Excerpted from AVAC Report: HIV Prevention on the Line, this update details attempts to test vaccine strategy which showed promise in the RV144 trial.
Intervention Update: What’s Next for AIDS Vaccines and the P5 Partnership?
What’s Next for the Pox-Protein Public-Private Partnership (P5)?
This timeline, appearing in AVAC Report 2014/2015: HIV Prevention on the Line, shows the progress and future of the P5.
An Advocate’s Guide to Tracking the P5 Development Tracks
This graphic, shown in the AVAC Report 2014/15, shows the P5 development and research track trials.
AVAC Report: HIV Prevention on the Line
AVAC’s annual report of the field, the upcoming CROI meeting and why the coming year is the best and worst of times for HIV prevention
Next week, scientists, advocates and clinicians will gather in Seattle for the Conference on Retroviruses and Opportunistic Infections (CROI), a venerable HIV meeting that often triggers media coverage of the AIDS epidemic and the potential for curbing it and preserving health in people living with HIV.
A range of data is expected from CROI including “late-breaker” abstracts that will showcase data from IPERGAY and PROUD, two trials of oral PrEP using TDF/FTC in gay men and other men who have sex with men in Europe and Canada, and another trial of the microbicide 1% vaginal tenofovir gel in South African women. There will also be data from a PrEP “demonstration project” that provided the strategy in a real-life context for Kenyan and Ugandan couples with one HIV-positive and one HIV-negative partner.
We don’t know what the specific headlines will be, but we can say with confidence that one take-away must be this: The future of HIV prevention is on the line.
In our latest report, AVAC Report 2014/15: Prevention on the Line, we provide a clear agenda for what needs to happen, what’s missing, and why it matters now more than ever before.
Specifically, we argue that:
- Ambitious prevention goals matter. They can galvanize new action, in part by expanding our sense of what’s possible.
- But these goals will only work if they’re feasible, well-defined, measurable, and backed by adequate resources and political support. The prevention goals issued so far are inspiring but they don’t yet meet those requirements.
- As the UNAIDS “Fast Track” for 2020 set aspirational goals, clear short-term targets are also urgently needed. We can’t wait for five years to see if the world is on track to end the AIDS epidemic.
- The global AIDS response is running at a major financial deficit. New targets will not be met—and may even be irrelevant—if we fail to close a growing global funding gap.
Recent breakthroughs in HIV research have transformed the ability to curb new infections, making it possible to contemplate the end of the global AIDS epidemic. But prevention could be left behind if global leadership fails to make it a priority.
Recently, UNAIDS issued broad goals for HIV testing, ART provision and virologic suppression over the next five years. According to the agency, achieving these “90-90-90” goals would put the world on track to effectively end the AIDS epidemic by 2030.
On the prevention front, UNAIDS seeks to reduce new infections worldwide from 2.1 million in 2013 to 500,000 in 2020, and to eliminate stigma and discrimination. These are ambitious goals and worth aspiring to. But something important is missing from the picture—intervention-specific targets with the specificity, strategy and resources to match. The goal is great. What’s missing is how to get there.
In twenty years, we will have ample hindsight as to whether today’s targets mattered in the quest to end AIDS.
But right now, foresight and focus are urgently required. We’re concerned about whether the targets that have been set are the right ones, how much targets matter—particularly in the context of a global response running at a disastrous funding deficit—and where prevention targets other than those focused on the antiretrovirals in HIV-positive individuals—fit in. We’re also cognizant that targets can turn from audacious to absurd in the blink of an eye if financing, political will and community buy-in are missing.
AVAC works in coalitions in many of the countries hardest hit by the epidemic. Targets that are developed Geneva, Washington DC and other corridors of power can bear little resemblance to the realities of AIDS endemic countries and communities. Where there’s no reality, there’s no relevance. It’s essential that countries have the technical and financial resources to make global targets relevant to national context. Otherwise, the loftiest goals will be ignored.
As we argue in this Report, targets have played a critical role in changing the course of the epidemic. Likewise, a poorly-thought out target can have no impact at all. Right now, it’s critical that targets and tactics are matched to the lofty but achievable goal of bringing an end to AIDS. This is why we’ve devoted the first section of the Report to a look at why targets matter, what targets are missing, and how advocates for a comprehensive response need to work together to ensure smart, strategic targets across the spectrum of prevention options.
We also focus on issues that underpin (and, sometimes, undermine) the ability to meet these targets. We identify three specific areas for action:
- Align high impact strategies with human rights and realities. Biomedical advances of the past eight years have made it scientifically plausible to talk about ending the epidemic. But plausible doesn’t mean possible. Today some scientists and public health professionals are focused on what can be achieved biomedically—without enough attention to the structural and social contexts in which treatment prevention are delivered. At the same time, some rights-focused partners speak of HIV as being exclusively pill-oriented, suggesting that there isn’t any dynamism or action on the rights-based fronts. It need not be a permanent rift—indeed it cannot be. If science does not get synched up with human rights then then there is little hope of bringing the epidemic to a conclusive end.
- Invest in an oral PrEP-driven paradigm shift. The world is failing to deliver the most effective interventions with smart strategy and at scale. Daily oral PrEP for HIV prevention is just one example. Global targets for PrEP may be released in the coming months, but there aren’t any plans in place to meet them. Demonstration projects are small and disconnected, funding is limited and policy makers aren’t heeding the growing demand from men and women, including young women in Africa. Now is the time to spend and act to fill these gaps.
- Demand short-term results on the path to long-term goals. It will be years before the world has an AIDS vaccine, cure strategies, long-acting injectable ARVs or multipurpose prevention technologies that reduce the risk of HIV acquisition and provide contraception. But there’s plenty of activity in clinical trials and basic science for these long-term goals. This activity needs to be aligned with short-term goals that can be used to measure progress and manage expectations.
As AVAC Report goes to press this week and as we prepare for CROI next week, the United States is grappling with profound questions about the ways that the lives of Black men and women are valued under the law. The world is trying to understand how the West African Ebola epidemics got out of control—and how to bring them to an end. And there is continued concern and vigilance over anti-homosexuality laws in Nigeria and the Gambia, and in hate-mongering environments and legislation that endanger LGBT individuals and many other marginalized groups around the world.
These events are not separate from the work that we do to fight AIDS. They embody the issues of racism, inequity, poverty and security that drive the epidemic that must be addressed to end it. In addition to the HIV-specific work laid out in these pages, it is essential to work towards fundamental, lasting and positive change in each of these areas. That will be history-making, indeed.
In Childhood Vaccine Controversy, an Indirect Lesson for HIV/AIDS Advocates
This blog post first appeared on The Body
From all the recent attention to parents’ rejection (and some politicians’ naiveté) of vaccines and a possible resurgence of measles in the United States, one welcome theme has emerged: Such a controversy could never occur if vaccines weren’t so powerfully effective in the first place.
Former Secretary of State Hillary Clinton put it best on Twitter, writing, “The science is clear: The earth is round, the sky is blue, and #vaccineswork.”
Melinda Gates spoke for many when, in a widely circulated interview, she said, “We’re incredibly lucky to have that technology and we ought to take full advantage of it.” She prefaced that by saying that people in poorer countries can truly understand the power of vaccines because they’ve experienced the devastation that preventable diseases can bring to their families.
The anti-vaccine movement has gained ground in the U.S. in part because vaccines work so well that many parents have never seen the devastating effect of the diseases that vaccines protect us from.
From the beginning of the HIV/AIDS epidemic we’ve hoped for a vaccine that could help control and eliminate HIV in the same way polio and to a lesser degree measles have been controlled. That hope for and need for a vaccine has stayed with many of us through the rise and spread of HIV treatment, new prevention options and through many setbacks and a few breakthroughs in vaccine research.
It is the power of vaccines — the seeming magic that can keep disease at bay – that keeps us hoping and working toward an HIV vaccine.
But for many in the global community of advocates, researchers, funders and policymakers seeking to end the HIV/AIDS epidemic, an HIV vaccine has slipped off the list of “must haves” to respond to the epidemic, and even sometimes is left out of the equation when they talk about how to end AIDS.
To be fair, recent advances have altered how a vaccine would fit into the HIV/AIDS response. Within just a few years, we’ve learned definitively that antiretroviral treatment not only saves the lives of people living with HIV, but drastically reduces their chances of transmitting the virus. We’ve seen that daily pre-exposure prophylaxis (PrEP) with Truvada (tenofovir/emtricitabine) is highly effective at helping HIV-negative men and women avoid infection. In sub-Saharan Africa, voluntary medical male circumcision is being rolled out widely after studies showed it can greatly reduce heterosexual men’s risk of infection. Other new options for women and men are in clinical trials.
But amidst the drive to scale up these options — enthusiastically supported by this author — are troubling assertions that current tools might be sufficient to end AIDS.
Most advocates know this isn’t true. They realize that today’s treatment and prevention options can get us well on our way toward ending the epidemic, but that our work will never be finished until we have an effective vaccine.
The problem is that knowing it isn’t enough. We need to continually raise our voices in support of the full range of prevention strategies, including those that still remain to be developed. Beyond the clear need, three critical reasons should drive us all to be advocates for HIV/AIDS vaccine research:
- An effective vaccine is now more possible than ever. In 2009, a trial showed for the first time that an experimental vaccine modestly reduced the risk of HIV transmission. Now, researchers are testing potentially improved versions of the same approach, known as a pox-protein prime-boost vaccine, while preparing a range of other strategies for clinical trials.
- Basic science continues to open whole new areas of vaccine discovery. Over the past six years, a remarkable number of basic science discoveries of new antibodies have presented vaccine researchers with entirely new avenues for research and development.
- With advances occurring in other areas of prevention, the impact of an effective vaccine could be even more transformative. As of 2013, some 2.1 million people were becoming infected with HIV annually. But the number has been declining, and the continued scale-up of treatment, PrEP and other options could greatly reduce that figure in the next decade. By the time a vaccine is available, its role could very well be to drive the number of infections close to zero.
My organization AIDS Vaccine Advocacy Coalition (AVAC) was founded 20 years ago with the mission of advocating for AIDS vaccine research. Since then, we’ve expanded our advocacy to include many other critical prevention technologies, but our commitment to the vaccine search remains paramount. We urge you to join us.
In the case of measles, antipathy toward vaccines is an unfortunate but not-too-surprising consequence of their stunning success. With HIV, antipathy is simply not an option.
Press Release
With future of HIV prevention “on the line,” AVAC calls for sharper, bolder strategy to end the epidemic
Contacts
Mitchell Warren, mitchell@avac.org, +1-914-661-1536
Kay Marshall, kay@avac.org, +1-347-249-6375
New York — In a report issued today, AVAC warned that global HIV prevention efforts are in jeopardy due to an absence of strategic targets, resources and specific implementation plans to translate science, slogans and goals into action. The report calls for a robust set of global HIV prevention targets tailored to specific interventions and demands action in several key areas of the global AIDS response, including expanded rollout of daily oral pre-exposure prophylaxis, or PrEP, and alignment of science and human rights-based agendas.
“We’re at a make-or-break moment and the future of HIV prevention is on the line,” said Mitchell Warren, AVAC’s executive director. “Advances in HIV treatment and prevention research have made it possible to contemplate ending the AIDS epidemic in our lifetimes, but that will only happen with smarter planning, increased resources and greater accountability.”
The report was released ahead of the Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle (Feb. 23-26), where researchers are expected to present data from several major HIV prevention trials, including studies that could help drive global implementation of PrEP, as well as a key study of a tenofovir-based vaginal gel for women.
Report calls for smart, realistic goals and targets for HIV prevention
Today’s report, entitled Prevention on the Line, takes a close look at global goals for HIV prevention and what it will take to make them a reality. UNAIDS recently adopted the broad goals of reducing new HIV infections worldwide from 2.1 million in 2013 to 500,000 and eliminating stigma and discrimination, both by the year 2020.
Drawing upon lessons from WHO’s “3 x 5” HIV treatment initiative and other case studies, the AVAC Report concludes that ambitious prevention goals are critical – but that they will only work if they’re feasible, well-defined, measurable and supported with adequate resources and political commitment. In the case of the new UNAIDS prevention goals, the report points to a critical need for more specific, interim targets that can be tracked between now and 2020; for better data and monitoring approaches; and for resource allocations that are directly tied to achieving those targets.
“The UNAIDS prevention goals for 2020 are ambitious and inspiring,” said Warren. “But something important is missing from this picture: how to get there. We need a clear path forward, including short-term targets, so we don’t wait five years to see if the world is on track. And new targets won’t be met – and may even be irrelevant – if we fail to close the growing global funding gap for HIV prevention.”
Bold action needed to advance AVAC’s agenda to end AIDS
The report also recommends key actions to advance AVAC’s three-part agenda to end AIDS. First issued in 2011, the agenda calls for sustained efforts to deliver proven prevention tools, demonstrate and roll out new options such as PrEP and develop long-term solutions such as long-acting ARV-based prevention, vaccines and cure strategies.
Key recommendations for 2015 include:
1. Align high-impact HIV prevention with human rights and realities. Research has demonstrated the potential of high-impact prevention strategies, including biomedical approaches like HIV treatment for people living with HIV and voluntary medical male circumcision (VMMC). But these strategies won’t succeed in the real world if we give short shrift to human rights concerns, or if we fail to involve affected communities in designing and implementing prevention programs. Recent experience with treatment and VMMC, in particular, has shown that community buy-in is an essential ingredient of successful rollout and scale-up.
2. Invest now to scale up access to PrEP. Landmark trials have shown that daily oral PrEP is a powerful HIV prevention tool, and studies at next week’s CROI meeting could provide additional support. But the pace of rollout remains far too slow. Demonstration projects are small and disconnected, funding is limited and policy makers are not yet heeding growing demands for access. Funders should invest now in large-scale targeted implementation of PrEP, linked to national programs. National regulatory authorities and health ministries should prioritize licensure and rollout.
3. Accelerate research into long-term solutions. We must sustain and accelerate research on solutions such as an effective AIDS vaccine, long-acting antiretroviral prevention and treatment and a cure. Just like the rest of the AIDS response, this research needs its own short-term targets, aligned to long-term goals.
The new report and related resources, including downloadable graphics, are available now at www.avac.org/report2014-15.
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About AVAC: Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic.
New Px Wire: Top Ten Things to Watch in 2015
Welcome to the New Year! Wondering where to put your attention and advocacy energy for the next 12 months? We don’t presume to have all the answers, but our new issue of Px Wire includes a highly selective list of ten issues, events and developments to hold attention and spark actions in 2015 — and beyond.
Want to see the bigger picture? Check out our updated timeline of biomedical HIV prevention research in the centerspread!
Biomedical HIV Prevention Efficacy Trials, 2014–2016
UNAIDS Report has Bold Vision, Key Messages—But Needs More Precision on HIV Prevention
UNAIDS recently released Fast Track: Ending the AIDS Epidemic by 2030, its report for World AIDS Day (December 1, 2014). Coming nearly two weeks early, the launch was, itself, fast-tracked—and there’s plenty of “we can’t wait” urgency within the pages of the report, starting with the first page (that does more, typographically, with red ribbons than you might believe is possible). It reads:
“We have bent the trajectory of the AIDS epidemic. Now we have five years to break the epidemic or we risk the epidemic springing back even stronger.”
This is on target and a message to convey urgently and with clarity. UNAIDS has its work cut out as an agency that can provide leadership, mobilize resources and push for the shift to community-based service delivery that emerges as one of the core recommendations in the report.
In broad strokes, it’s the right message, with the right vision, at the right time.
But an effective response depends on strategy, details, milestones, resources and specifics—and these are still lacking. This is to be expected, as the UNAIDS Prevention and Non-Discrimination Targets are still in draft form.
The Fast Track World AIDS Day report is clear on what needs to happen to achieve the “90-90-90” goal that calls for 90 percent of people living with HIV to know their status, 90 percent of those to be on antiretroviral therapy (ART) and 90 percent of those to be virologically suppressed by 2020.
It also suggests the components of prevention programming that should also come on line—listing, in various places, male and female condoms, voluntary medical male circumcision, oral pre-exposure prophylaxis (PrEP) for sex workers, men who have sex with men, serodiscordant couples and adolescents, as well as cash transfers for young girls, harm reduction, structural interventions, mass media and behavior change. These prevention elements appear in different subsets throughout the document, leaving some confusion about what, exactly, is essential.
Everything that the UNAIDS report lists is important. But the details of what goes where—which packages, in which places—and what specific terms mean are missing. Cash transfers, for example, can be delivered in a range of ways, with different objectives and different outcomes.
There are also some elements that receive considerably less emphasis. Research and development of more potent ARVs for treatment and prevention, new prevention options for women and other key populations, vaccine and cure strategies, are fundamental to long-term success in “breaking the epidemic”. Within the five-year timeframe set by UNAIDS, there are short-term milestones to set and achieve in each of these areas, even though the ultimate goals may not be reached for many years.
The good news is that this is a solvable problem. We as advocates and activists must use our impatience and collective wisdom to fast-track a process to ensure that clear targets, resources and messages are developed with the same strategy, rigor and urgency as 90-90-90.
AVAC is working with many of our partners to inform this process. This new report adds urgency to this task and clarity to the questions we need to address. As the report stresses, we must all “hold one another accountable for results and make sure no one is left behind.”
In the coming days, AVAC will release “Prevention on the Line”—a briefing paper with core recommendations for effective target-setting across the research-to-rollout continuum. This will summarize core messages and analysis that will be expanded in AVAC Report 2014/15. To receive the Report and other updates in your inbox, please join our Advocates’ Network. Stay tuned—and stay in touch.
Leaders in the field discuss progress towards an HIV vaccine at CSIS event
The Center for Strategic and International Studies hosted “Ending Epidemics Through Technology: Developing an HIV Vaccine,” featuring a keynote presentation by Dr. Anthony Fauci, Director of the US National Institute of Allergy and Infectious Diseases, which was followed by a discussion with Margie McGlynn, President and CEO of the International AIDS Vaccine Initiative and Mitchell Warren, Executive Director of AVAC.
A recording of the 90-minute event is available here. The keynote and discussion featured lessons from industry, how Ebola relates to AIDS, the need for an AIDS vaccine, advances presented at the recent HIV R4P conference and the current AIDS vaccine pipeline.
For more on recent advances and AIDS vaccine resources for advocates, visit AVAC’s vaccine page.