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.

 

MSH Supports Growing International Acceptance of Option B+, Encourages Country Adoption, Further Research

Drs Scott Kellerman (left) and Erik Schouten at "Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings?" a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Drs Scott Kellerman (left) and Erik Schouten at “Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings,” a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Cross-posted on MSH.org

July 31, 2012 – As the international community gathered for the XIX International AIDS Conference last week, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+.

Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.

The government of Malawi, with the support of MSH, adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission, to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.

Unable to quickly and accurately ensure results from CD4 counts on HIV-positive women, and struggling to adjust treatment regimens given the high fertility rates and frequent pregnancies, Malawi elected to combine ART with PMTCT in a new approach they dubbed Option B which offers lifelong treatment to all HIV-positive pregnant women, regardless of their CD4 levels. The Malawi Ministry of Health devised this approach with support of MSH’s Basic Support for Institutionalizing Child Survival (BASICS) program, funded by USAID.

Dr. Erik Schouten of MSH and colleagues described the bold, new approach in a Lancet article in July, 2011. Option B+ puts women and children first, and, as Schouten and colleagues argue, will likely be cost-effective for countries, like Malawi, in the long-term.

In April, 2012, the World Health Organization (WHO) released a programmatic update on “Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants” (PDF). In the executive summary, the WHO said:

Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs. While these benefits need to be evaluated in programme settings, and systems and support requirements need careful consideration, this is an appropriate time for countries to start assessing their situation and experience to make optimal programmatic choices.

Since July, 2011, MSH has helped trained a cadre of 3,366 health workers in Malawi. Within the first year of implementation in Malawi, the number of HIV-positive pregnant women starting ARV treatment has increased six-fold from 1,200 per quarter prior to implementation, to 7,200 in the quarter ending in June 2012. MSH is currently working on a cost-benefit analysis, and is studying the efficacy and challenges of option B+ scale up for preventing vertical transmission in Malawi.

Now others are following Malawi’s lead, particularly in light of Ambassador Eric Goosby’s and UNAIDS’ Michel Sidibe’s call for eliminating pediatric HIV by 2015 (PDF). Earlier this year, Uganda announced its intention to adopt Option B+; UNICEF began a thorough review of the approach; and other countries have expressed a strong interest in moving toward including Option B+ in their strategies for decreasing vertical HIV transmission.

Throughout the XIX International AIDS Conference, researchers and global health leaders touted the benefits of Option B+, and discussed the potential for combining ART and PMTCT in other countries. At a satellite session on Sunday, July 22, leaders from UNICEF, the International AIDS Society (IAS) and MSH discussed Option B+ for preventing vertical transmission. Dr Chewe Luo, Senior Programme Advisor at UNICEF, discussed the topic in depth during her plenary speech on July 25. And in the closing words of the conference, two rapporteurs gave a hat-tip to Option B+, displaying early data from Malawi, provided by Dr Erik Schouten of MSH.

“Option B+ is a game-changer and one of the most exciting developments in decreasing vertical transmission and pediatric HIV in recent years. In short, it calls for treating the mother, preventing vertical transmission to the child, and continuing to treat the mother. It offers the promise of much reduced vertical transmission rates while simultaneously decreasing maternal morbidity and mortality from HIV,” says Dr. Scott Kellerman, MSH’s global technical lead on HIV & AIDS.

MSH is thrilled that the global momentum toward Option B+ is building. Option B+ may not be right for every country or every situation, but in Malawi – and likely in many more countries – Option B+ will prove efficacious and cost-effective in not only protecting babies, but also in treating HIV-positive women. MSH is proud to have been a part of the inception of this idea and looks forward to working with our broad network of HIV & AIDS programs throughout sub-Saharan Africa and the world, using our technical capacity and research ability to investigate the operational issues that need to be addressed and understood for optimal implementation and scale-up of this approach.

Learn more about Option B+:
For additional information or to arrange for a press interview, please contact Barbara Ayotte, Director of Strategic Communications, at 617.852.6011 or bayotte@msh.org.

 

On Day 3, Three Women, Three Calls: Keep Mothers Alive, Make Women Count, Invest in Programs for Girls

XIX International AIDS Conference (AIDS 2012) Washington D.C. Wednesday Plenary Session Linda H.ScruggsAIDS Alliance for Children, Youth and FamiliesUnited StatesUSA and Canada © IAS/Ryan Rayburn - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington DC, Wednesday Plenary Session, Linda H. Scruggs. © IAS/Ryan Rayburn – Commercialimage.net

Day three of the XIX International AIDS Conference opened with an impassioned plenary by three powerful women speakers, calling for more concerted action for women and girls living with HIV, particularly adolescent girls.

Dr Chewe Luo, Senior Advisor HIV/AIDS, UNICEF, spoke about the Global Plan to Eliminate New HIV Infections in Children by 2015 and Keeping Their Mothers Alive. Targets of the plan include: 1) Reducing infections in children by 90%. (In 2011, 333,000 children were infected with HIV, with 29% of new infections in Democratic Republic of the Congo, Nigeria and Malawi.) 2) Reducing HIV-related maternal deaths of women during pregnancy, delivery or post-delivery, by 50% by 2015.  3) Eliminating mother-to-child-transmission.

Luo highlighted the benefits of giving triple therapy or single dose Nevirapene throughout breast feeding; this could reduce mother-to-child-transmission to less than 5%. She described pilot studies in 11 countries and improvements in access to antiretrovirals (ARVs) for women: from 48% in 2010 to 57% in 2011. Despite improvements in Eastern and Southern Africa, the Caribbean, Eastern Europe and Central Asia, “we still need to do better in Western Africa,” she said. The decline in HIV infections in children was roughly 10.8%  from 2010 to 2011 but, “this is not enough,” said Luo. “We should have reached 20% by now.”

She cautioned that treatment should have started earlier for pregnant women and cited several options that countries have, mostly based on cost: Option A and B which are treatment therapies for the mother for a limited time and the newer Option B+ which provides triple ART for pregnant women for life.

“We will not achieve the goal of eliminating PMTCT without some serious innovations. And that’s what this strategy [Option B+] is about,” said Luo.

OPTION B PLUS: BOLD CHOICE TO SAVE MOTHERS WITH HIV IN MALAWI

Malawi is the first country to implement Option B+. “We need to look at PMTCT as a component of ART and access treatment early,” said Luo. “This is the bottom line for me.”

“Option B+ must be scaled up. I applaud Malawi for being so bold.” Benefits of Option B+ include reduced infant HIV infection.

Luo then turned her attention to the “unacceptable” percentage of children not receiving ART. “We are failing to reach children,” she said.

She ended with a call to action. We need to: 1) simplify our prevention approach and integrate PMTCT and ART programs at the community level; 2) introduce innovative approaches to reach adolescent girls and pregnant teens; 3) change treatment regimens for children; and 4) collaborate with community groups.

GENDER EQUITY AND EMPOWERMENT: LINDA’S STORY

Linda Scruggs, a consultant and a woman living with AIDS, delivered an inspirational account of her own struggles and brought her rousing comprehensive agenda to “Make Women Count” and end gender discrimination and stigma to a standing ovation. Scruggs told many stories of both gender inequity and gender empowerment.

“For the last 20 years, women have been asking for an international platform for their rights, to count us in. Today I stand to give us direction and a recipe for change. We want women  to work with women that have the tools for us, by us, with us. … It is not enough to create a task force or write a paper, what we need is to be part of the solution. We are the Mothers of the Earth.”

Linda reflected: “What does a woman with no self- esteem look like?  What does a woman whose uncle molested her look like? What is a woman who can’t read or write, broken and voiceless? That woman was me.”

Linda told stories of women, broken or affected by disease. “We are at the table and a force to be reckoned with. We need a big change and need to create jobs and training for HIV positive women.”

UNFINISHED AGENDA: PROTECTING  ADOLESCENT GIRLS

Dr. Geeta Rao Gupta, Deputy Executive Director of UNICEF, also made the case to turn the tide for adolescent girls and highlighted the need for gender equality. Adolescent girls aged 15 to 24 bear the brunt of the epidemic. Of the 4.8 million young people with AIDS, 3 million of them are girls.

The challenges of adolescent girls are immense: early sexual debut, child marriage, increased risk of HIV and STIs, sexual violence, and risk of early pregnancy and HIV infection. Many are forced early into transactional sex to survive or they depend on older men to survive. Most lack basic information on condoms or sex education.

Geeta offered recommendations to accelerate the pace of protection for adolescent girls:

  1. We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
  2. We need to educate girls — empower them to make choices.
  3. We need to start early; make adolescents visible in routine data systems and follow their health status after age 5. (Right now, they don’t appear in the data unless they get pregnant or contract HIV and then they are included with adult data.)
  4. We need to invest in innovations to reach adolescent girls through social media and networks.
  5. We need to engage with adolescents as partners.

As Anthony Lake of UNICEF has so eloquently said: “We invest so much in keeping girls alive in their first decade of life. We must not lose them in the second.”

We need a world that is AIDS-free and fair for all women and girls. That must be our legacy.

Barbara Ayotte is MSH’s director of strategic communications.

Join MSH: Events, Presentations, Booth 162

Cross-posted on MSH’s Global Health Impact blog.

Over 40 Management Sciences for Health (MSH) staff from around the world will join the twenty thousand health workers, activists, researchers, donors, and policy makers at the XIX International AIDS Conference, “Turning the Tide Together”. Visit us at the following events, poster and oral presentations, Booth #162, or online.

Catch live blog updates, July 22-27, and follow us on Twitter with #AIDS2012, #PMTCT, and #OptionBplus. (Kaiser Family Foundation is providing live conference webcasts.)

MSH EVENTS

Join MSH and partners at these 2012 International AIDS Conference featured events:

Beyond MDG 6: HIV and Chronic NCDs:
Integrating Health Systems Toward Universal Health Coverage

Sunday, July 22, 11:15 – 13:15, Session Room 2

  • Moderated by John Donnelly, global health journalist
  • Panelists
    • Dr. Jonathan D. Quick, Management Sciences for Health
    • Sir George Alleyne, Pan American Health Organization
    • Till Baernighausen, Harvard School of Public Health
    • Dr. Jemima Kamano, AMPATH
    • Dr. Doyin Oluwole, Pink Ribbon Red Ribbon Initiative at The George Bush Institute
    • Dr. Ayoub Magimba, Tanzania Ministry of Health and Social Welfare

Facebook event

Prevention of Vertical Transmission and Beyond:
How to Identify, Enroll, and Retain Children in Treatment Programmes in Resource-Limited Settings

Sunday, July 22, 15:45 – 17:45, Mini Room 1

  • Co-chaired by Nick Hellmann, EGPAF and IAS-ILF, and Chewe Luo, UNICEF
  • Panelists
    • Erik Schouten, Management Sciences for Health
    • Angela Mushavi, Ministry of Health Zimbabwe
    • Dorothy Mbori-Ngacha, UNICEF
    • Nandita Sugandhi, CHAI
    • Scott Kellerman, Management Sciences for Health

HIV & Health Systems Strengthening in Fragile States:
What We Don’t Know, Can Kill…What Approaches are Needed to Improve HIV Prevention, Care, and Treatment?

Thursday, July 26, 18:30 – 20:30, Session Room 5

  • Moderated by Susannah Sirkin, Physicians for Human Rights
  • Panelists:
    • Dr. Jonathan D. Quick, Management Sciences for Health
    • Amin Islam, International Rescue Committee
    • Peter Mutanda, International Rescue Committee – Kenya
    • Steve Solter, Management Sciences for Health

Special Satellite Event

Care and Treatment for People with Chronic Conditions:
What can we learn from the HIV Experience? A Health Systems Perspective

Sunday, July 22, 11:15-13:15, Session Room 8

Dr. Jonathan D. Quick, MSH President & CEO, will deliver closing remarks.

  • Sponsored by World Health Organization, UNAIDS and the Global Health Workforce Alliance
  • Co-chaired by Dr. Ariel Pablos-Méndez and Dr. Masato Mugitani, this special event features: Dr. Margaret Chan, Mr. Michel Sidibé, Paul de Lay, Dr. Sania Nishtar, Dr. Jarbas Barbosa de Silva, Jr., Dr. Milly Katana, Dr. José M. Zuniga, and Dr. Hiroki Nakatani. Moderated by Dr. Richard Horton (Editor-in-Chief, The Lancet).

MSH Affiliated Events

Voluntary Pooled Procurement of HIV/AIDS Commodities:
What Does it Take to Make VPP Achieve its Objectives and Maximize its Benefits?

Sunday, July 22, 09:00 – 11:00, Mini Room 9

  • Organized by the Grant Management Solutions Project
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria established the voluntary pooled procurement (VPP) for core health products. VPP aims to increase the speed of delivery, and ensure the supply, reliability and quality of health products, secure attractive prices for them, and help strengthen local procurement and supply management capacity, states the Global Fund’s website. What hinders and what helps VPP succeed will be the topic of this panel discussion.

Global Fund Country Coordinating Mechanisms:
Providing Oversight and Leadership during the Transitional Funding Period – A Capacity Building Session

Sunday, July 22, 11:15 – 13:15, Mini Room 1

  • Organized by the Grant Management Solutions Project and The Global Fund
  • This two hour session in English is designed for CCM members, Global Fund implementers, technical support agencies, civil society and development partner constituencies involved in CCM governance and oversight. The session will focus on grant oversight for the current transitional funding period 2012-2014: 30 minutes will be devoted to presentation, 30 minutes to Q&A and 1 hour to smaller group work using case studies to train on analyzing and solving problems of oversight and prioritization. These sessions will address the core challenge of the 2012-2014 period for GF beneficiary countries – how to successfully steward their grants so as to maintain patient coverage and access to quality services. A French session will be held at this time in Session Room 9.

Supply and Demand of HIV/AIDS Commodities:
Can the Global Market and National Supply Chains Support Continued Rapid Scale Up of HIV/AIDS Treatment?

Thursday, July 26, 18:30 – 20:30, Mini Room 2

  • Organized by The Partnership for Supply Chain Management and USAID Global Health Bureau Office of HIV/AIDS
  • The international community has agreed to a goal of universal access by 2015. If donors increase funding to provide treatment to 15 million, can a sufficient volume of ARVs and other commodities be manufactured and distributed in target countries? Will national supply chains be able to receive and distribute many times the current volumes? Participants will learn about the integrated nature of global supply chains to meet public health needs, and discuss obstacles in the global supply chain to meeting the goal of access to HIV/AIDS treatment.

Visit us at Booth #162

More information on:

  • Prevention of Mother-to-Child Transmission (PMTCT) and Option B+ (Sunday & Wednesday)
  • Health Systems Strengthening (Monday & Thursday)
  • Pharmaceutical Management (Tuesday)

Follow live conference updates

See you in DC or online, “turning the tide together”!