Turning the Tide After AIDS 2012: Moving Toward an AIDS-Free Generation Together

President William Clinton at Closing Session of AIDS 2012. © IAS/Steve Shapiro - Commercialimage.net

President William Clinton at the closing session of AIDS 2012. © IAS/Steve Shapiro – Commercialimage.net

It’s been nearly two weeks since former President William J. Clinton closed the last session of the XIX International AIDS Conference(AIDS 2012) and delegates returned home.

This year’s conference featured commitment and calls for an AIDS-free generation, a growing interest in Option B+, and new research towards a cure.  Here are some reflections from what we learned at AIDS 2012, where we truly started “turning the tide together”.

Clinton calls for a blueprint toward an AIDS-free generation

Secretary of State Hillary Rodham Clinton at AIDS 2012. © IAS/Ryan Rayburn - Commercialimage.net

Secretary of State Hillary Rodham Clinton at AIDS 2012. © IAS/Ryan Rayburn – Commercialimage.net

Secretary Hilary Rodham Clinton announced significant funding towards preventing mother-to-child transmission (PMTCT) of HIV, South Africa’s plan for voluntary medical male circumcision, and money for “implementation research,” civil society, and country-led plans. Sec. Clinton also called on Ambassador Eric Goosby to provide a blueprint for achieving an AIDS-free generation during her plenary address. Numerous other stakeholders echoed her commitment. But, if we really want to achieve an AIDS-free generation, the $7 billion funding gap that stands between where we are now, and where we should be, will need to be erased.

Option B+ takes center stage

Dr Chewe Luo at AIDS 2012 (Photo credit: S. Holtz/MSH)

Dr Chewe Luo at AIDS 2012 (Photo credit: S. Holtz/MSH)

There is growing consensus that countries should embrace Option B+ to decrease or eliminate vertical HIV transmission. Option B+ — whereby HIV-infected pregnant women are put on antiretroviral treatment for life regardless of their CD4 count — originated in Malawi. In its first year of implementation, the country has seen a 6-fold increase in ART uptake among HIV-infected women. Many plenary speakers and presenters, including UNICEF’s Dr. Chewe Luo, praised the approach and encouraged uptake in other countries.

Elimination of pediatric AIDS by 2015

Along with Option B+, there is a renewed call to action to end pediatric HIV by 2015. MSH welcomes that discussion and the political commitment to achieve it. Great progress has been made toward this ambitious goal in the short history of preventing mother-to-child transmission of HIV: from 2009 to 2011, the number of new HIV infections in children decreased by 24% to 320,000 last year. That is still too many. It is clear that we will not achieve the goal of eliminating pediatric HIV unless we apply some serious innovations and new thinking.

Photo credit: AIDS 2012.

Key vulnerable populations face a growing epidemic

The epidemic is still growing in key vulnerable populations, including: men who have sex with men (MSM), sex workers, and injection drug users (IDUs). Participants discussed lessons learned and programming improvements to help stabilize and turn the tide on the growing HIV epidemic among MSM. For many years HIV care, treatment and prevention programming for sex workers has been less than effective. This year there seemed to be more momentum and reexamination on how we approach prevention in sex worker communities. The IDU population is perhaps still the most marginalized and difficult to reach in many countries. At AIDS 2012, we saw the beginnings of change as countries are starting to think about how to scale up national responses to reach this at-risk population.

Scott Kellerman (left) moderates a session at AIDS 2012. (Photo credit: S. Holtz/MSH)

Scott Kellerman (left) moderates a session at AIDS 2012; Erik Schouten (right), panelist. (Photo credit: S. Holtz/MSH)

Treatment is prevention

Our prevention toolkit is growing. The most promising prevention efforts currently include male medical circumcision and treatment as prevention, pre-exposure prophylaxis, with ongoing hope for further advances in microbicides and vaccines. Male medical circumcision has been shown to dramatically reduce the risk of HIV infection for men by about 60%. The HPTN 052 study that concluded last year definitively proved that initiation of antiretroviral therapy (ART) by HIV-infected individuals substantially protected their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission. New research presented shows that not only is treatment as prevention effective, its very cost-effective as well.

No longer do we have to qualify the term treatment as prevention, we now know that treatment is prevention. Now the hard work begins, how best to bring these innovations to scale

Tackling HIV & AIDS and chronic non-communicable diseases (NCDs)

Panelists at AIDS 2012 Satellite Session: Beyond MDG 6, July 22, 2012. (Photo credit: S. Holtz/MSH)

Panelists at AIDS 2012 Satellite Session: Beyond MDG 6, July 22, 2012. (Photo credit: S. Holtz/MSH)

Delegates discussed how to use the HIV & AIDS infrastructure to tackle chronic non-communicable diseases in low and middle income countries. One session, “Beyond MDG 6: HIV & NCDs” led by MSH, Pan American Health Organization (PAHO), and partners, focused on how the global health community can fight the dual epidemics by integrating health systems toward universal health coverage (UHC). In other sessions, experts noted the long neglected reality that is now upon us: with the phenomenal success of ART treatment programs, we’re now faced with an aging population of people living with HIV, and dying from tuberculosis (TB) and chronic NCDs.

Searching for a cure

Researchers released new findings at the conference, renewing a focus on finding a cure. Although all agree we’re not there yet, promising findings provide for some measure of optimism: We’re getting people on treatment; we’re getting viral loads down, maybe we can beat this.

“The science has been telling us for some time now that achieving a cure for HIV infection could be a realistic possibility,” said IAS President Françoise Barré-Sinoussi, PhD, Director of the Regulation of Retroviral Infections Unit at the Institute Pasteur in Paris. “The time is right to take the opportunity to try and develop an HIV cure – we might regret never having tried.”

Involving communities and countries for sustainability

XIX International AIDS Conference (AIDS 2012) Washington D.C. © IAS/Steve Shapiro - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington D.C. © IAS/Steve Shapiro – Commercialimage.net

Many presenters throughout the week reinvigorated discussions around bringing care, treatment and prevention services to the community via door-to-door testing, care, treatment and support — a not so subtle reminder that successful programs must adapt to suit the communities they serve and not the other way around. Also encouraging was the news that many countries, even those that extremely resource-limited, are contributing increasingly larger proportions of the resources to the HIV & AIDS response.

Other experts eloquently reminded us of the continued intersection of the HIV and TB epidemics, the role that social determinants of health (such as poverty) play in perpetuating the epidemic, and the unmet $7 billion funding gap needed to truly provide universal access for HIV & AIDS drugs. One session captured the unique challenges of improving HIV prevention, care and treatment in fragile states.

Kuala Lumpur & Melbourne: Looking to 2013 & 2014

Optimism filled the convention center during AIDS 2012. To be sure, challenges remain, and we have much to do to close the treatment gap and move sincerely towards elimination of pediatric HIV, but for the first time in memory, the hope that filled the halls was palpable and there was a sense that we can move forward and decrease the terrible hold that HIV has had on people these last 30 years.

As we reflect on what we learned, we also look to the future for HIV & AIDS treatment, prevention, and care. For the next two years, we look forward to being in Asia and hope to see much increased participation from our Asian colleagues. We’ll be meeting in Kuala Lumpur, Malaysia, in 2013 to discuss the scientific progress made by ourselves and our colleagues. The Kaiser Family Foundation and Center for Strategic & International Studies (CSIS) high-level panel said that key issues in Melbourne (AIDS 2014) will likely include country-level and human rights concerns, and more on the search for a cure, as well current results on implementation science and results of the HPTN052 studies.

"Turning the Tide Together" AIDS 2012.

We’re looking forward to seeing you there, and continuing this vital work together.

What was your favorite moment or lasting impression from AIDS 2012? What do you hope will be different in Kuala Lumpur (2013) or Melbourne (2014)? Tell us your thoughts below.

 

5 Days, 5 Plenaries, a World of Experience

The XIX International AIDS Conference featured five full days of plenaries with high-level speakers and community activists. The plenaries exemplified the diversity of topics covered throughout, and the global experience of people attending the July 22-27  conference. The plenary round-ups below are a great way to re-enter the experience of AIDS 2012, whether you attended the conference or just want to learn more.

Chioma Nwuba Wows the Crowd at AIDS 2012

Chioma Nwuba at AIDS 2012 discussing sustainability and local ownership.

Chioma Nwuba at AIDS 2012 discussing sustainability and local ownership. (Photo credit: S. Holtz/MSH)

The Kwara state of west-central Nigeria suffers many health-related challenges: an HIV prevalence rate of 2.2 %, a large geographic area, difficult terrain, a rural population, poor access to health facilities, long waiting time at facilities, and shortages of human resources for health. These are some of the factors thought to contribute to poor uptake of HIV testing and CD4 investigation (a test to determine whether or not a patient is eligible for HIV treatment) and the high level of attrition of patients living with HIV at all stages of the treatment process — from HIV testing to commencement of treatment to long-term treatment.

Enter Chioma Nwuba, laboratory specialist with the Prevention and Organizational Systems – AIDS Care and Treatment Project (ProACT) in Kwara state to the XIX International AIDS Conference. On Wednesday, July 25, Chioma presented “A laboratory-based approach to reduce loss to follow-up of HIV positive clients” to a standing-room only crowd at the oral abstract session on HIV linkage retention in care. She described the “MSH” leadership and management approach used by the ProACT project: The hospital management committee assessed the situation and made decisions that ultimately streamlined service delivery at the facility — ensuring sustainability and local ownership.

Thanks to the intervention: data clerks now fill laboratory request forms instead of clinicians; lab technicians collect and test blood rather than clinicians; escort services are strengthened so patients are enrolled and undergo lab tests on the same day; lab tests are provided Monday through Friday rather than just once a week; and test results are provided quickly to ensure initiation on treatment.

Twelve months after the intervention, the number of clients accessing CD4 investigations increased from 53.8% to 93.3%, the number of clients lost along the treatment process reduced from 58.7% to 10.7%, turnaround time for certain test results decreased from 7 days to 24 hours and the average client wait time decreased from 4 to 1.5 hours.

The project staff have found that strengthening laboratory systems helps increase uptake of CD4 investigations, shorten client waiting time and ultimately reduces loss-to-follow-up, especially among clients attending clinics from hard to reach communities with difficult terrains.

ProACT is a five-year, 60-million-dollar, follow-on project to the Nigeria Leadership Management and Sustainability (LMS) AIDS Care and Treatment Project (LMS-ACT). ProACT supports HIV & AIDS and TB services in six Nigerian states: Kogi, Niger, Kwara, Kebbi, Taraba, and Adamawa. The project places a strong emphasis on building the capacity of government and civil society organizations to strengthen health and HIV & AIDS systems for delivery of integrated health and HIV & AIDS and TB services.

 

Day 5: Living and Aging with HIV, Dying from TB and NCDs

Judith Currier speaking at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC.  © IAS/Ryan Rayburn - Commercialimage.net

Judith Currier speaking at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

Volunteers were handing out t-shirts as we arrived at Friday’s plenary of the XIX International AIDS Conference. When Marie from Results South Africa asked all t-shirt recipients to stand, over a quarter of the delegates rose from their chairs. These individuals represented the percentage of people worldwide who are co-infected with HIV and tuberculosis (TB). This powerful metaphor — 25 % of the people in the room on their feet — highlighted the morning’s theme: integrating HIV/AIDS care and treatment into disease-specific and broader health services.

The “Bell Tolls” For HIV & TB

The session’s first presentation, “Science and Implementation to Turn the Tide”, was delivered by Dr. Tony Harries, senior advisor at the International Union Against Tuberculosis and Lung Disease. Dr. Harries began by stating that 350,000 people had died from HIV/TB co-infection in 2010, and that many of these deaths were preventable.

With evidence-based research and World Health Organization (WHO) recommendations, Dr. Harries argued that co-diagnosis, early ART, and isoniazid preventative therapy (IPT) are answers to the pressing problem of increasing HIV/TB co-infection.

Harries also emphasized a need for “better, cheaper, and quicker” TB diagnostic tests. He explained the benefits of two diagnostics: Xpert MTB/Rif, which provides TB test results in two hours, and Urine TB LAM, which derives a diagnosis in just 30 minutes. “Diagnosis is not just about accuracy,” Dr Harries explained. “It is also about feasibility, speed, costs, and overall impact in saving lives.”

Harris concluded his presentation by urging health professionals to address HIV/TB co-infection by advocating for improved policy and practice, conducting needed research, implementing evidence-based strategies, and tackling poverty, which drives the epidemic. After this call to action, Dr. Harris closed with powerful quote from the famous British poet, lawyer and priest, John Donne: “Any man’s death diminishes me because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”

Aging with HIV — Dying from NCDs

Dr. Judith Currier from the University of California then took the stage to present her talk on “Non-communicable Diseases (NCDs) and Aging in HIV.” She began by praising the public health community for supporting improved access to ARVs, which has extended the lives of many people. She shared positive results that show half of all people living with HIV in the US by 2020 will be over the age of 50.

While enjoying the many benefits of longer lives, Dr. Currier also explained that this longevity puts HIV patients at risk for other health problems, including NCDs. The most prevalent NCDs impacting HIV patients today include cardio-vascular disease, cancer, diabetes, and chronic respiratory disease. In 2008, 36 million people died of NCDs. To address the crisis of NCDs among HIV patients, Dr. Currier suggested the following interventions: (1) improved screening and monitoring for NCDs; (2) early diagnosis of NCDs in TB patients and prompt care; (3) smoking cessation interventions; (4) dietary and exercise education; (5) earlier start of ART; (6) tailored ART regiments to reduce the risk of NCDs; (7) expanded global use of safer ART drugs; (8) evaluated treatment for NCDs in HIV patients; and (9) integrated screening and treatment of NCDs in HIV treatment programs.

“HIV and NCD epidemics are colliding on a global scale and failure to address these problems could lead to an erosion of ART benefits,” Dr. Currier warned. In her closing statement, Dr. Currier left the audience with a call to action, punctuated with a collective mandate to “Make healthy aging with HIV an achievable goal.”

Improving Health Systems for HIV

The final presentation, “Optimization, Effectiveness and Efficiency of Service Delivery” was facilitated by Yogan Pillay, Deputy Director General for South Africa’s Department of Health, Strategic Health Programs. Pillay began his speech with praise for South Africa’s recent success in testing 20 million residents for HIV, enrolling 1.7 million people in ART (since 2004), circumcising 500,000 men in the past year, and reducing the nation’s vertical transmission rate from 8% in 2008 to 2.7% in 2011. Despite these promising trends, Pillay cautioned that South Africa’s advances cannot be sustained without greater health system efficiency and effectiveness. “We are treating more people so we need a health and social system that can support [them],” he explained.

To improve health system efficiencies, Pillay urged the community to: increase spending on high impact interventions; improve efficiency of direct service delivery; and reduce spending on indirect costs. Pillay emphasized cost analysis as a means to help health leaders identify the correct spending mix to achieve optimal outcomes. To improve cost effectiveness, Pillay suggested service integration, resource tracking, and conducting an expenditure analysis across funders to identify inefficiencies. Pillay also recommended that the community work collaboratively to improve national health plans by optimizing service delivery models, harmonizing and improving different actors, identifying bottlenecks, highlighting equity concerns, developing research networks and conducting further research on sustainability.

Pillay concluded by emphasizing the importance of political will and collaboration in enhancing the quality and effectiveness of national health systems: “Countries need to take the lead!” he urged, “Partners and countries can fill the investment gap together!”

Yogan Pillay describing South Africa's health system at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn - Commercialimage.net

Yogan Pillay describing South Africa’s health system at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

These speeches set the stage for an inspiring final day of the conference while also reinforcing the current global HIV needs and the evidence-based recommendations for an effective response. While the t-shirt exercise was daunting for some, the three presentations left conference participants with an urgency to act, strategies to employ, and evidence to motivate their continued response to the ever-evolving HIV pandemic.

Marie articulated this hope and call as she closed the t-shirt exercise saying: “Let’s move past one in four deaths from TB and celebrate together when we meet again in Melbourne!”

Jessica Charles is communications specialist at MSH’s Center for Health Services.

HIV and Health System Strengthening in Fragile States: Improving HIV Prevention, Care and Treatment

AIDS 2012 Fragile States panel

Panelists at the session HIV and health system strengthening in fragile states, July 26 at AIDS 2012 conference. (Photo credit: S. Holtz/MSH)

MSH in collaboration with the International Rescue Committee (IRC) and Physicians for Human Rights (PHR) sponsored a lively satellite session at the XIX International AIDS Conference in Washington DC discussing, “What are the keys to working on HIV & AIDS in fragile states?” Moderated by Susannah Sirkin of PHR, the session included an exciting interchange among panelists and delegates in the audience.

MSH President Dr. Jonathan Quick led off the discussion with a number of observations on fragile states, which included the point that a state which is not functioning effectively, (inadequate services, high levels of violence, etc.) — regardless of the cause — could be considered fragile. Each fragile state is unique, but all face similar challenges in that access to health services is difficult; often the population, at least in certain regions, must cope with considerable violence and insecurity.

The panelists, Peter Mutanda and Aminul Islam of IRC and I, contributed insights into the many vexing questions posed by dealing with HIV in fragile states where governments and society are overwhelmed by other problems and challenges that at times seem to dwarf the issue of HIV. In some fragile states, the prevalence of HIV is relatively low. These countries need to balance the immediate crises they face and the large numbers of preventable maternal and child deaths with the need to deal with HIV now to forestall a more serious epidemic down the road.

Members of the audience brought up fascinating examples of work that NGOs and ministries have done trying to deal with HIV in such fragile states as Democratic Republic of the Congo and Somalia. The discussion included these key issues:

  • What can we learn from fragile states where, despite overwhelming problems, some health programs are effective?
  • How should fragile states prioritize HIV amid other concerns?
  • What should be done when data are poor or non-existent?  How high a priority should fragile states place on obtaining better epidemiologic and surveillance data versus other pressing needs?
  • In fragile states where donors provide most health funding, how can country ownership of health programming be obtained? Who is ultimately responsible for deciding on health priorities, given the fact that ministries of health in many fragile states are barely functioning?

While we didn’t necessarily provide answers to these challenging questions, the discussion was stimulating and thoughtful for all who attended — and gave all of us a lot to think about as we return to work on strengthening health systems for HIV in fragile states.

Steve Solter, MD, MPH, is MSH’s country lead and technical lead on fragile states. MSH is currently working with partners in several fragile states, including South Sudan, Democratic Republic of the Congo, Afghanistan, Haiti, and Liberia.