What It Will Take to Achieve an AIDS-Free Generation

In a November 8 address, Secretary of State Hillary Rodham Clinton set forth a bold vision that the end of HIV and AIDS is finally in sight, marking the first time in history that the U.S. government has made it a policy priority to end HIV and AIDS.

Major scientific advances in the last few years offer an historic opportunity for achieving an AIDS-free generation, Secretary Clinton said. This goal is attainable through a combination of three proven interventions—prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision, and antiretroviral (ARV) treatment to prevention transmission—in addition to condoms and other prevention tools. The Obama Administration is characterizing this approach as “combination prevention.”

Here, EngenderHealth experts on HIV and AIDS offer their perspectives on the U.S. government’s new policy as well as the new 2011 Worlds AIDS Day report released by the Joint United Nations Programme on HIV and AIDS (UNAIDS).

Pamela W. Barnes, President and CEO

Bringing family planning back into the conversation…

I fully applaud the ambitious goal set forth by the Obama Administration, yet its response doesn’t measure up to the realities facing the majority of individuals living with HIV—women and girls—in Africa. Achieving an AIDS-free generation will require a broad, integrated approach that extends beyond PMTCT to include reproductive choice, which is a fundamental human right for women and girls and an indispensable component of a comprehensive solution to ending HIV and AIDS. (Photo: Pamela Barnes on the right)

Family planning is part of a four-pronged approach to achieving strong sexual and reproductive health for women living with HIV. We can all cheer when a mother gives birth to an HIV-free baby—no doubt, PMTCT is a critical tool for HIV-positive women who wish to expand their families. But the reality is that we cannot have comprehensive PMTCT without family planning.

To be effective, PMTCT services must encompass comprehensive care for pregnant women, mothers, and newborns, including family planning, primary prevention, and care and treatment for HIV-positive women and infants. Moreover, women with HIV who have just delivered a healthy baby through PMTCT must also have the means to avoid or delay future pregnancies, if that is what they wish to do.

The bigger picture of reproductive health...

In the broader context of sexual and reproductive health, we must also ask ourselves: How do we keep that same mother healthy throughout her life? She may access HIV treatment, but in these very same places, getting pregnant is one of the riskiest things she can do. For example, in places like Niger, a woman has a one in 16 chance of dying due to pregnancy in her lifetime, so meeting a woman’s broader reproductive health needs, including family planning, is imperative if we are to make measurable progress.

Paul Perchal, Director, HIV and STI
Universal access to HIV programs is the lynchpin to achieving an AIDS-free generation…

We are in a truly new era of the AIDS response, with unprecedented opportunities for realizing an AIDS-free generation, but we have a long way to go. Universal access to HIV programs is the lynchpin to achieving an AIDS-free generation. By the end of 2010, only about 47% of eligible people living with HIV were on ARV treatment, and about 48% of pregnant women living with HIV received PMTCT treatment. Moreover, after male circumcision was shown to offer protection against HIV, the United Nations set a goal for 20 million African men to be circumcised by 2015, yet to date only about 600,000 have undergone the procedure. For these numbers to change, strong referral networks are key – they help with client follow-up, and will be critical in scaling up comprehensive prevention, care, and treatment programs.

On “combination prevention” (PMTCT, MC, and care and treatment)…

Combining proven approaches must also include behavioral interventions (such as encouraging people to use condoms to reduce risks of transmission) and structural interventions (such as using microfinance loans to reduce women’s dependence on transactional sex for income). Even if HIV services are available, people may not access them or adhere to care and treatment unless they develop positive health-seeking behaviors and can do so without facing stigma and discrimination.

A shared responsibility…

An effective global response to HIV and AIDS involves a shared responsibility and ongoing moral and financial commitment from both developed and developing countries, communities, and donors. We also need to help support and strengthen local governments and civil society organizations by building their institutional capacity to increase transparency and accountability and ensuring that donor resources actually reach the people they are meant to support in a timely and cost-efficient way.

On the new global framework described in the 2011 UNAIDS World AIDS Day Report…

The comprehensive global framework for HIV and AIDS should deliver significant results if countries, donors, and multiple development sectors can commit to it. The framework underscores the need to promote “social enablers,” such as human rights and the capacity of community-based organizations, as well as “program enablers,” such as community-centered program design and delivery, integration, management and incentives, and research and innovation.

Achieving universal access to HIV prevention, treatment, care, and support by 2015 through the framework will require scaling up funding, including moving closer to spending 15% of government revenue on health (as per the Abuja Declaration for Africa), as well as using existing resources more cost-efficiently. It will also require leveraging synergies with other sectors such as gender, education, social protection and welfare, and economic development.

Finally, maximizing critical enablers requires program efforts and new innovations that function together and include a combination of biomedical, behavioral, and structural components.

Insights from 2011 Int’l AIDS Society Conference

Back from Rome where they participated in this year’s International AIDS Society (IAS) Conference, Mark Barone and Jared Nyanchoka, Technical Advisors at EngenderHealth, took time to share highlights from the annual meeting:

Q: What were some research highlights from the conference?

A: Two major research advancements drew much attention at the conference: 1) treatment as prevention and 2) pre-exposure prophylaxis, known as PrEP. In the first case, a large, randomized study showed that when people living with HIV begin antiretroviral (ARV) treatment before they normally would, their chances of transmitting the virus are reduced by an astounding 96%. The second breakthrough involved two randomized studies among heterosexual couples in Botswana, Kenya, and Uganda, which showed that a daily dose of ARV drugs for HIV-negative men and women reduced the risk of contracting HIV by 60-70%.

Another interesting study addressed male circumcision for HIV prevention, one of EngenderHealth’s HIV focus areas. A study from South Africa showed for the first time that male circumcision reduced the number of new HIV infections within a population. Among 15- to 34-year-old men, there was a 76% reduction in new HIV infections between 2007 and 2010 in the Orange Farm area outside of Johannesburg.

Q: What are the key issues emerging in light of the recent findings involving HIV treatment for prevention?

A: Treatment as prevention took center stage at this year’s IAS conference in Rome. While everyone seems very excited about these amazing results, many debates have surfaced about the practical issues that must be addressed before this approach can become a reality.

Currently, in Africa, as in other parts of the world, many people need treatment now, yet are unable to get it because of lack of availability and resources. How can we begin giving anti-HIV drugs to people who do not need them yet clinically, even though we know that doing so will decrease the chances of passing HIV to others? Treatment-as-prevention approaches are extremely expensive, and stigma is an obstacle to getting tested and accessing treatment. There are also concerns about human rights issues surrounding drug distribution in limited resource settings. These are only a few of the many issues that complicate this discovery.

It is also important for people to keep in mind that treatment as prevention and PrEP have a major behavioral component. People actually need to take the drugs. With past prevention measures (condom use, reduction in sexual partners, safe drug injection practices), we have seen that behavior change is not easy. We must not be lulled into thinking that these prevention approaches using ARV drugs will be any more likely to succeed without significant efforts.

The ethics of using placebos in future HIV research were also debated at the conference, particularly with regard to developing an HIV vaccine. How ethical will it be to give placebo medication in place of other near effective biomedical approaches such as treatment as prevention and PrEP when researching effectiveness?

Q: What new HIV-related research did EngenderHealth present at the conference?

A: EngenderHealth gave two poster presentations on our male circumcision work in Kenya, both of which were very well-received. One demonstrated that male circumcision provided by non-physicians (nurses and clinical officers) is safe, effective, and acceptable, when the providers are well trained and facilities have the required equipment and supplies. The second confirmed the safety and acceptability of the Shang Ring, a novel device for adult male circumcision that EngenderHealth is researching in Africa. Participants were eager to use the findings as a lobbying tool to push their governments to support male circumcision.

Q: What role do you think this and similar conferences play in knowledge sharing and advancement?

A: Scientific conferences are crucial for knowledge sharing. They provide a forum for presenting the latest developments and advances in the field, for exchanging ideas about projects, and for immersing oneself in the latest work in many different subfields of HIV research. Conferences allow researchers to present their data and solicit input from others, as well as provide input on others’ work. They allow for critical discourse, discussion and debate that help to move the field forward and provide an opportunity to network with colleagues and to develop new collaborations with people from around the world.