Top Five Lessons from Vienna

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Many themes emerged during the 18th International AIDS Conference last week in Vienna. Here is our list of the top five:

Universal Access to HIV Treatment and Prevention Remains Elusive Goal

From comments by Bill Gates to the many activist demonstrations, a main theme at IAS 2010 was fear over dwindling funds dedicated to the HIV/AIDS pandemic. The Obama administration took significant heat for recent budget proposals for FY2011 that indicate a retreat from the promise to fund global AIDS at $50 billion over the next five years. Austria also faced targeted criticism for not committing funds to the Global Fund, despite its role as the host country for IAS 2010.  Various speakers and activist actions also called out Canada, Germany and France for back-peddling on their commitment to global AIDS and the Global Fund, while African activists challenged their own leaders to honor the Abuja Declaration and to commit 15 percent of their respective budgets to health.

Also of note was the grave concern expressed by activists from Eastern Europe and citizens of the former Soviet Republics about changes in Global Fund eligibility criteria that may put their proposals at a disadvantage.  Numerous stories and presentations highlighted the failure of many of these governments to put resources into harm reduction and into treatment programs serving the highly stigmatized populations of injection drug users (IDU), commercial sex workers and prisoners who represent the major HIV-affected populations in the region.

Keeping Step with PrEP

There are many trials testing the ability of antiretrovirals (ARV) to prevent acquisition of HIV infection underway, and the results of two such trials gained quite a bit of attention at IAS 2010. Most notably, the CAPRISA trial demonstrated that  a vaginal gel containing tenofovir can protect women from acquiring HIV, lowering the rate of HIV infection in women in South Africa using the gel by 39 percent compared to the placebo arm of the trial over two and a half years.  A CDC Safety Study also found that oral tenofovir used for pre exposure prophylaxis (PrEP) was safe, well-tolerated and did not seem to promote increased behavioral disinhibition in HIV-negative MSM in three U.S. cities. Additional studies are underway, but there is now great hope that this biomedical tool could empower women and men to protect themselves from HIV infection. 

However concerns are being raised about whether resources will be available to offer this prevention tool to those who need it the most.   Implementing PrEP must be viewed in the context of the huge unmet treatment need of those already infected with HIV, and the work still to be done to scale-up other prevention interventions such as male circumcision and prevention of mother to child transmission (PMTCT) programs.

Early Treatment Preserves Health and is Cost-Effective

Several sessions exemplified the cost effectiveness of treating early versus treating later – when costly opportunistic infections begin to emerge. During a “When to Start” panel, Dr. Peter Mugyenyi, Director and Founder of the Joint Clinical Research Center in Kampala, stated that the cost of treating an opportunistic infection like cytomegalovirus for one month is equal to the cost of providing HIV treatment for three years in Uganda. 

The results of the CASCADE study, also presented at the conference, support early treatment as well, with patients that started HIV treatment when their CD4 cell count was between 350 and 500 faring better than those who initiated therapy with CD4 counts at 350 or below. Another study by South African researcher Meyer-Rath presented compelling data on the cost effectiveness of treating infants early as well, in part because early treatment conserves resources that would otherwise be spent on hospital costs.

HIV/TB Co-Infection:  Important Findings but Low Profile

In a late breaker session, French researcher Blank presented data from the CAMELIA trial showing that initiating ARV therapy at the earliest opportunity when treating HIV/TB co-infection is most beneficial.  The clinical trial in Cambodia found prolonged survival in untreated HIV-infected adults with very weak immune systems and newly diagnosed TB by starting anti-HIV therapy two weeks after beginning TB treatment, rather than waiting eight weeks, as has been standard.

In a concurrent session focused on TB/HIV, STOP TB Partnership Director, Marcos Espinal and UNAIDS Director Michel Sidibe signed a compact to coordinate their efforts to escalate the field response to HIV/TB co-infection. This  collaboration will hopefully improve the dismal performance to date in ensuring that HIV patients are screened for TB, and in prescribing isoniazid preventive therapy to HIV patients who do not have active TB disease.

There was also an important meeting of the TB/HIV Working Group of the STOP TB partnership focusing on the special challenges related to TB/HIV co-infection and multi-drug resistant TB experienced in Eastern European countries, especially among IDU.

Nevertheless, it was disappointing that issues related to HIV/TB co-infection did not merit a plenary talk at the conference given that TB accounts for nearly  a quarter of HIV-related deaths worldwide.

Bridging the Gap

An IAS 2010 pre-meeting with HIV/AIDS health experts, policy makers and economists focused on how HIV fits into the larger agenda of strengthening health systems in developing countries. Does investing in HIV treatment and prevention mean an investment in health infrastructure overall, or are the two separate and distinct? Experts argued that lessons learned from the scale up of HIV programs informed investments in overall health systems. And while existing data on the interactions between the two are scarce, most agree that in order to best utilize scarce global health funding, bridging the gap between researchers, donors, implementers and other sectors must happen. The meeting was an important attempt to forge common ground and end the debate about whether donor governments should be funding disease-specific programs like HIV prevention or treatment programs, or financing health system development in poor countries.

Two of the presentations from this pre-meeting are available online: Bridging the Divide: Inter-Disciplinary Partnerships for HIV and Health Systems; and When Does HIV Funding Strengthen Health Systems?

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