Investment in Women-Focused PrEP R&D, 2017

Out of the US$63 million invested in PrEP overall, US$16 million (or 25 percent) was for research explicitly focused on women. Most of this research was preclinical, with an emphasis on discreet products with long-acting formulations, e.g., PrEP implant studies and long-acting injectables. Almost 30 percent of the implementation studies focused on the uptake of and adherence to oral PrEP in high-risk women, and 15 percent focused on PrEP for pregnant and breastfeeding women.

The full report, HIV Prevention Research & Development Investments 2017: Investing to end the epidemic, is available for download. And all the graphics are available as well.

Prevention Research Funding Report 2017: Investment slows and continues to concentrate in a few funders!

[UPDATE]: The new report was a feature story by UNAIDS, Global HIV prevention targets at risk.

Today, the Resource Tracking for HIV Prevention R&D Working Group (Working Group) launched its 14th annual report—which details 2017 investments—at the HIV Research for Prevention (HIVR4P) conference in Madrid.

Flat and/or reduced funding for HIV/AIDS and other global health issues threatens to roll back progress worldwide. There is belated and widespread acknowledgment of a prevention crisis that can only be addressed by taking today’s tools to scale while researching new ones. Given this backdrop, the report is a powerful advocacy tool. This year’s report notes troubling trends in investment flows for biomedical HIV prevention at a moment of major promise in the research landscape. The report tracks the origins, trends and direction of global funding as well as the resulting effect(s) on the prevention research funding landscape.

Key Findings
The report shows that funding for HIV prevention research funding declined for the fifth consecutive year—and by 3.5 percent in 2017 to US$1.13 billion—the lowest total observed since 2005. This reduction was unevenly distributed. Investment increased for pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision (VMMC) but decreased for AIDS vaccines, microbicides, prevention of vertical transmission (PMTCT), treatment as prevention (TasP) and female condoms.

The overall decline is driven largely by a reduction in US public-sector funding, with levels dropping by 5.8 percent from 2016 to US$830 million. This is a five-year low in investment. Outside the US public sector, another major decrease came from the European Commission, with funding levels dropping by 47 percent to US$7.6 million in 2017. The impact of these cuts was cushioned by increases from Australia, Brazil, Canada, Japan and the Netherlands. While the number of philanthropic donors decreased from 12 to 10 in 2017, levels of funding grew by 4.1 percent to US$164 million or 14.6 percent of overall funding. This is largely due to the 6.6 percent increase in investment from the Bill & Melinda Gates Foundation.

The report notes that the HIV prevention R&D space is at an exciting yet precarious juncture. Ongoing late-stage efficacy trials for preventive AIDS vaccines, long-acting injectable PrEP and antibody-mediated prevention could yield new options in the coming years. Then there’s also the dapivirine vaginal ring that is currently awaiting a regulatory opinion from the European Medical Association. However, the current funding landscape is not set up for sustainability or longevity, which is essential to help ensure that new products move from research and eventually to those who need it. Out of every dollar spent on HIV prevention research, 87 cents are from the two biggest donors, the US public sector and the Gates Foundation—a literal case of having all the coins in one basket. The report advocates for diversifying the funding base and developing long-term funding strategies to support the delivery of innovative prevention tools and a durable end to the epidemic.

The Resource Tracking Working Group hopes these reports will serve as tools for advocacy and be used to inform public policy that supports and helps to accelerate scientific progress. We thank all of the individuals who contributed data to the report and who gave time and effort as trial participants.

Check out the report, share it with your fellow advocates, and be sure to let us know if your organization is a funder or recipient of HIV prevention grants, or if you have further questions!

We are kicking off the launch of the report with a press conference at HIV R4P, which can be viewed live at the conference Facebook page and will be archived on the conference website.

Press Release

Continued declines in HIV research funding put global prevention targets at great risk

Contacts

AVAC: Kay Marshall, [email protected], +1-347-249-6375
IAVI: Anita Kawatra, [email protected], +1 212-847-1055

Madrid – HIV prevention research funding continued to decline in 2017 for the fifth consecutive year, driven largely by a five-year low in US public sector funding, according to a report released today at the HIV Research for Prevention (HIVR4P 2018) conference in Madrid, Spain.

The Resource Tracking for HIV Prevention R&D Working Group’s 14th annual report, Investing to End the Epidemic, documents funding that fell to the lowest level in more than a decade: In 2017, funding for HIV prevention research and development (R&D) decreased by 3.5 percent (US$40 million) from the previous year, falling to US$1.13 billion.

This declining funding comes at a time of great optimism for research, with a slate of efficacy trials across the prevention pipeline – including major HIV vaccine, passive antibody and next generation PrEP efficacy trials – and critical follow-on research for proven antiretroviral-based prevention options, notably the dapivirine vaginal ring. But it also comes a time when the broader HIV field is grappling with a prevention crisis that is exacerbated by decreased funding for the overall HIV response and a lack of political will to adequately fund a response that will ensure the world meets the ambitious prevention targets to end the epidemic.

The Working Group warns that getting to zero new infections will not only require the expansion of existing options like voluntary medical male circumcision (VMMC) and oral pre-exposure prophylaxis (PrEP), but also the development of innovative new products, including long-acting, antiretroviral-based prevention options and a vaccine. Sustained funding is critical to keep the full gamut of HIV prevention research moving forward in a timely manner. Even small declines in funding can delay or sideline promising, new HIV prevention options that are needed to end the HIV epidemic.

“Make no mistake. We are in a prevention crisis and we cannot afford a further funding crisis,” said Mitchell Warren, AVAC executive director. “It is unacceptable that donor funding for HIV prevention research continues to fall year after year even as research is moving new options closer to reality. We need continued and sustained investment to keep HIV prevention research on track to provide the additional tools that are required for sustainable, durable control of the HIV epidemic.”

The US government continued to be the major funder of HIV prevention research, contributing almost three-fourths of overall funding. A decrease of almost six percent, though, brought funding to a five-year low of US$830 million. The Working Group noted that sharp declines in US government funding have a major impact on the biomedical HIV prevention R&D field. With uncertainty around continued political will to fund the HIV response, this trend is extremely worrying.

Together, the US public sector and the Bill & Melinda Gates Foundation (BMGF) represented 87 percent of the total global investment in 2017, an imbalance that has continued for several years. The Working Group in this year’s report cautioned against the disproportionate impact of shifting donor priorities by these two donors on cutting-edge research, noting that a US$50 million decrease in vaccine R&D in 2017 was largely attributed to cuts from the US government, while a 67 percent increase in VMMC funding in 2017 is due largely to enhanced investment from BMGF. The Working Group renewed a call to diversify the funding base to ensure both the sustainability of the field and that decades of gains made in scientific innovation are not lost to fluctuating investment.

The Working Group noted with concern that funding by the European Commission (EC) dropped by almost half from 2016 to 2017 (US$14.4 million in 2016 to US$7.6 million). Noting increases in public sector funding from Canada, Brazil and the Netherlands, the Working Group called on other European countries to increase investment in critical HIV prevention tools to help end the epidemic and to offset the drop in EC funding.

“A true end to AIDS will only be possible if we can develop and deploy an effective, accessible HIV vaccine and other biomedical innovations to prevent HIV infection,” said Mark Feinberg, M.D., Ph.D., President and CEO of the International AIDS Vaccine Initiative. “Decades of research are paying off with the most exciting advances we’ve seen to date. But progress can only continue with sustained public and private sector investment in HIV prevention R&D.”

As researchers, implementers, advocates and funders gather this week in Madrid to review progress in HIV prevention research, there is much to be optimistic about in HIV science and in the accumulated knowledge of how to end the epidemic. At the same time, sobering changes in the funding and policy environment could imperil future progress and wipe out the progress made. Funding constraints, policy changes, shifting donor priorities and shifting demographics will all play a role in the world’s ability to respond to the continued challenges that HIV presents.

“With 5000 people becoming infected with HIV every day it is critical that we both scale up the effective HIV prevention programmes we currently have and invest in new technologies and solutions so that they can become a reality for the populations most affected by HIV,” said Tim Martineau, Deputy Executive Director, Programme a.i. UNAIDS. “Doing both will avert new infections, save lives and reduce the rising costs of life-long antiretroviral treatment.”

The report and infographics on prevention research investment are online at www.hivresourcetracking.org and on social media with #HIVPxinvestment.

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Since 2000, the Resource Tracking for HIV Prevention R&D Working Group (formerly the HIV Vaccines & Microbicides Resource Tracking Working Group) has employed a comprehensive methodology to track trends in research and development (R&D) investments and expenditures for biomedical HIV prevention options. AVAC leads the secretariat of the Working Group, that also includes the International AIDS Vaccine Initiative (IAVI) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). This year’s report is additionally made possible by the support of several donors, including the Bill & Melinda Gates Foundation and the American people through the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID). The contents are the responsibility of AVAC and the Working Group and do not necessarily reflect the views of PEPFAR, USAID or the United States Government. AVAC does not accept funding from the pharmaceutical industry.

Towards a Demand Creation Cascade

Many countries report low initiation and continuation of PrEP. This doesn’t mean people don’t want the product. They might not want the program that’s offering it; or they might not be being reached. A “demand-creation cascade” such as the one proposed here for PrEP is one way to evaluate the program and the product. It would measure how many people received the full suite of demand-side activities the program hopes to deliver at a given stage. The precise set of steps would depend on the service-delivery design and strategy in question.

Phases of Informed-Choice PrEP Counseling

This flow chart emerged from socio-behavioral research, including surveys and in-depth interviews with Kenyan and South African women. The research team set out with the goal of adapting the informed-choice approach used in family planning programs for use in PrEP, a prime example of fields learning from each other. The result is very clinic-centered; AVAC has added the column at the far right to reflect additional elements. However, it is a step towards much-needed exploration of how to make informed choice a reality in HIV prevention today.

Putting Women at the Center: Informed choice in 2018 and beyond

We need to give women the choice to use DTG or not and to use contraception if indicated and desired. We need to support choices across options, with risk reduction—not use of a specific product—as the primary outcome. We need to give women the choice to use DMPA-IM or –SC or not, and to use HIV prevention as desired.

No Prevention, No End – AVAC launches new report and call to action

Today AVAC released No Prevention, No End, our 2018 annual report on the state of the field. Starting from the title—which humbly borrows the cadence of the call for an end to state-sanctioned violence against Black Americans, “No Justice, No Peace”—through to the closing words, “This is the worst possible moment for slowing down,” the Report is a call to action and guide for addressing the HIV prevention crisis that threatens progress in curtailing epidemics worldwide.

Click here to download the Report and individual sections and graphics; click here for a new episode of the Px Pulse podcast which covers the Report’s key themes and features lead author Emily Bass, AVAC’s Director of Strategy and Content.

UNAIDS named the prevention crisis in its July 2018 report, Miles to Go. It acknowledged that the scale-up of antiretroviral treatment, while essential, is insufficient as a prevention strategy. AVAC has been warning of an imbalance in approaches and investments across approaches, and calling for ambitious targets matched with political will, financing, timelines and more since the UNAIDS targets were first launched in 2014. (Check out AVAC Report 2014/5: Prevention on the Line for a summary of this critique of targets.)

In this year’s Report, we call out three core problems with primary prevention and the global HIV response, identifying the risks they bring and the path to a solution. Specifically, we focus on:

  • Investing in demand creation: The private-sector gloss on this term cannot obscure its essential role in making primary prevention work. Strategies that might save lives are condemned as unwanted or unfeasible when they’re delivered in programs that lack integrated demand-side thinking, which is a science and not a set of slogans.
  • Making informed choice central to HIV prevention: Programs that offer more than one option, along with a supportive environment for a provider and client to discuss risks, benefits and personal preferences aren’t a luxury but a necessity. The family planning field has metrics to measure choice; HIV should pick these up, with prevention programs leading the way.
  • Unstinting radical action: Progress in the global AIDS response is tenuous; so is the state of democratic institutions and the future of the planet. These interconnected issues require more bold action, including from countries that are aid beneficiaries, and from the citizens of those countries who unite to hold truth to power. In the HIV prevention context, this means accountability for primary prevention at every level, including research for next-generation options.

AVAC is launching this Report as many stakeholders in HIV prevention research gather in Madrid for the HIV Research for Prevention (R4P) conference. Visit our special R4P page to find us on-site and follow along from afar, to see how the themes of this year’s Report resonate in a global and wide-ranging discussion of HIV prevention research and implementation at a critical time.

PrEP Messaging: Using radio to reach communities with oral PrEP messages

This story is part of a series of reports from the ongoing POWER Study, which is developing cost-effective and scalable models for PrEP delivery in Kenya and South Africa. AVAC and the University of Washington (UW) have teamed up to help answer questions from implementers rolling out PrEP in a variety of settings. Using qualitative stories from the UW PrEP projects, these blogs share lessons learned from the field and actionable insights for implementers developing strategies for delivering PrEP.

Joel Odondi must be doing something right. The former chaplain for a girls’ school has become a trusted expert on HIV prevention to radio listeners across Kenya – delivering messages that correct misinformation, counter myths, explain scientific concepts, and frame public health debates on PrEP and a host of other issues related to HIV. Keeping an ear out especially for what young women need to hear, Odondi uses a powerful combination of responsiveness, accuracy and credibility to get the job done.

Joel Odondi on the mic

It started ten years ago, when Odondi turned to a local radio station in Kisumu to get out messages about PrEP. The idea was to inform the community about research going on in their backyard on a new HIV prevention intervention, PrEP, and enroll people in the study, known as Partners PrEP, which also sponsored the show. Since that launch, the show was popular enough to continue through the open label extension study, demonstration study, and scale up program that is part of national roll out.

At the time, Odondi was part of the Partner’s PrEP team in Kisumu. It was a phase III placebo-controlled trial of daily oral TDF or TDF/FTC as PrEP for the prevention of HIV among heterosexual men and women in sero-discordant partnerships in Kenya and Uganda. Odondi saw that the providers and the scientists had developed a strong program to explain the study and how PrEP works. But that wasn’t enough.

Download a tool for radio engagement written by Odondi

“Those messages were not reaching the rural women, the village girls and that was a problem. Among other things, they needed information in their own language, Luo. I lost my sister to HIV and it was important to me to find a way to help make someone’s life better. I wanted to address issues of stigma and combat those myths with facts.”

Odondi started at two Luo speaking stations with hour-long shows where he would talk about PrEP, how it worked and who it was for. He talked about knowing your status and connecting with services. He confronted myths about the research process. He talked about why young people are vulnerable to HIV exposure. He talked about condom use, abstinence, voluntary medical male circumcision, morality and public health, and the importance of protecting young people as an investment in the future.

“Many of the participants [in PrEP demonstration projects] come from rural areas. It’s a challenge to get information to them. But they listen to the radio. And the radio gives you a kind of celebrity. It’s a kind of authority.”

Ten years later, Odondi is the Community Liaison Officer for the POWER study (Prevention Options for Women Evaluation Research) and the Lead Technical Advisor for Community Outreach for the Partners Scale-Up project operated out of KEMRI (Kenya Medical Research Institute). As part of his work on these projects, he has 18 shows a month on six different stations in three languages, Luo, English and Swahili, including stations in Nairobi that are heard across Kenya. Through all these stations his shows reach millions.

Each show starts with a 20-minute discussion between him and a station host on a prepared subject, the rest of the hour they open the phone lines and answer questions. The phone lines routinely fill up and stay full through the hour. His prepared remarks come from material he gets from the community through a couple of channels: he holds weekend workshops where he provides HIV prevention information to young women and they write down questions for him; the stations give their listeners a phone line where their questions and concerns are recorded for Odondi to review in advance of a show; and he provides a help line number over the air and promises that someone is always available to answer.

People call. A lot. Odondi is able to provide them with information about where to get PrEP in their area which has led to increased enrollments in both the POWER study and Partners Scale Up project.

“The same questions come up. The young people want to know if they are eligible to take PrEP. They want to know the side effects, if they have to take it forever, could they get an injection instead. Religious leaders ask me if PrEP will be abused, if it promotes promiscuity. One called into a show to say HIV was God’s punishment. I said ‘No. This is a health issue.’ When they bring the religious point of view, I can bring in a new point of view, a research literacy point of view.”

Sometimes he shapes his radio program based on new findings from the clinics he works with in his role in POWER and the Partners Scale Up project. “We saw a gap in HIV testing. So the station promoted my next show on the topic of testing with short spots on ‘What to do if you’re positive’ and ‘What to do if you’re negative’.”

When it comes to reminding people to take PrEP every day there are a few analogies he turns to again and again. “PrEP works if you take it. It’s the same if you want security — you have to lock your door every day. Condoms don’t work in your pocket. Wear a seatbelt every day for that one day you are in an accident.”

Odondi takes extra care in his messages to young people. He says it’s a real mistake to assume you know what they need. He attends community discussions about PrEP and listens to the voices of young women to stay up to date. But some parts of his message don’t change. “First I tell them they are special, their energy and spirit is our future. Then I tell them they [young women] are vulnerable and talk about condoms and sexual health and other risks. Finally, I tell them ‘you can be part of the solution,’ and invite their ideas. And then I listen.”

Additional Resources

  • Odondi has authored this brief outline on the benefits of radio as a tool for community engagement, complete with highlights of commonly asked questions and topics he covers.
  • Hear Joel Odondi explaining PrEP on the radio airwaves of KBC English, a Kenya-based news service.

logos for USAID, PEPFAR, and POWER

POWER (Cooperative Agreement AID-OAA-A-15-00034) is made possible by the generous support of the American people through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the United States Agency for International Development (USAID). The contents do not necessarily reflect the view of USAID or the United States Government.

Oral PrEP Enrollment Snapshot

For trends in oral PrEP uptake, check out the Oral PrEP Enrollment Snapshot. This PowerPoint deck illustrates major findings from the tracker with heat maps showing where people are initiating PrEP, updates against targets and more. A PDF version is also available.

PrEP Initiations by Country in Africa

AVAC tracks global PrEP use by conducting quarterly surveys of ongoing oral PrEP demonstration and implementation projects, and collecting data from manufacturers and government agencies. This graphic shows data on PrEP initiations in Africa. For more trends in oral PrEP uptake, check out the Oral PrEP Enrollment Snapshot slide deck and visit PrEPWatch.