Like Super Models? Check This Out!

This week, PLoS ONE released a special issue devoted entirely to the subject of voluntary medical male circumcision—one of the most effective biomedical prevention tools available today. This one-time procedure reduces men’s risk of acquiring HIV by up to 75 percent for life—and when sufficient numbers of men in a community have undergone the procedure, then women’s overall risk of acquiring HIV drops too. It’s an indispensable part of the effort to end epidemic levels of HIV.

One of the things that’s also unique about VMMC is that it was introduced at a public health level more than five years ago. So there’s a wealth of real-world information about the cost and effectiveness of reaching men at different ages, in different contexts and with different outreach strategies. That’s why we’re calling the information in this new supplement “super models”—because they are mathematical models that are based on a lot of real information (not just projections or best guesses). This gives them strength, specificity and urgency.

Pick up the journal or download the PDF and you will find an urgent call for scaling up VMMC and a compelling history of roll out to date. To begin with, most programs reached the men and boys who it was easiest to find, not necessarily the populations who needed the procedure the most. Reinforcing the call to action, the super models show the potential impact of VMMC, and how countries can make decisions according to their context. There is also a helpful question and answer post that simplifies some of the core messages.

As the lead editorial of the special issue concludes: “To achieve further scale-up, a combination of evidence, analysis, and impact estimates can usefully guide strategic planning and funding of VMMC services and related demand-creation strategies in priority countries. Mid-course corrections now can improve cost-effectiveness and scale to achieve the impact needed to help turn the HIV pandemic on its head within 15 years.”

This is dense material. It’s also super important for advocates to understand and to act on the recommendations laid out in this document. Please be in touch with AVAC and/or join our Truthtellers listserv to share your questions, ideas and priorities.

Who do you love? Finding treasure at the last day of R4P

Greetings from the last official day of R4P 2016! It’s been a week of conversations, presentations, celebrations and—sometimes—consternation. And yes, it’s been a lot of words. New terms, familiar ones and the occasional Greek character (we’re talking to you α4β7 integrin).

Speaking of ancient Greek and also words: did you know that “treasure” and “thesaurus” share a common Greek relative? Thesaurus originally meant storehouse and treasure. From that, it was borrowed for the usage current today: a storehouse of words.

However, at the end of any gathering of this dynamic, dedicated field, what becomes clear is that the treasures are not the words but the people. The friends, fighters, thought leaders who propel this work forward. For our final update from the final day of HIVR4P, we offer you a round-up of (inter)national treasures.

Treasure 1: The adolescent girls and young women of western Kenya

Yesterday morning Kawango Agot (IRDO) presented data from a study in western Kenya aimed at understanding who adolescent girls and young women are having sex with—and why. This work is part of Kenya’s DREAMS initiative. Supported by PEPFAR, the Bill & Melinda Gates Foundation and private sector partners, DREAMS is a multi-country effort aimed at reducing incidence in adolescent girls and young women by 40 percent by 2017. Success depends on identifying and reaching those girls and women most likely to acquire HIV—and to understand how and why they are at such high risk. The data from Agot’s presentation may not be not the last word, but it is a stirring example of research that clarifies the lived realities of people who need HIV prevention.

Young women and adolescent girls reported having sex because they wanted chips (French fries) or because they wanted someone to give them a ride. They said that they had sex for money and for prayers, which they hoped would help them to pass exams. Fifteen- to nineteen-year-old girls who were in school but lacking one or both parents reported that their teachers were the only men with whom they sometimes used condoms. Every column and cell of Agot’s slide contained a world. It is a world we all have to work together to imagine differently. We start this effort by recognizing how invaluable, beloved and needed these adolescent girls and young women are. They are resilient, resourceful, forthright—and urgently deserving of a world where they wake every day to a reality that treasures their young lives.

Treasure 2: Young African men making the decision to get circumcised

Thursday brought insights into the decision-making paths that men in sub-Saharan Africa travel before undergoing voluntary medical male circumcision (VMMC). Tremendous progress has been made in rolling out VMMC in priority countries in the region. Continued success depends on acting on the kind of information presented today. Karin Hatzold (PSI) presented market research conducted by IPSOS that helped generate an understanding of how men make the decision to undergo VMMC—and how long this decision takes. As Hatzold described, an average of two years and three months passes between the time that a man becomes aware of VMMC and decides to undergo the procedure. These and other data were used to inform a strategy to create demand in specific target groups of men in Zimbabwe.

Later that day, Bertran Auvert of the French National Institute of Health and Medical Research (INSERM) reported on a “short-time” intervention designed to increase uptake of VMMC in Orange Farm, South Africa. The site of the first randomized trial to show the impact of VMMC, Orange Farm had relatively stable prevalence of VMMC between 2010 and 2015. Since population-level impact depends on coverage, Auvert and colleagues designed a short, household-centered intervention and piloted it in 983 households in one site within Orange Farm. The intervention brought VMMC prevalence up from roughly 50 percent to 80 percent—a finding that supports further investigation of this approach. Why is coverage so important? John Stover (Avenir Health) gave a presentation on the estimated number of HIV infections averted by the rollout of VMMC in ten priority counties in Kenya. By 2015, over one million Kenyan men had undergone the procedure. Three different modeling groups calculated the number of infections averted—and all came to the same conclusion: by 2015 VMMC averted 5 percent of the HIV infections that would have happened in that period. Stover reported that the impact, and numbers of infections in both men and women that are averted by VMMC, only increases over time—a potent reminder of the need to pursue ambitious VMMC scale up as part of combination prevention.

None of this would be possible without the boys, young and adult men who undergo the procedure. It is a profound personal choice and one with tremendous impact on the effort to end AIDS. We treasure you.

Treasure 3: The CAPRISA 256 Antibody

“It’s a South African national treasure,” remarked a researcher to Penny Moore (University of the Witwatersrand) about CAP256, a broadly neutralizing antibody isolated from a South African living with HIV. Moore—who is an absolute treasure of lucid, engaging and enthusiastic information about all things antibody—described new insights into how CAP256 can show us how broadly neutralizing antibodies develop. We won’t seek to replicate her explanation in detail—check R4P for the webcast—but it appears that CAP256 is elicited by a rare group of HIV viruses that have holes in the sugary glycan shield that makes up most of the virus’s outer covering concealing key parts of the viral anatomy. (Antibodies emerge or are elicited by the parts of the virus that the immune system is able to “see”. The antibody then binds to that specific part of the virus. Many antibodies bind to HIV without impeding it. But some antibodies target hidden regions of HIV that may only be exposed for briefly when the virus is binding to a cell. These kinds of antibodies can neutralize and block HIV activity.)

Treasure 4: Omololu Falobi Award Winners

The fifth Omololu Falobi Award for Excellence in HIV Prevention Research Community Advocacy was presented as part of the closing. The award is given in memory of Nigerian activist Omololu Falobi. Falobi is remembered by friends and fellow advocates as a talented journalist, an activist for social justice, an advocate for prevention research and a son of Africa who worked tirelessly to ensure Africans were taking ownership of their own HIV care and prevention. Since 2008, the award has been presented in his memory as an ongoing legacy to recognize his commitment and lasting contributions to HIV prevention research advocacy, and to honor those who follow in his footsteps. In a break with tradition, on the 10th anniversary of Falobi’s passing, the honor goes not to an individual, but the prevention advocacy movement. The 2016 award celebrates 85 advocates from 19 countries, all nominated by their peers in the field. These advocates represent thousands who are part of the movement that has helped fuel the great progress the field has seen over the last decade. Profiles of the 85 honorees are available online at www.avac.org/falobi.

Treasure 5: Ward Cates

We probably would have started this list with Ward, a beloved and sorely missed friend, colleague, mentor and advocate who passed away earlier this year. But Ward would have argued to put young African women first—the way he always did in his work as a researcher dedicated to advancing the sexual and reproductive health rights of all women and girls. And then he would have told us that you can’t just talk about the women—that men matter too. And we agree, as the list reflects. And then he probably would have wanted us to highlight the work of a younger investigator emerging as a thought leader in the field. So we did that too. Not stopping there, Ward would surely have urged us to recognize the critical role of advocates in shaping the HIV response. And then, and only then, might he have allowed us to celebrate him, as two long-time colleagues and friends, Mike Cohen (UNC) and Helen Rees (WRH), both did in talks at the conference’s closing session. In a way, this whole list is for—and because—of you, Ward. You taught us who and what to treasure. We will always treasure you.

Check out all the webcasts online—and stay tuned for future updates as we unpack our bags and all the data and discussions from Chicago!

HIV Prevention Research & Development Investments, 2000–2015: Investment priorities to fund innovation in a challenging global health landscape

This annual accounting of funding for biomedical HIV prevention research tracks trends and identifies gaps in investment. In 2015, reported funding for HIV prevention R&D decreased from US$ 1.25 billion in 2014 to US$1.20 billion. However, overall funding has remained essentially flat for over a decade. While investments towards research for preventive vaccines and female condoms increased from 2014 levels, investments towards microbicides, PrEP, TasP, VMMC and PMTCT declined.

HIV Prevention Research & Development Investments, 2000–2015: Investment priorities to fund innovation in a challenging global health landscape (1-pager)

This annual accounting of funding for biomedical HIV prevention research tracks trends and identifies gaps in investment. In 2015, reported funding for HIV prevention R&D decreased from US$ 1.25 billion in 2014 to US$1.20 billion. However, overall funding has remained essentially flat for over a decade. While investments towards research for preventive vaccines and female condoms increased from 2014 levels, investments towards microbicides, PrEP, TasP, VMMC and PMTCT declined.

Not To Be Missed: New report on funding for prevention research

The span of a decade—that interval that’s neither too long nor too short to bring innovation—is one that’s often used in the HIV prevention research space, usually to convey optimism. Back in 1997, then President Bill Clinton called for a national commitment to develop an AIDS vaccine within ten years. Just this week, Bill Gates said, “With the right leadership and investments over the next decade, we can discover and deliver a vaccine for HIV.”

The success of these forward-looking claims has always depended on sustained funding. Note, in both cases, the emphasis on commitment and leadership. No one is promising a vaccine with anything less. A look back at the last ten years provides a warning on this front. Released today, the Resource Tracking for HIV prevention R&D Working Group’s latest annual report on global investment into biomedical HIV prevention reports that overall funding for HIV prevention research and development (R&D) has remained essentially flat for over a decade.

Close followers of the annual “RT” report take note—a preliminary version was released at AIDS 2016 in Durban in July. The final version contains slightly updated data and the same overall messages: with a slight fall from US$1.25 billion in 2014 to US$1.20 billion in 2015, overall funding for HIV prevention research and development (R&D) has been more or less level for the past ten years.

And what a decade it’s been! Consider the developments in PrEP, the pipeline of injectable ARVs for prevention and treatment, the continued advance of the ARV-containing vaginal dapivirine ring, and the insights and advances that have come from sustained scientific inquiry related to the search for an HIV vaccine. These are exciting times. And the fact that all of this happened in the context of flat funding for research doesn’t mean that flat funding will get us where we need to go next. As Tom Hope, PhD (Northwestern University) stressed at an opening plenary of the HIV R4P conference where the report was launched, the fact that funding is declining concurrent with new discoveries is a major challenge for the field.

The report notes that preventive vaccine research funding constituted the bulk of all investments, followed by investments in microbicides, TasP, PMTCT, PrEP, VMMC and female condoms. With the exception of vaccines and female condoms, every other HIV prevention option tracked by the working group experienced a decline. These trends are somewhat reflective of the cyclical nature of large-scale clinical trials—when trials end, funding drops off. Likewise, as some interventions enter full scale rollout, like VMMC and TasP, research in this arena can be expected to slow down. Nevertheless, the overall trends bear close watching and strong advocacy to ensure that research continues.

The right products need to be tested in the populations who need them most. The report is also a powerful reminder that this isn’t necessarily how research works. It provides information on the demographic breakdown of almost 900,000 participants in ongoing HIV prevention trials in 2015, with the majority of these volunteers residing in sub-Saharan Africa, most notably Uganda, Kenya, and South Africa. Only one in eight trial participants in 2015 belonged to a population most affected by HIV, including MSM and transgender women, injection drug users, and cisgender women.

These sobering facts come in the context of a vigorous period in research and development. It’s a time of growing recognition from the global community that research has to be part of the long-term fight to end the HIV epidemic. Taking stock of all that’s been accomplished with ten years of flat funding, now is the time to support continued progress with additional, well-targeted resources.

The Resource Tracking Working Group hopes that this tool provides strong facts for advocacy and supports efforts to assess public policy and its role in accelerating 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 either a funder or recipient of HIV prevention grants or if you have further questions or information about resource tracking at all!

Press Release

A Decade of Flat Funding Could Imperil Progress of the HIV Prevention Research Pipeline

Contacts

AVAC: Kay Marshall, kay@avac.org, +1-347-249-6375
IAVI: Arne Naeveke, anaeveke@iavi.org, +1-212-847-1055

A PDF version of this press release is also available.

Report released at HIV Research for Prevention Conference highlights funding trends, opportunities and challenges for HIV prevention R&D

Chicago – A new report released today at the second HIV Research for Prevention Conference in Chicago documents 2015 funding, highlighting a decade of flat funding and its potential impact on continued innovation in the HIV prevention research and development (R&D) field.

The Resource Tracking for HIV Prevention R&D Working Group’s (RTWG) 12th annual report, HIV Prevention Research & Development Investments, 2000-2015 Investment priorities to fund innovation in a challenging global health landscape, finds that funding for R&D of new and emerging prevention options decreased slightly in 2015. This was due in part to decreases from the US public sector and a downswing in global philanthropic funding.

Steady progress in R&D for AIDS vaccines, microbicides, pre-exposure prophylaxis using antiretroviral drugs (PrEP) and treatment as prevention (TasP) confirms science’s critical role in providing solutions to end the HIV/AIDS epidemic. Yet research for these badly-needed solutions is in danger of being slowed or even sidelined by inadequate funding.

“It is critical that investments into HIV prevention innovations, science and technology are scaled up to put us firmly on the Fast-Track to ending AIDS by 2030,” said Luiz Loures, Deputy Executive Director, UNAIDS.

In 2015, funders invested a total of US $1.20 billion across R&D, down from US $1.25 billion in 2014, across eight key areas: preventive AIDS vaccines, microbicides, PrEP using antiretroviral drugs, TasP, HSV-2 vaccines and operations research related to voluntary medical male circumcision, female condoms and prevention of vertical transmission.

The report also finds that investment is being made along all phases of the research pipeline but remains concentrated among a few large investors. A more diverse base of funders would increase the stability of R&D financing and cushion the impact if any of the major funders were to reduce their investments. To improve continuity, RTWG calls for a more balanced funding base, especially through support of new investment by European and low- and middle-income countries. The US public sector (primarily via the National Institutes of Health) remained the largest global contributor at US$850 million, accounting for 70 percent of total funding. Together the US government and the Bill & Melinda Gates Foundation, the largest philanthropic funder, accounted for 81 percent of all funding in 2015.

“There is now very strong momentum in research and development, and we need to expedite the development of vaccine strategies and other new, biomedical prevention options that promise to be safe, accessible and effective for use throughout the world,” said Mark Feinberg, President and CEO of IAVI. “There must be adequate and sustained investment at all stages from early laboratory research and to clinical testing if we are to truly be able to contain the HIV pandemic and approach and end to AIDS.”

This is indeed a time of great optimism for HIV prevention research. Daily oral PrEP is gaining traction as a new prevention option in an increasing number of countries; an antiretroviral-based microbicide ring that showed modest efficacy earlier in 2016 will be further evaluated to determine its viability as a prevention option for women; large-scale efficacy trials of an AIDS vaccine candidate and an injectable form of PrEP are slated to begin soon and a novel proof-of-concept trial of antibody-mediated prevention is underway in several countries. Many more promising candidates in earlier stages are progressing toward pre-clinical and clinical evaluation.

Importantly, 2015 saw increasing investment in the science of delivery – or implementation research – primarily focused on delivery of TasP interventions. Such investments will become even more important to help ensure new prevention options move quickly and efficiently into prevention programs and begin to have an impact on HIV infection rates. There is also an increasing understanding that research must understand and integrate the needs and desires of people who will eventually use new prevention options. Ensuring that the perspective of those for whom new prevention options are being developed is included from the beginning of the research process can help ensure that safe and effective products can be rolled out swiftly and be more fully accepted.

“Innovative science needs innovative funding,” said Mitchell Warren, AVAC Executive Director. “We need an expanded and more diverse global cadre of funders who will be involved in and dedicated to advancing HIV prevention R&D, including product delivery. And these investments need to ensure that new options like daily oral PrEP, and potentially the dapivirine vaginal ring, do not sit on the shelf unused because we don’t know how to effectively deliver them, and that future R&D better meets the needs and wants of those for whom products are developed.”

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 IAVI, UNAIDS, 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.

Trial Participants by Prevention Research Area, 2015

Given the higher rates of acquisition seen across so-called key populations—members of highly burdened and underserved groups—it is critical to provide access to the research process such that they can participate and reap more immediate benefit of scientific progress. Greater efforts must be made to include key populations in this crucial process for the HIV prevention response to be truly impactful.

Global HIV Prevention R&D Investments by Technology, 2000-2015

In 2015, global funding for HIV prevention R&D declined slightly, from US $1.25 billion in 2014 to US $1.20 billion in 2015. This continues a decade of roughly flat funding. The US public sector remained the largest global contributor at US $850 million, and together with the Bill & Melinda Gates Foundation, the largest philanthropic funder, constituted 81 percent of all funding.

Slow and Steady Won’t Win the Prevention Race

Progress in voluntary medical male circumcision has made significant gains but still fell short of targets—or why VMMC isn’t a global priority and how to make it one. Excerpted from AVAC Report 2016: Big Data, Real People.

Breaking the Cycle of Heterosexual Transmission

Excerpted from Px Wire, this is a novel look at how to use today’s tools to break the cycle of heterosexual transmission that was so clearly defined in a major AIDS 2016 presentation.