HIV prevention for KPs in Africa. If we really want to help, then MSM must participate directly in the design of that help. AVAC is creating new opportunities through the PxROAR Program and other initiatives to inform and work with Africa KP around HIV prevention research, would you join us?

Capsules from CROI 2017

The annual Conference on Retroviruses & Opportunistic Infections (CROI) took place in Seattle from February 13th-16th, offering a dizzying parade of new data. Access available here.