18th International AIDS Conference held in Vienna 18-23 July 2010
SABCOHA Summary Report Contributors: Natalie Mayet, Alex Govender, Jenni Gillies,
Brad Mears, Liesel Heynike, Susan Preller and Thando Khaile, Peggy Maphanga The conference theme was “Rights Here, Right Now”. This theme promotes a response to HIV and AIDS that is based on the full respect for all Human Rights including the right not to be subject to stigma and discrimination.
The Conference was attended by more than 19 300 delegates from 193 countries. The Conference shared more than 6000 abstracts across 248 sessions structured into 6 tracks. A hive of activities provided delegates with options and choices of track sessions, development sessions, special sessions, oral poster discussions, posters exhibitions, exhibition stands, global village, satellite meetings, affiliated events – often happening concurrently.
South Africa was well represented with Honourable Deputy President Kgalema Motlanthe, the Minister of Health, Dr Aaron Motsoaledi, and the Emeritus Archbishop Desmond Tutu all sharing a platform at the opening, plenary and closing ceremony respectively.
Globally only about 40% of people living with HIV know their HIV status and there is the continuous call for all of us to know our status and know it early. There were many HIV positive conference delegates and some of them have been living healthy productive lives with HIV infection for more than 30 years. However, this was not the conference where a cure could be announced. Successes and difficulties of developing effective preventative vaccine for HIV/AIDS were presented and we still have a long way to go. For every two people started on therapy, five new infections occur.
A summary highlighting critical issues, important results and key recommendations is structured into the six tracks and three focus areas below.
Track A: Basic Science
Successes and difficulties of developing effective preventative vaccine for HIV/AIDS were presented. Still a long way to go.
Guidelines on how to effectively engage all stakeholders in the design and conduct of biomedical prevention trials were proposed.
Long-term use of ART has serious side effects resulting in diseases of the cardio-vascular system and other organs.
For every two people started on therapy, five new infections occur (still far from controlling and curtaining the epidemic).
Three major barriers to finding a cure were identified namely:
Existence of residual viral replication even under potent therapy combination.
Existence of anatomical sanctuaries or reservoirs (including brain, testis and gastro-intestinal tract).
Latently infected cells (t-cells, macrophages, astrocytes and stem cells).
Elite viral controllers managing to maintain very low levels of virus replication in the absence of therapy are precious sources of information for understanding the secrets of how to control HIV replica and disease progression in the absence of ART.
Track B: Clinical Science
Newer drugs may offer simpler, less toxic regimens while maintaining HIV suppression.
Starting ART earlier – definite evidence for initiating at CD4 less than 350 especially for TB and paediatrics. Data suggests benefit in starting ART at CD4 between 350 and 500. Limited cost benefit above CD4 of 500.
Co-infections or co-morbidities:
HIV/TB co-infection: initiative ART at the earliest opportunity (85% increased survival). Benefit in starting early in TB and IPT. Integration of HIV and TB programs is still lacking – an essential enabler for earlier ART initiation. Concerns shared regarding misuse of 2nd line TB medication and lack of ART.
HIV/Hepatitis co-infection: fracture rates higher in patients with HIV and hepatitis. HIV/HCV co-infected persons shows increased mortality despite curability of HCV. Hence call for scale-up in HCV testing, particularly for PLHIV. Treatment integration and improvements expected within a year.
HIV and malignancies: higher cancer incidence found in HIV patients.
Complications of HIV and ART: are benefits of remaining on first line ito death and loss to follow-up.
Caprisa 004 trial, is the first trial to show efficacy in protection of a vaginal microbicide against HIV infection (39%). No resistance and no safety issue. The vaginal gel contains tenofovir and requires application 12 hours before and after intercourse. This may present some practical challenges in terms of adherence but is ground-breaking in terms of clinical science. Despite excitement the product is far from market ready.
Significant reduction and safer sexual practices found in people between the ages of 15-64 years in ten countries.
Transferring cash to household to keep children in school showed success but uncertain if due to schooling or higher household income.
Strong evidence of cost effectiveness of needle and syringe programmes for IDUs across settings. Little data is available from Africa.
Violations of Human Rights are a barrier to knowing the epidemic in MSM. A study in SA shows MSM are reluctant to make use of public health services especially for STIs. Health care workers have poor or limited understanding of sexual networks. Stigma and discrimination prevent access to treatment and care services.
Study on commercial sex workers shows positive correlation between condom use and duration of exposure to HIV prevention programmes.
Prisoners are another marginalised and neglected group at high risk of HIV infection. HIV prevention among criminal offenders is feasible and effective. Evidence-based prison prevention programmes presented as best practice.
Male circumcision (Kenya) – rapid scale-up feasible and safe and task shifting to nurses cost effective. Recovery is faster in younger children ironically not sexually active.
PMTCT – despite advances in treatment poor access results in high rates of transmission.
Treatment as prevention: treatment lowers plasma viral load hence increases risk of transmission thereby reduction of HIV incidence.
Inconvenient truths – transmission during acute infection and of resistant strains remains a challenge.
Track D: Social and Behavioural Science
Human and financial resources remain global challenge.
AIDS orphans show worse mental health.
Increased psychological problems for Aids –orphaned children as they move into young adulthood
Children are being left behind – ito treatment.
Family-based approach to treating the child is important.
This is a new track. Over 1000 abstracts accepted.
Under performing in terms of universal access targets – less than 50% access to ART and PMTCT in low- and middle-income countries.
Health systems strengthening and financing remain a challenge. Finance levels – sustaining, flattening or reducing? Impassionate pleas to replenish GF. Innovative TAX for raising funding. In terms of the DOHA declaration countries should be investing 15% of GDP in health. Savings from drug cost reduction unlikely to address funding shortfalls.
New WHO guidelines shows increased cost benefit but may take longer to realise return on investment.
Retention is a critical issue – focus on systems to prevent falling off care rather than spending money on tracing.
Health systems strengthening: outreach campaigns can be more costs effective than facility-based services. Integrated care and coordinated assistance from NGOs can close gaps in cost and delivery.
All assumptions and models are held hostage to effectiveness of systems.
Track F: Policy, Law, Human Rights and Political Science
Human rights must be translated into national law. Decriminalisation of sexual work and drug use are critical within a human rights framework. Dialogue and information sharing is key for changing social attitudes.
Greater meaningful involvement of PLHIV, youth, people who use drugs, sex workers and MSM will better inform policies. The central role of the GIPA in building community systems was emphasised.
Focus area: LAPC (Leadership and Accountability Programme Committee)
The MDG goal of universal access to treatment for HIV/AIDS for all those who need it by 2010 has not been achieved. The future of universal access was debated at length in terms of cost, efficiency and human resources. New timelines and targets were required.
WHO treatment guidelines promoting earlier ART initiation means greater number currently in need of treatment and even more short-term financial costs.
A framework for accountability is required - 100 countries have no data to report.
Political leadership in terms of prioritising health is a country responsibility.
Criminalisation creates a climate of fear, is bad for public health and detrimental to HIV and AIDS responses. Dialogue and engagement with law and enforcement leaders would be beneficial.
CPC (Conflict Prevention Centre)
Emphasis on HIV and AIDS as a top health and humanitarian priority, many countries are reducing their investments in global health. Access to antiretroviral medicine is up and new infection rates have fallen globally by 17%.
Global Fund continues to advocate for more efficiency, innovation and the creation of new tools.
MMC and ART were proposed as priority interventions.
Other promising initiatives noted were ARV based prevention.
Community-based MSM programmes are most successful when owned by the targeted community. Intimidation and criminalisation are designed to oppress, silence and marginalise gay men.
Stigma and fear are still major barriers in some countries to policy and funding prioritisation.
Youth need to be empowered to represent themselves. Media can assist in this regard.
Funding for youth-led initiative is lacking.
Emphasis on human rights means decriminalisation.
Caprisa study is revolutionary: puts women in charge independent of partners.
Global financial crisis has reduced resources for HIV and AIDS.
Universal access fundamental building block for maternal and child health.
Vienna declaration – calling for end of war on drugs and decriminalisation of drug users.