October 31, 2014
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.
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.
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.