IAS 2023 brought together civil society, advocates, policy makers, donors, and scientists to share the latest HIV scientific findings and discuss where advocacy is needed to both advance research and ensure equity informs every aspect of the development process, from basic science to delivering new interventions. Read on for highlights from the conference.
AVAC at IAS
This satellite, co-sponsored by PATH, IAS, WHO and AVAC, put a spotlight on integrated, person-centered care, a central theme of the 2023 UNAIDS report launched at IAS 2023, The Path That Ends AIDS. UNAIDS reports that investing in person-centered priorities such as community-led services, integrating primary health care with HIV services, and a strong health workforce brings down incidence. And the pressure to scale up these approaches remains essential. According to the latest statistics in the report, only 42% of districts in African countries with very high HIV incidence are covered by prevention programs. Even more chilling, 4,000 adolescent girls and young women acquire HIV every week. A presentation in this session by former AVAC Fellow and CASPR partner Chilufya Kasanda from Zambia’s TALC put a face and a voice to this story. In Zambia, youth friendly services are scarce or non-existent, high rates of mental health issues are utterly neglected, and donors “flock to a few locations and leave out those who are most in need.” She said community advocates are too often dismissed as “people just making noise.” But, said Chilufyia, it’s young people who must receive support, their leadership must be nurtured and funded, and messages should be tailored just for them. “Young people need to know that pleasure, not only risk, is attached to sex. To get to pleasure, you need to be safe, that is the message.” Another AVAC Fellow, Elizabeth Onyango from Kenya’s Coast Sex Workers Alliance, called for accelerating access to the dapivirine vaginal ring. “Why is the ring not in our vaginas? Male condoms even come in different flavors! This is a women-first product and it needs more investment.”
Prevention will fail if the HIV response remains narrowly focused on products. Oral PrEP has brought invaluable lessons we have yet to learn about how to get programming right so that effective products actually reach those who need them. As AVAC Executive Director Mitchell Warren said at the conference, reflecting on the status of PrEP uptake since FDA approval in 2012- “Only 4m global PrEP initiations in 12 years is an epic failure. Science has given us products that work, but our policies and programs have failed to meet the needs.”
This session featured presentations from AVAC on a package of tools called Getting Rollout Right and the work of the Coalition to Accelerate Access to Long-Acting PrEP. Daniel Were of Jhpiego talked about lessons from the Jilinde project, Kenya’s ambitious program to deliver PrEP. The project adapted in real time to reach more people by recognizing that peer networks are essential, that stopping and starting PrEP is common, and that provider attitudes can be difficult to change. Daniel stressed the importance of focusing deeply on the people who need to use these products.
Investigators and advocates discussed innovative methods to test how new interventions compare to oral PrEP, and how to also make comparisons to HIV incidence in a given community. Models of community engagement were just as important in the conversation. Ntando Yola of APHA described robust programs that brought community members along as these complex new trial designs were developed. Investing in Good Participatory Practice means investing “in the platforms that equip and empower communities and advocates,” said Ntando. And for more on how trial design is evolving, check out AVAC’s Evolving Designs for HIV Prevention Trials.
U=U and Zero Risk
In a policy brief released at IAS 2023, the WHO directly affirmed zero risk of HIV transmission from people living with HIV who have an undetectable viral load using any WHO-approved test and who adhere to treatment. The brief, The role of HIV viral suppression in improving individual health and reducing transmission, also emphasizes the importance of expanding viral load testing, particularly in low and middle-income countries (LMICs) where access to testing falls far short of the need. The Lancet also published the WHO’s systematic review of the data behind this finding, championed since 2016 by the U=U campaign (undetectable=untransmittable).
A Call to Expand HIV Self-testing
The WHO announced new HIV testing guidelines, calling for countries to expand use of HIV self-testing (HIVST) and to promote testing through social networks. In a July 22 press release, the WHO said, “These recommendations are issued at a moment of unique opportunity, when self-care and self-testing are increasingly being recognized as ways to increase access, efficiency, effectiveness and acceptability of health care across many different disease areas, including HIV.”
HIV Research Highlights
Women Want CAB for PrEP as a Choice in HIV Prevention
Researchers presented findings from the open label extension study of HPTN 084 studying injectable cabotegravir (CAB) for PrEP, among individuals born female. Among 2500 participants in seven African countries, nearly 78% chose injectable CAB and 22% preferred oral PrEP. And a related study, HPTN 084-01, also found CAB for PrEP was generally acceptable to a small study of cisgender adolescent women in a study conducted in South Africa, Uganda and Zimbabwe. 92% opted to continue use of CAB for PrEP in the open label extension. The study also found that engagement of parents or guardians could be pivotal, providing young women with the support they need to make choices with confidence. The HPTN’s Erica Hamilton said the study reinforces how much choice matters. “The efficacy of CAB for PrEP was reassuring, but some participants still preferred the oral tablet [which also has very high efficacy] for various reasons.”
New Data on VMMC Among Gay Men and Other Men Who Have Sex with Men (MSM)
A small but noteworthy study from eight cities in China showed VMMC offered protection against HIV transmission among MSM. Researchers say this first randomly controlled trial demonstrating efficacy among MSM should be followed up by larger trials.
Tracking the Inclusion of Transgender People in Research
The launch of AVAC and the Office of HIV/AIDS Network Coordination’s (HANC) Clinical Trial Scoring Tool, provided an initial analysis of the inclusion of transgender people in HIV research and a tool for tracking inclusion in the future. This tool generated great excitement during the poster session. The score card evaluating HIV research since 1991 found less than 1% of participants in 41 key HIV studies included transgender populations. “Dozens of attendees from Harare to Montreal to Hyderabad had questions and expressed interest in using the scorecard and applying it to other populations, too.”