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Px Wire: July-September 2016

Volume 9, Number 3
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AVAC's Take

Oh, International AIDS Conference. You’re the meeting that’s impossible to ignore! You’re so big, so flashy, so full of contradictions: news and hot air, circus and seriousness.

And yet, a month on, we’re still thinking about you. Because, when it comes to the HIV response, what we sensed at Durban was a climate change. Like the one threatening our planet, it’s a dire situation and a call to action. The two most important data points from the whole meeting are: (1) new cases of HIV aren’t going down and (2) funding is. Really, that could have been enough to discuss for the whole week. But of course there was far more! At the end of the day, it is not so much what happens at the conference but what happens after. Here’s what crystallized last month in Durban. –AVAC

Data Dispatch

Non-ART prevention is on the agenda.

UNAIDS’ Prevention Gap report, released just prior to the conference, showed that overall there has been no decline in rates of new HIV diagnoses worldwide. This big picture masks major regional variations in incidence trends, but the overall report of flatlined incidence was a sobering wake-up call. It may have been exactly what was needed to make Durban a meeting where non-ART prevention was discussed frequently and fervently. For example, we’ve never heard as much PrEP love at an IAC as we did at Durban 2016.

click for the centerspread

There was also positive news on the dapivirine vaginal ring. New analysis of data from the completed ASPIRE efficacy trial, showed higher protection among women who used the ring consistently. The product has been designed to be worn in the vagina for roughly a month. The ring is now moving to the next step in the research process—open-label extension studies among efficacy trial participants who will now be offered the ring (no placebo) with clear messages that it works if you use it. Voluntary medical male circumcision, which is not dependent on adherence, and already showing population-level impact was on the back burner in most presentations. But a rising tide lifts all boats, and a pro-prevention platform for the global HIV response will undoubtedly include strong calls for VMMC. There were also strong, specific calls for a rights-based response that meets the needs of people who inject drugs, prisoners and sex workers, as well as LGBT people.

90-90-90 is getting “ground-truthed” ...kinda.

Is 90-90-90 going to change rates of new HIV diagnoses? The only way to find out is by measuring incidence in places where ART coverage and viral load monitoring are available on demand. One early data set presented at Durban came from the French research agency ANRS. They conducted a randomized trial (ANRS 12249 TasP) that provided some communities in South Africa’s KwaZulu-Natal province with ART as soon as HIV was diagnosed. Other communities in the province received ART at a later stage, according to national guidelines. Those communities with access to immediate ART had higher levels of ART initiation and higher rates of virologic suppression than those communities that received standard care. But no incidence reduction was seen in the study communities with immediate initiation. Similar data have been reported in Botswana. It’s likely that the impact of ART for prevention is going to be affected by gaps in coverage for specific demographics (e.g., by gender, age, etc.), or in terms of absolute levels of ART coverage in a community. Overall, at the end of the trial, ART coverage was less than 40 percent. That’s less than half the way towards the third “90” (virologic suppression), which may be why no impact was seen.

More data like those from the ANRS study are on the horizon. The SEARCH study, ongoing in East Africa, is rolling out a 90-90-90-inspired package along with basic health services—and soon—PrEP. In Durban, investigators reported that the study communities had exceeded the UNAIDS’ “90-90-90” goals for testing, ART and viral load suppression. The study noted that people younger than 25 were less likely to know their status, initiate ART and be virologically suppressed compared to older individuals. Will SEARCH lead to lower incidence? These data are expected in 2017.

Whether from SEARCH or other trials, funders and governments alike are looking for success. If the early data don’t all point to incidence reductions, that doesn’t mean these programs are failing. The message should be that ART scale-up needs to be matched by scale-up and monitoring of other essential interventions. This includes scale-up of VMMC coverage to 80 percent of eligible men in all countries where it’s a priority; development of treatment and prevention cascades that report by age, gender and key population status; massive scale-up of harm-reduction programs in the Eastern European and Central Asian regions where incidence is increasing most dramatically; and targeted, supported use of PrEP globally.

The most important data aren’t always where—or when—you think.

IAC room assignments often signal the relative importance of an issue. A bigger room can mean a bigger expected audience. In Durban, data on the impact of vaginal bacteria on women’s susceptibility to HIV, and on levels of vaginally delivered tenofovir, were presented in a “Special Session” in the arena-sized Session Room One.

Using samples taken from women who participated in the CAPRISA 004 microbicide trial, investigators identified a vaginal bacteria called Prevotella bivia that seemed to increase risk of acquiring HIV, and another one, Gardnerella, that metabolized tenofovir. Could it be that Prevotella bivia is part of the explanation of why young African women are so susceptible to HIV? And could tenofovir-munching Gardnerella explain why tenofovir gel didn’t show much protection overall in the efficacy trials? Well, maybe. Vaginal health is enormously important as part of a holistic approach to women’s sexual and reproductive health. But it’s important to note that there’s no evidence that vaginal bacteria adversely impact the drug levels of oral PrEP, which arrives in the cells of the vaginal mucosa via the blood stream, not a vaginally applied gel. So this question would need to be examined separately. In the trials where young women weren’t protected by oral PrEP, they weren’t taking it, according to tests that looked for the drug in their blood.

Meanwhile, at a 7am satellite session, a World Health Organization-commissioned report on existing data regarding the potential interaction between hormonal contraception and HIV risk found “increasing concern” about Depo-Provera, or DMPA, and its impact on women’s risk of getting HIV. That’s the first time a systematic review of available data has indicated that the data suggest there is cause for concern. It’s also the first time this concern has been quantified. If there is an impact—and that’s still an if—it’s somewhere at or below a fifty percent increase in risk compared to a woman not using DMPA. That’s the kind of impact that deserves at least as much attention as the impact of vaginal bacteria on susceptibility—and AVAC is working with collaborators to ensure that attention is indeed paid. We have detailed resources and regular updates on these new findings that you can get by subscribing to our Advocates’ Network.

Some global warming trends are good.

The best news from Durban and the best reason to go to an IAC is to feel the heat of the activist movement, which is not just surviving but thriving and taking new forms, with youth-led protests, smart and urgently needed campaigns to protect generic medications and much more. We left Durban hot and heavy for change.