Friday 31 October 2014

I'm dreaming of being around when we announce we have got rid of Aids....

South African Minister of Health, Aaron Motsoaledi, congratulates the HIV R4P for successfully facilitating the cross-fertilisation of ideas and research on biomedical prevention

Glenda Gray from the Perinatal HIV Research Unit at the University of the Witwatersrand reports that 60% of sex workers in South Africa are thought to be HIV positive but only 30% are receiving treatment. The above slide shows the general level of abuse suffered by sex workers, who also frequently experience discrimination at health care facilities.
Gray urged doctors and nurses to remember their ethical obligation to treat all patients with equal respect, including sex workers.

We need to take pride in being African

Alex Coutinho,

Alex Coutinho, Director of the Infectious Diseases Institute, Kampala, urges other African scientists to remain in Africa and not to emigrate to the developed world

So when will The Next Big Thing be available for general use?

WYCLIFFE MUGA writes: The one question research scientists dread most – but one which journalists are obliged to ask – is, “So when will this be available for general use?”

What makes this question so difficult to answer is that there is a large gap between the successful implementation of an early medical trial and and the products arising from this trial actually reaching the intended market.

After the creation of a new intervention against HIV, for example, there will still be the issues of regulatory approval; scaling up production to obtain economies of scale; arranging for distribution channels etc.

All this will be even more difficult with the Next Big Thing in the fight against AIDS: Multipurpose Prevention Technologies (or MPTs).

For example, research is under way to test the efficacy of vaginal rings embedded with antiretroviral drugs, (the dapivirine vaginal ring) as an intervention to prevent HIV infection.

If and when efficacy is proved,  application for regulatory approval for general use is the next step. Hopefully, one day, it will be possible to embed slow-release drugs in the same vaginal ring, for three different interventions: microbicides to block HIV infection; other microbicides to fight the more routine sexually transmitted infections (STIs); and contraceptives.

In theory this would take the question of “extending choice” to a whole new level. Women could decide which combination of options would best address their individual needs.

But in practice, there are bound to be problems – especially in Africa – even with something this innovative. For there is a long-entrenched resistance to contraception in much of Africa, where large families are still preferred. And of course there is the continuing stigmatization of those who are HIV+ve.

Still, what is crucial about this new approach, and the research into these new technologies, is that it puts the woman in charge, which in itself represents a great leap forward.

A reminder of scientific progress (past, present and future)


CRYSTAL NG writes: A man caught my eye this week.
He’s an 8-meter-high sculpture towering over passersby of the Cape Town International Convention Centre. His name is Olduvai, a nod to the Rift Valley area that scientists believe was home to some of humankind’s oldest ancestors.

It’s fitting that a symbol of “human endeavour” (per the artist) is bearing witness to this week’s HIV R4P Conference – itself a testimony to ongoing global efforts to push the boundaries of HIV prevention science.

Olduvai even sports the same color as the red ribbon that has come to mark HIV/AIDS awareness and support.

Yet it is women who bear the burden of the HIV/AIDS epidemic. It is women who make up the majority of HIV-positive adults in sub-Saharan Africa; women who are often forced to withdraw from school or employment to take care of HIV-infected relatives – or themselves; and young women who are twice as likely worldwide to be infected as young men.

Several presentations have highlighted progress in developing new prevention tools and new ways to deliver existing tools – from new insights into cellular mechanisms to advances in developing vaginal rings, gels and tablets to rolling out options like PrEP and combination prevention packages. There have also been some exciting announcements, including the termination of the placebo arm of ANRS’s IPERGAY study due to high PrEP effectiveness.

We still have work to do for women. As we head into the last sessions of the conference, I am already looking ahead to R4P 2016. By then, we could have results from three Phase III trials of two women-initiated products: 1% tenofovir vaginal gel used around the time of sex (developed by CONRAD with results expected in early 2015) and the dapivirine monthly vaginal ring (developed by the International Partnership for Microbicides with results expected in 2016).

This week, Chris Beyrer stressed the need to “know your epidemic.” We know the impact of the epidemic on women – and I’m so encouraged by the progress being made to help them protect themselves. Perhaps the next time I see Olduvai, he’ll be heralding a new prevention landscape for women.

Poster parade

AVAC executive director, Mitchell Warren, explains the importance of achieving a tipping point at which the rate of treatment initiation exceeds new infections
Kessuda Khuwsroy of Mahidol University, Thailand, demonstrates her vaccine research

Thursday 30 October 2014

Arm advocates with the appropriate facts so that they can drive change in their own countries

CHARLES BROWN writes: Maureen Milanga, a staffer at Health GAP in Keyna and an alumna of the AVAC Advocacy Fellows program, presented a poster demonstrating how advocates from Kenya, Zimbambwe and Nigeria were able to influence their countries by strategically raising their voices to increase demand for key interventions. Their work has helped secure a number of significant changes—including global WHO guidelines that recommend early ART initiation for sero-discordant couples regardless of CD4 counts. Demand is also driving expanding attention to the need to deliver post exposure prophylaxis (PEP – ARVs given after a person suspects they have been exposed to HIV) for key populations like sex workers in Zimbabwe and South Africa. There has also been increased effective engagement of communities in trials.

However, a lot still needs to be done to scale up pre-exposure prophylaxis, or PrEP (programs that provide ARVs to HIV-negative people to reduce their risk of HIV infection). This includes additional research, demonstration projects and large scale roll out programs. 

It is important to note that advocacy requires appropriate strategy for each country in order to create meaningful change. They need to be given basic facts about the research and the prevention/treatment options for them to influence policy makers. Advocates can then frame arguments that help the policy makers see themselves as beneficiaries of the action—whether by saving costs, lives or earning the respect and alliance of the key constituencies driving change.

The uneasy alliance between media and scientists

WYCLIFFE MUGA writes: The fight against AIDS requires a massive and continuing public health information campaign and the media is crucial to this. Newspapers, radio stations, TV stations, and online blogs are all needed to communicate the research findings of biomedical research scientists, the implementation of protocols, policy change, etc.
That, at any rate, is the noble theory.

The reality is that we will sometimes get misleading headlines like these:

· Contraceptives Double HIV Risk – THE STAR (KENYA)

· HIV-ve Women Test Positive After Drug Trials – THE SUNDAY MAIL (ZIMBABWE)

· Microbicide Gel’s Dismal Failure: Who Shoulders The Blame – THE POST (ZIMBABWE)

All these headlines, incidentally, are fatally flawed, and in no way an accurate indication of the stories that follow: Contraceptives do not double HIV risk; no women in Zimbabwe who went into drug trials HIV negative ended up being HIV positive; and microbicide gels are one of the more promising interventions against HIV infection, currently in the pipeline.

The headlines were almost certainly the work of over-eager newspaper sub-editors, intent on “sexing up” what they considered to be uninspired (and possibly, incomprehensible) articles on HIV clinical trials

And they remind us that there can be no cosy relationship between media practitioners (who are primarily concerned with TV ratings or newspaper circulation) and research scientists (who will often declare as “an exciting breakthrough”, what the rest of the world sees as a very small step in a very long journey).  On the contrary there will be a constant tension between the two, punctuated by an occasional clash.

It also raises this question: given a limited sum to spend on improving communication on HIV, would you use this money to teach journalists the complexities of biomedical research? Or would you provide training for researchers on how to work with the media?

The HIV self-test kit: coming soon to a pharmacy (or sex shop) near you

WYCLIFFE MUGA writes: If you like movies at all, by now you will have seen – many times – the scene in romantic comedies in which a woman walks into her bathroom to perform a simple test which will tell her (with a high degree of accuracy) whether or not she is pregnant.

OK, for all I know it is not just romantic comedies which have this scene as a standard feature. Maybe it is equally common in science fiction; or thrillers; maybe even in zombie movies. I wouldn't know. I only watch comedies.

But here is the point to consider: is there any way to inject humour into a movie scene in which a man or woman goes into the bathroom to administer a self-test to find out if he or she was infected by HIV??

I don’t think so. It is possible to make fun of a woman getting pregnant when she did not want to. But HIV is far too serious for humour.

In any event, for all the decades that the AIDS scourge has ravaged the planet, it has been the established procedure to first submit to intensive counselling (usually by a certified counsellor) and only then have the HIV test done. It has been understood all along that you have to prepare people psychologically for the possibility of the tragic news that they are HIV+ve.

So, going by the Health Systems Trust of South Africa website, here is the good news: “Home-testing kits for HIV have reached the shelves of pharmacies, despite concerns on their accuracy and the wisdom of testing oneself for the virus that causes AIDS. For just R70 and five minutes, the do-it-yourself test promises quick, easy and 99% accurate results to one of the most serious questions facing South Africans.”

And, on the same webpage, here is the bad news: “AIDS counsellors are concerned that DIY tests bypass the counselling necessary to prepare for an HIV diagnosis…Deputy AIDS director Celicia Serenata said the Health Department did not encourage the use of home AIDS tests but there was no legislation to regulate their sale.”

What we talk about when we talk about women

EMILY BASS writes: Women are at the heart of the AIDS epidemic--and at the forefront of the search for successful solutions - as activists, educators, trial volunteers, nurses, care givers and so much more. Here in South Africa, this is clear and, on the face of it, simple enough. But listening to sessions over the past few days is a reminder of all the ways that even the simplest statements need to be complicated. Here are a few examples:

1) At yesterday's amazing plenary on key populations, Chris Beyrer, Johns Hopkins researcher and President of the International AIDS Society, talked about how the definitions and measurements of sex work among women in prevention trials really varied quite a bit.
These trials dont have a standard way of figuring out whether women do sex work. (There's many reasons for this; and it is worth acknowledging that for some trials receiving US funding, language is or has been affected by the Bush-era requirement that PEPFAR grantees repudiate sex work--a provision that's since been overturned by the US Supreme Court but is still being enacted for complex, bureaucratic reasons). Anyway--back to the issue. Some trials ask, simply, "Are you a sex worker?" it is hard for women who have faced extreme stigma and discrimination in the health setting to always answer this question affirmatively. 
In some trials, they ask about number of sex partners, exchanging sex for money, food and so on and interpret from there who is engaged in sex work. Beyrer's point was that these questions and definitions weren't standard--and that makes it hard to say, with clarity, what kind of sex work women are doing (or not) in some trials--and therefore complicates the issue of what we do or do not know about sex workers.
2) In a session on hormonal contraceptives and HIV risk that was packed with interesting information, there was a presentation on the differences between the genital tracts of women from the US and from Africa. Wait? I thought. No one has ever done this? Guess what? It didn't seem they had. And guess what else? There are differences. In the Contraceptive Hormone Induced Changes (CHIC) study, women from Pittsburgh in the US and Zimbabwean women are providing samples and information to help investigators understand how the genital tract changes with contraceptive use. The data presented were baseline--eg without contraceptive use. And they found, after controlling for many other factors, that the Zimbabwean women had higher concentrations of CD4 cells in their cervix than US women. (These were all HIV negative women). What causes these differences? The researcher didn't know. But this isn't the first time that the field has paused and realized that immune profiles are different in different parts of the world. So-called "normal" ranges of laboratory values are often set based on information from US or high income individuals--and vaccine trials have had to do preparatory work to re-calibrate and re-define normal in other parts of the world. Clearly, work remains to be done on what this means for women.

3) Liars and housewives: There was a major session on adherence among participants in the VOICE trial. Many participants did not use the gel or pills as prescribed in the protocol--even though they said that they did at study visits, and even returned the right number of pills.. After the trial, researchers went back to try to understand why women said one thing and did another. They found out lots of interesting things that I won't go into here--though you can and should watch the webcast of this session. But what a lot of advocates--civil society, HIV positive women, young women--heard in that session was explicit and implicit questions about "why women lie?" A much-tweeted remark from researcher Ariane van der Straten said " We all lie all the time, every day. These women are just like us." This was welcomed (at least I think that's what the tweeting meant) but it still left us all labelled as liars. That language hasn't sat well with many of the women advocates here and I think we need to be careful how we talk about these findings together, because the liar label is a hard one for anyone to bear. In that way, too, we are all similar. That same day, there was a presentation on early safety and acceptability research on long-acting injectable ARVs--another potential prevention strategy. In the Q&A, a researcher who was asked about acceptability said, that while they've gathered some information it was all from "Pittsburgh housewives." What? Have we returned to the 1950s? In an earlier post, I raised a jargon alert. "Housewives" sets off a major non-jargon alert--that language is not just casual, it's dismissive and almost certainly inaccurate.

We can and must do better, watch our language, work together as women in all our diversity--including transgender women. As poet elder Adrienne Rich once said, this is the "dream of a common language."
KAY MARSHALL writes: Wednesday was key populations day at the HIVR4P conference. Key population is HIV jargon for groups that have disproportionately high rates of HIV infection – so groups that might be more at risk for HIV infection.

The morning plenary sessions focused on HIV prevention needs of key populations, human rights and making sure research works for these groups.

An afternoon session on “Good Participatory Practices” in HIV prevention research focused on the nuts and bolts of engaging communities – including key populations – in research.

The end of the day brought a sometimes impassioned, but always informative discussion among advocates, representatives of key populations (gay men, sex workers, people who use drugs) and the media about working together.

A message for the media

A Nigerian activist in the Good Participatory Practices session makes a point about the need for researchers to support gay men and others at risk of violence

Advice from Ugandan activists to western activists on responding to the anti-gay law in Uganda.
Beautiful and fierce women featured in trial recruitment materials for HIV vaccine trials in the US
Some Liberia church ministers are using ebola to stir up homophobia

How to make sure your research centre doesn't get burnt down

WYCLIFFE MUGA writes: Crossroads in Cape Town is your classic African “tough neighbourhood”. It is a shanty town – a slum. So how do you go about getting volunteers from a place like that – a place in which all authority is usually viewed with doubt and suspicion – to participate in clinical trial which involves such potentially sensitive interventions as “vaginal rings”, “vaginal gels” and “vaginal microbicides”?

How do you make sure that, in a township with a history of violent protests, rumours that your new clinic is really a front for a thriving business in the accumulation and sale of human blood, will not lead to a large and angry mob, turning up with used tyres and gallons of kerosene, and proceeding to burn the place to the ground?

These are some of the challenges which the Desmond Tutu HIV Foundation faced when it opened the doors of its Emuvundleni Research Centre situated in New Crossroads. Devoted to HIV prevention trials (including vaccines, microbicides and pre-exposure prophylaxis) it had to find a way to conduct research on perhaps Africa’s most intensely stigmatized disease, in one of Africa’s most unforgiving neighbourhoods.

The Community Engagement Coordinator explained that, in their experience, the key was to make it clear, in every way, that the local communities were “much more than a source of trial participants”. The centre had to be seen as deeply invested in the well-being of the community. Relationships and bonds had to be formed which transcended the immediate medical needs of the participants. Youth engagement programmes had to be conceived and implemented.

Above all, and to preclude any possibility of negative “pushback” from the community after the study was already fully launched, there had to be prior diligent and prolonged counselling to ensure that when “informed consent” was given, it really was truly well informed. Hence an elaborate filtering procedure was needed to ensure that all who were enrolled knew what they were in for – including potential side effects.

“No short-cuts, when it comes to informed consent” has been the guiding principle for volunteer enrollment. And that is why the Desmond Tutu Emuvundleni Research Centre building is now being expanded to create room for more labs and other research facilities – when it could otherwise so easily have been burnt down.

Why we young women had to resort to putting up the Visible Panty Line

YVETTE RAPHAEL writes: Wednesday was the day we were finally going to be seen and heard: the day that young women from Burundi, South Africa Uganda and Kenya were going to make it all about us. While everyone was in plenary session, we young women plotted to get the most attention when researchers, policy makers and the conference elite walked out of the plenary. Well, we did succeed in catching their collective eye with our visible panty line (VPL)—a clothes line with colourful, sexy lingerie clipped to it. This attracted scores of conference-goers to our corner. But while everyone was curious, not everyone wanted to participate in the activity—which involved writing messages and clipping them to the line. Instead, I watched as the usual suspects wrote messages about issues affecting young women and a few wrote about strategy ideas to improve the young women’s agenda. I was secretly waiting for a researcher to prove me wrong.  None did.

This was disappointing because we young women have a lot to say to researchers about the prevention options we want - if only they would listen. For instance, we know that PrEP works. We know young women between the ages 19-24 are most affected in many parts of the world. We also know this group hasn’t been a priority for demonstration projects of PrEP (pre-exposure prophylaxis).

I attended two oral poster presentations on PrEP and microbicides adherence in women. Speaker after speaker explained that they had gathered evidence about how women lie in about product use (aka adherence) trials. I wanted to say to them: “We do not lie as a choice but as a negotiation. Women lie to their partners, to their family, to their community and in trials because we prioritize other people and not themselves. Some of reasons given to explain that "the lies" were – “I did not use the gel because my partner does not like the slipperiness”, “My partner felt it and I had to remove it.” Women who didn’t use a PrEP or microbicide containing an ARV had their samples measured for detectable drug in the blood. They were told their pharmacokinetic levels that indicated no product use. “I beg you to forgive my PK levels,” was one of the responses I observed. Why do we do it?

After all these lies, I rush back to the Advocates Corner and our Visible Panty Line.

Phew, these young women, like our mothers, have submissively found their space on the floor. And then the old women came and the heterosexual man came: again they wanted to help young women. This is what they should do or shouldn't do. But why don't they want to listen to the women themselves?

I am livid: they are doing it again! They are gagging young women.

Ugandan researchers reveal their findings

Rachel Sarah Kyeyune of the Infectious Diseases Institute in Kampala reveals the result of her study into the effects of multivitamin supplements given to HIV positive Ugandans who have just begun treatment
Juliane Etima has been monitoring the ethics of microbicide trials. She discusses the results with Doreen Kemigisha.  The study is a joint project between Makerere University in Kampala and Johns Hopkins

The Visible Panty Line

Looking out, looking in: an advocacy session

The thorny issue of ethics

WYCLIFFE MUGA poses a question: Suppose that a research team of scientists came up with an AIDS vaccine that was 50% effective. What would you recommend that they do with it?

1. Do some more research to try and make it 100% effective?
2. Rush out to make it available to those who need it most?
3. Study its long-term side-effects, bearing in mind that – as was famously the case with Thalidomide – some cures are worse than the disease?
These are questions that AIDS researchers have been grappling with for decades now. And they are also questions that already engage those who are at the centre of the storm, in the global rush to find a cure for Ebola.

A similar dilemma arises when you seek to implement AIDS interventions in an at-risk population which is criminalized in the statute books of the specific country.

Take commercial sex workers, for example: In Germany and The Netherlands, where commercial sex work is perfectly legal, it is relatively easy to come up with programmes directed at this at-risk population. But in many African nations, not only is sex work illegal, but the mere act of carrying a bunch of condoms can get a woman arrested for prostitution. How then can you protect such vulnerable populations, when the cheapest and most effective barrier to infection may be impractical for them?

It is one of the unavoidable issues of AIDS research that an element of choice has to be built into the interventions proposed, as what works for the general population, may not work with the most-at-risk populations.

This has led to a call from some advocates for decriminalizing sex work, as a potent intervention against HIV infection. Also the need for “sex-worker-friendly” health services.

Wednesday 29 October 2014

Young women influencing the agenda

DEFINATE NHAMO and TEREZIA NJOKI OTIENO write: In a session on Reproductive hormones and HIV risks, the data showed the need for the ECHO trial, which is a proposed trial that would evaluate three different contraceptive methods (DEPO-provera, the Jadelle implant and the copper IUD) in relation to HIV acquisition. There’s been a lot of debate and discussion about ECHO recently.

The presentation by Christine Wall on hormonal contraception use and the risk of female to male HIV transmission in a Zambian Cohort showed no HIV risk for men in discordant relationships. Elizabeth Byrne's presentation showed there is some risk of HIV acquisition among injectable progestogen contraceptive (IPC) users in South Africa compared to women who were not using hormonal methods. Byrne also looked at why this might be. She looked at both the natural hormone, progestogen and progestin (the synthetic form of the hormone). Women who are not using hormonal contraceptive and are ‘cycling naturally’—getting their periods—have regular changes in levels of progestogen. IPC users have high levels of progestin due to the contraceptive. In both of these groups of women, elevated hormone was linked to elevated levels of HIV target cells in the cervix.

At the end of this session, Helen Rees, one of the principal investigators of the proposed ECHO trial spoke to the continued need for this trial. She remarked that the data—including presentations from this session—were confusing and/or contradictory, thus the need to get adequate and accurate answers from ECHO as to to whether hormonal contraception increases the risk of HIV. She spoke to the real possibility of the ECHO trial happening noting that it “appeared” it would move forward. This wasn’t a firm confirmation—an important clarification since the session chair suggested that it was certain.

In a lunch-time session at the Advocates Corner, young women advocates and researchers had a dialogue on young women’s access to HIV prevention: past, present and future. Young women from Uganda, Kenya, Burundi, South Africa, Zimbabwe and other regions, raised issues of lack of sexual and reproductive health (SRHR) access, including family planning and information. One participant noted that the young women want to use pre-exposure prophylaxis (PrEP) but it is not available. American advocate Anna Forbes stressed that the initial demonstration projects have not targeted young women even though they are more at risk for HIV infection. Plans are underway for demonstration studies for young women in South Africa and Kenya that will answer if PrEP is feasible among young women. There is therefore a need for young women to start influencing the agenda to address their specific needs.

During a presentation today on PrEP and Microbicides adherence in women, extensive evidence was presented on why some women were not using the products. There was evidence presented on why some women did not use the product. Reasons ranged from having non -supportive partners, fear of possible side effects to peer pressure. The researchers described the impact of discussing “PK” data with participants in VOICE. PK stands for pharmacokinetics, and in this case it refers to the presence of detectable drug in the women’s blood (both the gel and the oral pill in VOICE had tenofovir-based drugs). Adherence to the products was very low in all the VOICE arms—and there was no evidence of protection in any arms.

 In a follow up protocol known as VOICE-D, study sites talked to women about their product use, and then also shared the PK data for individual women. Women who said they had adhered very well sometimes changed what they disclosed when their PK data was shared—showing that they had not It was exciting to hear that giving women P.K results initiated discussion on product use. One of the interesting points in the session seemed to be that there is a difference in how long it takes for PrEP to begin to provide protection in women versus men—we’d like to follow up and learn more. Very little was presented on why some women did use the microbicide products in the VOICE trial.

The way we were - and the way we should be

STEVEN WAKEFIELD writes: This blog reads best with a Gladys Knight and the Pips singing “The Way We Were” in the background. Especially the lyrics: Can it be that it was all so simple then, Or has time rewritten every line, And if we had the chance to do it all again, Tell me, would we? Could we?

Today at the R4P HIV conference there was a wonderful session of six ten minute presentations under the topic “Good Participatory Practice In HIV Prevention.” These sessions provided an excellent follow-up to the plenary talks this morning “Targeting Biomedical Preventions to Different At-Risk Populations”.

We heard some clear suggestions on how GPP had been used to expand and extend community engagement. Each presenter noted specific examples of practical utilization of these principles. Unfortunately there was little time to note three important factors: 1) The relationships that lead to successful GPP implementation are best actualized when scientific leadership provides resources (sufficient dollars, rand, euros…) to hire and trust staff to navigate relationships.
 2) Persons must be trained after they express a willingness to serve science and scientific endeavors on behalf of their communities. They give an incredible amount of time and energy in love for their communities and in as responding volunteers to improve life locally. 
3) The shaping of the science of prevention requires a dialogue that results in better understanding for community and researchers but also demands willingness to discover new paths forward as both roles work for better life.

It is not just about the proper conduct of science. It is not just about fighting a virus. Back in the 80s as we marched on the steps of City Hall in Chicago, Dr. Renslow Sherer asked “is this a rally about HIV/AIDS, human rights, sexual freedom or what?” I answered “yes”. GPP ensures we all work for a better human experience in the face of a virus that continues to mystify.

Put a ring on it.... microbicides inserted in vaginal rings to protect against HIV

Thesla Palanee-Phillips from Wits Reproductive Health and HIV Institute in Johannesburg reports on  developments in intravaginal rings for HIV prevention in women
Tea time

Leading from the front, finally

WYCLIFFE MUGA writes: Attending the opening plenary session of this conference, I listened to the South African Minister of Science and Technology, Naledi Pandor MP, talk about on-going efforts by her ministry to work ever more closely with the South African biomedical research establishment, and to find more money to support their work.

The speech was impressive as much for its content as for its polished and informed delivery. (Online copy can be found here -

How times change.

Seems like just the other day when another polished and very impressive South African politician – and like Ms Pandor,  one who had spent many years in exile during the apartheid era – filled us all with horror with his casual dismissal of the scientific consensus on AIDS.

I speak, of course of former South African President, Thabo Mbeki.

How this shrewd and able man ever allowed himself to be the intellectual captive of outer-fringe AIDS-denialist groups, will long mystify me.

South Africa has always been the clear and undisputed leader in all technological and biomedical research in sub-Saharan Africa. It was clear to many of us all along that until the day came when South African resources and expertise – the very things which Ms Pandor was pledging to dedicate even more of in the fight against AIDS – came into the arena, Africa had no chance of winning that war.

The inaugural Desmond Tutu Award goes to ......Archbishop Desmond Tutu

MUNYARADZI MAKONI writes: The inaugural Desmond Tutu Award for HIV Prevention Research and Human Rights has been awarded - to Archbishop Desmond Tutu.

The award recognises the link between HIV prevention research and respect for all people affected by the epidemic says Mitchel Warren, executive director of AVAC, a global advocacy for HIV prevention.

It’s no coincidence that the first award goes to Tutu.

“What is exciting about this award is it’s been given to someone who has championed and HIV prevention from the pulpit,” says Warren.

The award will be given at successive biennial HIV R4P meetings to a researcher or anyone who has demonstrated commitment to fight HIV.

Sex workers: the struggle continues

AMANDA LUYENGE writes: Particularly in South Africa where sex work hasn’t been legalised, sex workers are at risk of contracting the virus every day and those who have contracted it struggle to access treatment. Decriminalising sex work has been under discussion since 1994 but until this day, the struggle continues and so does the spread of HIV.

The HIV Research 4 Prevention conference kicked off this Wednesday morning by looking at targeting biomedical preventions for different at risk populations. You might be wondering what an “at risk population” is, well this is a group of people who share a characteristic/s that causes each member to be vulnerable to a particular event, in this case HIV. Sex Workers are seen as a population at risk of HIV because they make a living by having sexual intercourse and sexual intercourse is the main form in which HIV is transmitted. They are at risk because they are not protected by the law. Instead the law turns its back on them and they are left in the little corner with little access to anything, particularly treatment.

Dr Chris Beyer, a researcher from the Johns Hopkins Bloomberg School of Public Health pointed out a few barriers in HIV treatment and prevention around sex workers. Sex workers are ashamed of visiting health care centres to get medical treatment because people will look askance at them and so they would rather carry on and keep spreading HIV. 

If we plan on reaching an HIV free generation, we need to look at this at-risk population because, with increasing unemployment, the number of sex workers increases.

We need to tailor strategies to suit specific communities

ROB NEWELLS writes: One of the challenges we have had in the United States around PrEP implementation, particularly among black men, is mistrust of the medical establishment. Even as the Affordable Care Act serves to address issues with health care access, many black men remain suspicious of doctors and pills.

For a community plagued by health disparities and other structural challenges, resistance to PrEP may also be an issue of power dynamics. During the Wednesday plenary at HIVR4P, we heard about a community concern that biomedical interventions like PrEP inherently shift the focus of control toward the medical establishment and government bureaucracies, and away from community. How do we overcome implementation challenges if the community does not feel it has control – or worse – if the community feels like it is being controlled?

Over the first two days of HIVR4P, what has piqued my interest is the idea presented by both Anthony Fauci and Chris Beyrer that HIV prevention strategies need to be tailored to specific populations. It’s really common sense. One size does not fit all. As Dr. Beyrer said in his Wednesday plenary presentation, there may be different standards for different populations, even in the same community. We know that treatment as prevention is an effective strategy for people living with HIV. PrEP works for men who have sex with men, serodiscordant couples, and people who inject drugs. There is hope for vaginal rings and microbicide gels that would benefit female sex workers. ARV-based prevention is a power tool in the toolbox of HIV prevention options, but it will serve us well to remember that combination prevention is not just about combining biomedical interventions.

Biomedical interventions are the shiny, new toys in the HIV prevention world. They are the electric drill and the nail gun in our prevention toolbox, but we can’t forget that the screwdrivers and hammer are still in there, too, and they have to be just as available as the power tools. 

An article published as part of Lancet’s HIV and Sex Workers series in July 2014 suggested that “new biomedical technologies must be additive to, not replacements for, more established prevention modalities.” Just because we have new, effective ways to prevent HIV transmission does not mean we can afford to retreat from evidence-based prevention methods. We need to understand the local epidemic, identify key populations, and develop tailored combination prevention approaches, including behavioral and biomedical prevention options, and the community must be involved every step of the way.

PrEP for a new era

EMILY BASS writes: It was an exciting morning for pre-exposure prophylaxis (PrEP) using daily oral TDF/FTC (brand-name Truvada). In the morning plenary session, Chris Beyrer, of Johns Hopkins University and president of the International AIDS Society, spoke about HIV prevention in sex workers, gay men and other men who have sex with men. Beyrer pointed out that there is only one country implementing PrEP--the United States--at a national level. 

"I can’t wait until the PrEP era begins," Beyrer said. "Hopefully it is going to be soon." Beyrer is a staunch human rights advocate--founder and director of the Center for Health and Human Rights at Johns Hopkins--and it is good to hear support for PrEP in the context of a rights-based response. As he noted, there are many concerns in civil society about biomedical interventions like PrEP and ART for treatment and prevention, since the medical establishment is, often, linked with the state--eg governments that may be actively criminalizing and persecuting the very populations who are being targeted with new biomedical strategies. Beyrer's embrace of both rights and biomedical interventions is exactly what's needed--and it will be exciting when the PrEP era, as he defines it, begins.

Speaking of the PrEP era, it took a leap forward while the plenaries were taking place, as the French research agency ANRS released a press release announcing that its IPERGAY trial, which had been designed to evaluate intermittent PrEP use, had found evidence of efficacy and was going to end its randomized, placebo-controlled design. 

Briefly, this trial was launched after the iPrEx trial of daily oral PrEP showed efficacy in gay men, other men who have sex with men and transgender women. It sought to test intermittent use and had a placebo arm--a design decision that raised ethics questions from the outset, given the evidence of efficacy from iPrEx. The investigators had explained that since PrEP was not available or evaluated in France, the design was warranted. Plenary speaker Brigid Haire, who gave a compelling, nuanced talk on trial ethics and biomedical prevention, mentioned these questions specific to IPERGAY--perhaps at the precise moment that the press release was being released announcing the changes in the trial. (Kudoes to Haire and indeed anyone who isnt checking email compulsively during conferences...)

 In a delicious turn of phrase, Haire referred to the "tantalizing whiff of data" from the UK PROUD study of PrEP in gay men and other MSM. This trial found compelling evidence of efficacy earlier this month--a finding that triggered a review of the IPERGAY protoocol. It's exciting when a field evolves in real time--let's hope it keeps happening, as fast as Beyrer suggests it should.

From the conference floor..

Tiffany Hensley-Mccain from the Pharmaceutical Department, Washington National Primate Centre at the University of Washington, centre, discusses her research into Dysfunctional neutrophil response to SIV infection with, left, Madeleine Bunders from the Academic Medical Centre at the University of Amsterdam and Christina Thobakgale from the University of KwaZulu Natal

Supplying condoms is one thing; getting people to use them is another

WYCLIFFE MUGA writes: In a teaching session conducted by Prof Helen Rees, a really important question was raised; something absolutely fundamental for the public health policy aspects of the fight against HIV.

Here is the question: In light of the steady diminishing in global funding for HIV research, what really is the more important goal: to reduce HIV infection. Or to seek to stop HIV altogether?

In short, should we go flat out for the ideal solution? Or should we be content with doing the best we can, given the limitations that reduced funding imposes?
One (partial) answer is to focus on key populations. For example, in sub-Saharan Africa which accounts for about 42% of all HIV-related deaths and infections and yet is the one part of the world with the lowest access to health services, one might ask: What are the social drivers of this epidemic? Why are people vulnerable, and who are the people most at risk?

In most of Africa, young women are the most at risk. In some parts of the world, the most vulnerable are intravenous drug users. In the US, it is men who have sex with men.

But in the East African coast, intravenous drug use is an escalating problem.

One of the most frustrating aspects of HIV research is that every solution seems to create a fresh challenge. An example is in the use of anti-retroviral drugs in prevention of HIV infection. Pre-Exposure Prophylaxis (or PrEP as it is known) has been found to be dramatically effective with sero-discordant couples (one partner HIV positive; the other negative) and prevents one partner from infecting the other. The logical extrapolation of this is that what works with sero-discordant couples should work just as well with the general population; and so everyone considered to be at risk of HIV infection, should take up the same treatment regimen.

But then here is the question: Would someone who was not already infected agree to take Anti-Retroviral drugs for years on end, to prevent infection? This seems especially unlikely as some ARVs have unpleasant side effects?

While trying to get some idea from online sources of condom use across Africa, for example, I came across this: While the supply of condoms increases year on year, this does not guarantee an increase in their use. Poverty, relationship with parents, peers and partners, limited HIV information and education, gender dynamics, and beliefs and attitudes about HIV have all been found to work against condom use across sub-Saharan Africa – (See more at:

Apparently, supplying condoms is one thing: increasing their use is another.

The witchcraft potential of foreskins


WYCLIFFE MUGA writes: When the programme of Voluntary Medical Male Circumcision (VMMC) was first announced in Uganda (around 2007) one of its greatest critics was the Ugandan President, Yoweri Museveni. This was somewhat surprising because President Museveni had long been praised all over the world, as an African leader who had taken a place at the frontline of his country’s fight against AIDS (Uganda then having the dubious record of being one of the countries most devastatingly affected by HIV.)

On the face of it, President Museveni appeared to have a point: His argument was that this claim that male circumcision had been proved to reduce HIV transmission by 60% would be understood by most Ugandan men to be the long-dreamed-of get-out-of-jail-free card. And that on the assumption that the chances of getting infected had been drastically reduced, they would engage in wanton promiscuity which would ultimately INCREASE – rather than reduce – the incidence, and ultimately the prevalence of HIV.

And since this was at a time when it was widely anticipated within Africa, that sooner or later a ‘silver bullet’ against AIDS would be discovered in some sophisticated lab in Western Europe or North America (more or less what seems to be happening with Ebola now) this seemed to be a perfectly valid argument.

But, as it turns out, President Museveni was wrong. The VMMC programmes have been perhaps the single most important intervention against AIDS thus far, in the countries where such programmes were rolled out. Already about 6.0 million men have voluntarily submitted to circumcision and the target set is for 20 million men by 2016 or thereabouts.

And “risk-compensation studies” have since demonstrated that the men, who undergo such circumcision, are not in fact any more reckless in their sexual conduct than those who do not.

Of course – in my view, anyway, and as this is a self-selected cohort – there is the question of whether it is not the case, that such men who have already demonstrated a willingness to take steps to protect themselves and their families from the scourge of AIDS would be the very men most likely to be very careful and least reckless in their sexual conduct. And in any case, any man who is enrolled in this programme receives the most intense counselling imaginable, and all kinds of ancillary clinical services. Surely these too contribute to the drop in new HIV infections among circumcised men.

Back to the question of foreskins: With 6.0 million men circumcised over just a few years, well, that is a ton of foreskins: what do you do with them?

Of course the point here is that any medical intervention taking place within Africa – whether successful or not – will be subject to all kinds of rumours and speculations as to what the REAL objective is (e.g. “Might this be a new family planning method?” Or, “Why would anyone want to harvest so many foreskins, unless they knew that there is some kind of powerful juju which such foreskins can be used for?” Which would automatically lead to “Shouldn’t they be paying us for these valuable foreskins??”)

Just so you know: Dr Sgaier assured us that ALL the foreskins are treated as “biological waste” and are promptly incinerated.

Tuesday 28 October 2014

No, this is not Sexpo

LIZ MCGREGOR writes: There is lots of talk about sex at the Cape Town Convention Centre at the moment: words like anal sex; vaginas and penises are constantly popping up. No, this is not the Sexpo – it is HIV R4P, the archly-named international conference on biomedical methods of protecting ourselves against getting infected with HIV.

It is wonderfully non-judgemental – who you choose to have sex with, how often and in what manner – is totally irrelevant. The only subject of interest is how you stop a virus from destroying a human body.

The consequences for the intimate and emotional aspects of sex have not been entirely overlooked. As one of the many leading scientists here, Jared Baeten, professor of global health, medicine and epidemiology at the University of Washington, remarked: "We must remember that sex is not just a clinical activity. There is a whole generation which has grown up knowing only fear in relation to sex."

But, with more than two million people becoming newly infected last year, we need to throw everything at the virus.

At the ICC this week, four scientific prevention methods are under the spotlight – none are fail-safe and some are still nowhere near ready for universal use.

Medical male circumcision is the most accessible: it has been proven that a man who is circumcised reducing his risk of getting HIV from an infected partner by at least 60%.

Vaccines are still the holy grail and we are inching closer to finding one that works but we’re not there yet.

Another option being tried is Pre-exposure Prophylaxis: this means someone who is not HIV positive but is at risk takes anti-retrovirals as precaution. It is suggested it is used by an HIV-negative person if their sexual partner is HIV positive. Or in high risk groups – like the receptive partner in men who have penetrative sex with men. But obviously it is difficult to persuade someone who is not sick to take drugs which are potentially toxic. And it is very expensive as a public health option.

Treatment as prevention does work, however, when taken by an HIV-positive person, as it reduces his or her viral load and thus makes them far less likely to infect a partner.

The most promising option is microbicides, which are inserted into the vagina or rectum before and/or after sex. The results of a big study carried out in Cape Town are due early year and, so far, it is looking very hopeful.

Jargon watch: meet Fiebig

EMILY BASS writes: There comes a time at every scientific conference where someone says something I’ve never heard before. Today that was “Fiebig Stage.” Turns out, this is a series of phases of acute infection (another term that was a complete mystery when I first heard it—it means: someone who just got infected—like last week, yesterday, or within the very recent past.)
The phases are determined by the emergence of various traces of HIV, starting with components of the virus itself (viral RNA or vRNA), then the p24 viral proten (tested in the p24 antigen test) and on to HIV-specific antibodies. A little Google-ing revealed that this term has been around for several years, perhaps longer. But it seems to likely to get thrown around more as research starts to focus more and more on immune responses and treatment in these early, early days—it’s one component of cure research, an emerging area of research.
The good news is that it’s relatively easy to decipher—after all, many of us learned the WHO stages of HIV infection, which were used to describe illness in the absence of ARVs and/or CD4 cell monitoring. The less-good news is that it gives scientists, or anyone else, really, another way to use language that strips the person living with HIV out of the sentence. You might hear, “This person was a Fiebig Stage II.” But, if today’s presentation is any indication, you might also hear, about a group of people, “The Fiebig Stage IIIs.”

Language matters. When we stop referring to people and start referring to stages, it’s a further wedge between the science and the people who it can benefit. (This goes, too, for “the chronics”—another term used today, apropos of people with chronic HIV infection aka people who have had HIV for a while.)
Stay tuned for more jargon alerts as the conference goes on!

If it works, we should use it

ERIC MCHEKA writes: "While numbers and slogans are important in themselves, focus should also be given to interventions that are making positive impact," that's how Mitchell Warren, Executive Director of AVAC, opened the 2014 HIV R4P Advocates' Pre-Conference Workshop.
In his talk, titled, HIV Prevention: Research, reality & context, Warren observed that, "method mix is needed by the community members and not the policy maker." And so it is critical for civil society to push for access to the full range of biomedical interventions which research has proven efficacious, like PrEP (Pre-exposure prophylaxis) and VMMC (voluntary medical male circumcision). Such interventions have to be embraced by policy makers in Africa, if the quest to end the AIDS epidemic by 2030 is going to be achieved.
Warren summed up by saying that, "It is therefore incumbent upon us to ensure that all our efforts are aimed at rolling out interventions that would save more people from contracting HIV in our communities." I couldn't agree more.

Ebola: the lessons from HIV

EMILY BASS writes: People infected with ebola will never form their own version of ACT UP. They can't. The course of the infection from diagnosis to severe, immobilizing illness is swift. Post-diagnosis, quarantine is mandated. There so many things that led to the birth of the extraordinary AIDS activist movement--led by and for people living with the virus--including the fact that some of the first people diagnosed were white North American men who expected and felt entitled to a prompt response from a functioning health system. But the lifecycle of the virus also played a role. A movement led by and for people living with a virus is only possible in the context of a virus that you can, yes, live with, work with, protest and organize with, without putting one's own health or the health of others at risk. Ebola doesn't allow for this sort of organizing. So there just won't be a peaceful army of people living with ebola protesting the government inaction, underfunding and stigma driving this new epidemic. The good news is, there probably shouldnt be. If change depends on disease-specific based advocacy, there's going to be a lot of duplication, a lot of wheel-reinvention, a lot of competition for limited resources and global attention. So it's both strategic (not to mention overdue) that long-time AIDS activists, many of whom have spent decades working on HIV, TB and malaria, are looking at how to apply the lessons from the ACT UP era to ebola, today.

There's now an ACT UP Against Ebola movement forming in the US, complete with its own Facebook page Some of the activity, both on the page and in rapid responses organized over the past week, are focused on replacing hysteria with rationality in the American Ebola response--which includes national guidelines issued by the US CDC as well as state-by-state policies that range from mandatory at-home quarantine for travelers returning from West Africa (a major disincentive to US health workers volunteering in those areas) to self-monitoring and fever reporting. (A great review of some recent activities can be found here - -- with regular updates on the Facebook page.)

The US response is, of course, focused on fear--and not fighting an actual ebola epidemic. The larger question facing this group and all concerned health activists is: How do we develop and implement an agenda that makes the response in West African countries grappling with the virus more effective. One key step is bringing the voices of activists from these countries--Sierra Leone, Guinea, Nigeria, Mali, Liberia--to the fore. This hasn't happened, yet, but the conversations are beginning to percolate and shift into proactive outreach to help define specific goals and solidarity actions. "There are isolated individuals who are talking about it," says Micheal Ighadoro, AVAC Program Assistant and Nigerian AIDS activist. "We haven't started having the conversations as a group.

Here at HIV R4P, this solidarity is extending beyond civil society. In her opening plenary, the Minister of Science and Technology, Naledi Pandor, MP, said that she had just instructed her staff to look into initiatives that would bring South African expertise to the fore. These efforts--which could have had an even greater impact had they been triggered six months ago--are still essential. And as the AIDS epidemic has shown, when activists from all sectors work together--anything is possible.

Laying it all out

Nicollate Nkoko from Kenya displays a poster demonstrating her research into HIV transmission in infants
A study of the safety of using vaginal and rectal OTC lubricants conducted on monkeys

Eva Muro from Tanzania studied how to reduce drug resistance in mother to child transmission

The curious case of the sex workers who can't get HIV

SUNDAY 26th OCTOBER – SESSION 1 – PRINCIPLES OF HIV TRANSMISSION AND INFECTION: (Led by Amapola Manrique - Global Vaccine Enterprise)

WYCLIFFE MUGA writes: Some years ago, a small group of commercial sex workers – actively pursuing this line of work in a Kenyan slum (Majengo in Nairobi) were identified as having an innate immunity to the HIV virus. They had apparently been repeatedly exposed to HIV+ve customers, and yet had not once tested positive for HIV themselves. My question was, how is it that these women cannot get HIV infection, no matter how many HIV+ve men they have sex with? And why has this not led to any breakthroughs in the fight against AIDS?

The answer is that most ‘live’ HIV research is conducted using monkeys. Monkeys have their own variety of what in humans is HIV. It is called SIV – Simian Immunodeficiency Virus (as opposed to HIV being ‘Human Immunodeficiency Virus) – and apparently can exist in the bodies of monkeys without doing any real harm. So research in monkeys can give all kinds of insights and data about how these viruses behave. But there are obvious ethical barriers to what can be done to study a human being who simply cannot get infected with HIV despite repeated (and indeed, overwhelming) exposure to the virus.

This is a world-class conference on HIV. Many speakers are leaders in their fields. And yet what one hears all the time is, “Nobody knows”. For example, nobody knows why those women in the Majengo slums cannot get infected by HIV despite being engaged in (mostly unprotected) sex work. Nobody knows why - in 70% to 80% of infections - it is a single virus only, that will move across the vaginal (or rectal) mucosa and pass on HIV infection between sex partners. It all suggests a selective process: but nobody knows how or why.

But that is the way of science: again, contrary to popular assumption, it is not about one heroic figure emerging who will somehow come up with the shattering insight which finds a key to an AIDS cure or an AIDS vaccine which effectively stops all new transmission.

Victory against AIDS will involve many small incremental steps, and the efforts of thousands of dedicated scientists around the world.

And this is why conferences as this one are important – they allow for networking opportunities between scientists, policy makers, the media, activists/advocates and many others who are collectively involved in the global effort to put an end to one of the most deadly scourges of our time, and possibly the greatest public health challenge of recent decades.

At the end of this first day in Cape Town, it is clear that I am not here to find out the answers to my questions, as provided by the top experts: I am here to learn what kind of questions the experts are asking each other.

A Kenyan in Cape Town


WYCLIFFE MUGA writes: There are no direct flights from Nairobi to Cape Town. You first have to fly to Johannesburg; and then take a ‘local flight’ to Cape Town. It was a huge relief to be able to use the ‘new international terminal ’at the Jomo Kenyatta International Airport, as it compares favourably with the passenger terminals at both O.R Tambo International Airport in Johannesburg, and the Cape Town International Airport. On a previous visit to South Africa, when I got back to Kenya, I was embarrassed at how poorly our Nairobi airport compared to the South African airports, never mind JKIA is supposed to be a “major regional transport hub”.

In case any South African is reading this, let me tell you in case you do not know: the great Kenyan national obsession is to “catch up with South Africa”. We hear very often that economic development in Africa revolves around four main countries: Egypt to the north; Kenya in the east; South Africa; and finally Nigeria to the west.

And though both Egypt and Nigeria are much richer than Kenya (as is South Africa, of course) you will rarely hear a Kenyan say, “Why can’t we be more like Nigeria? Or more like Egypt?” It is South African roads, airports, sea ports, universities, and other marvelous public infrastructure which keep us awake at night, with the recurring question: Will we ever catch up with South Africa?

One other notable aspect of this trip: on the Johannesburg-Cape Town segment of the flight, there was a white South African man, making jokes and laughing very loudly with the stewardesses. I was seated right at the back, and just one row in front of him, so I heard (even though I did not understand) every word they were saying.

So, why did I not understand what was being said? Well, they were not speaking in English. Nor was it Afrikaans (which I would be able to make out, even if not comprehend). No, they were speaking in one of the “native languages” of South Africa. This white South African not only spoke the language (Zulu? Sotho?) fluently, but could even tell elaborate jokes in the language. He was only laughing moderately himself: but the all-black crew of stewardesses, plus the white lady he was sitting with (presumably his wife) were absolutely in stitches.

Kenya is considered to be a successfully multiracial country. We may have the most bitter tribal resentments but we have no inter-racial animosities to speak of. But I cannot imagine seeing that kind of thing on an internal flight (say, Nairobi to Mombasa) – a white Kenyan loudly making jokes with the cabin crew, in a local language (e.g. Kiswahili). Certainly I have flown between various Kenyan towns and cities for decades now, and not once seen anything like that.

Like HIV, ebola started among poor African people

Helen Rees, Executive Director of the Wits Reproductive Health and HIV Institute of the University of the Witwatersrand: "Ebola started among poor African people in four pour African countries. It was only when [the number of] deaths started to be bigger and the world became insecure that the world mobilised a response.

There were vaccines and medicines sitting on shelves and not being progressed because it was a disease of poor people in poor countries. That is exactly what happened with HIV. [With ebola], it is being squeezed into a couple of months.

Now we are seeing fear and panic across the world - and we are getting stigma as a result. In Liberia, a community of men who have sex with men are being blamed for ebola by a particular Catholic bishop. Politicians are making hostile decisions with regard to quarantine."

Sex and death

Jared Baeten, professor of global health, medicine and epidemiology at the University of Washington: "We must remember that sex is not just a clinical activity. There is a whole generation which has grown up knowing only fear in relation to sex"

Young South African women still getting infected at an alarming rate

Slide showing that 44% of women aged 23 to 34 in Vulindlela  are HIV positive

Science Minister Naledi Pandor calls for South Africa to research ebola prevention as well as HIV

South Africa's Professor Helen Rees opens the HIV R4P conference at the ICC...

Helen Rees points out that South Africa is still the epicentre of the Aids epidemic. We have more than two million people on treatment. But the change in political leadership means we are also now at the forefront of HIV research - and prevention strategies are our key focus

Monday 27 October 2014

At the media training workshop for community journalists and communications officers on October 23, ahead of the conference

From left: Manju Chatani, Angelo Kaggwa-Katumba, Manju Chatani and Kay Marshall from AVAC listen as Dr Katherine Gill from the Desmond Tutu Foundation explains the latest developments in HIV prevention research

FROM LEFT: Mary-Anne Gontsana from Ground-up; Bucy Kowa and Aviwe Maham from Radio Zibonele and Alison Best from TB/HIVCare listen as Desiree Rorke from Die Tygerburger asks a question