Reflecting on the XVI International AIDS Conference in Toronto
05 September 2006
The XVI International AIDS Conference in Toronto was not a groundbreaking event, and no major announcements were made. On the positive side, prevention was put firmly back on the map at this year’s conference, along with a focus on health systems and nurses. There was also positive data put forward showing African adherence rates to antiretrovirals are as good, or better than those of the North – underlining the importance and effectiveness of adherence support. There were also welcome announcements from the Bill and Melinda Gates Foundation of $500m extra support for the Global Fund, and by the UK Department for International Development which will be funding three global networks run by, and providing support for, people living with HIV.
Less positively, high-level political leaders were visible by their absence,and many participants expressed frustration that the conference did not seem to be linked with, or building on, other global processes, such as the UN high level meeting, or the G8. Bill Clinton, Bill Gates, Stephen Lewis and actor Richard Gere provided limited action for the media, while South Africa and the host country Canada drew most of the media and activists’ flack.
Below we highlight some of the high points and low points at this year’s event.
It was a good conference for:
1. Prevention
Prevention featured widely at the conference, with many calling for a refocusing of efforts. A plenary on prevention and key messages highlighted the need for prevention efforts to be scaled up as treatment moves towards universal access. Emerging new prevention technologies were discussed, including circumcision, scaling up HIV testing, pre exposure prophylaxis (PREP) and microbicides.
2. Circumcision
With a trial last year showing an approximate 60% reduction in HIV transmission in men who are circumcised compared to those not circumcised, there were strong calls for more widespread availability of circumcision for HIV prevention. One study presented at the conference showed the acceptability of circumcision to men and pilot programmes have been looking at the feasibility of providing circumcision. So far, there is no World Health Organization policy on circumcision as a prevention intervention, but there many personal endorsements, for example by Stephen Lewis.
3. Provider-initiated HIV testing
“Treatment delayed is treatment denied”
Despite concerns by several human rights activists, provider-initiated (or opt-out) testing is increasingly being accepted as another means of providing access to HIV testing. Providing point-of-care HIV tests with consent to opt out as a routine part of medical care makes sense in situations where antiretroviral treatment is available, prevalence is high and ongoing counselling and support are available in clinic and in the community.
Dr Kevin de Cock, HIV/AIDS Director at the World Health Organization, talked about redefining the standards of medical care so that provider-initiated testing becomes the accepted norm – it has worked for antenatal HIV testing in many situations. One of the problems with waiting for people to come forward for testing is that almost every study shows that people access testing services too late to benefit from ARV treatment. There is a very high death rate for individuals (in some cases up to 70% of the mortality) in the first six months of starting antiretroviral treatment in programmes in resource-poor settings because people present with CD4 counts that are very low (much less that 200).
Community organisations have a key role to play in the ‘community preparedness’ for this approach, ensuring that individuals are provided with information about HIV and testing prior to accessing medical services, to empower them to be able to make informed choices and to opt out if they wish.
4. Pre exposure prophylaxis or PREP
Pre exposure prophylaxis, or PREP, is the taking of a drug to prevent infection before an individual has been exposed to HIV. This is in contrast to post exposure prophylaxis, or PEP, when the drug is taken after exposure (PEP is well accepted after needlestick exposure and increasingly after proven or strongly suspected sexual exposure).
PREP featured a lot at the conference despite there being no effectiveness data (efficacy) yet. There are a number of PREP trials ongoing at the moment with the drug Tenofovir (TDF), and two more planned with Truvada, a combination drug that contains Tenofovir and emtricitabine (FTC).
There was excitement at a late breaker at the conference, which reported on the safety of the approach. The trial (THLB013) enrolled 936 women in Ghana, Cameroon and Nigeria. There were no differences in adverse events in the drug-taking group compared to the control group (who took a placebo). Although there is excitement that there were 2 seroconversions (0.86 per 100 person years) in the Tenofovir group compared to 6 (2.48 infections per 100 person years) in the placebo group which gives a rate ratio of 0.35, the trial was too small to conclude that Tenofovir protected against HIV infection ( the 95% confidence interval is from 0.03- 1.93).
Despite all the talk about PREP and the concern that it is being used already, one study (THLB0101) showed that knowledge and awareness of PREP in three populations of men who have sex with men was actually very low, with only one possible use of PREP (which actually appeared to be PEP). Nevertheless with suggestions that PREP could be highly cost effective if it is very effective (greater that 80% effective), the need to do more research into the acceptability and policy implications of PREP will become increasingly important.
5. Microbicides
The efficacy trials of microbicides will be available by mid-2007 and it is almost certainly true that there will be at least one commercially available microbicide by 2010. This is assuming that the trials show them to be effective. A full list of ongoing efficacy trials is given in the 2006 Global HIV Prevention Working Group Report: New approaches to HIV prevention: accelerating research and ensuring future access.
It was also a good conference for certain aspects of HIV treatment:
6. Adherence
A meta analysis of treatment programmes showed that Africans on HAART were as likely, if not more so than individuals from northern industrialised nations, to have HIV infection suppressed due to good drug adherence.
As adherence, and hence viral suppression, is a function of good, supportive infrastructures (including treatment support workers and strong community), this suggests that treatment programmes in resource-limited settings are focussing on adherence support and should continue to do so.
7. Free ARV programmes
People on free treatment do clinically better (i.e. survive better) than people who pay for treatment. Anecdotal evidence has supported this, however this has now been cited in a study in the Journal AIDS (Bisson-Gregory-P, Frank-Ian, Gross-Robert et al: Out-of-pocket costs of HAART limit HIV treatment responses in Botswana's private sector. AIDS 2006, vol. 20, no. 9, p. 1333-6).
8. Health Systems
Health systems need to be strengthened. There is increased commitment to the principle that antiretroviral treatment and universal access will not occur without strengthening extremely weak health systems in resource-poor settings. This is in addition to identifying a solution to the severe shortage of human resources in those systems.
The World Health Organization launched its Treat, Train, Retain strategy for nurses and several sessions were interrupted with activist chants of ‘open your purses we need more nurses’.
Community organisations have a key role to play in health systems strengthening.
The work of Alliance implementing partner Association African Solidarité (AAS) was mentioned in several presentations in the conference, and was one of only 12 organisations featured on a map in the conference’s global village highlighting key community interventions. AAS has had an impact on both the magnitude and the quality of the community and governmental response in Burkina Faso. AAS’s Projet Orange has influenced national and regional policy and the organisation helped develop national policy and operational guidelines on adherence.
It was not such a good conference for:
1. Understanding what universal access will actually mean…
At the conference, universal access was referred to as 80%, 50% or even ‘whatever the government can afford at the time’.
There was also a lack of clarity and commitment around setting national targets to achieve universal access, as had been agreed at the UN high level meeting at the end of May.
We must ensure that the push to achieve universal access includes marginal and hard to reach communities.
2. Prevention of mother-to-child transmission of HIV (PMTCT)
Painfully absent in the conference apart from a few presentations. Professor Nduati of the College of Health Sciences at the University of Nairobi highlighted the fact that the staging of HIV illness in the mother had an adverse effect on both transmission and survival of her child. If treatment (i.e. HAART, rather than prevention with a single dose or short course therapy) is given to mothers, it reduces transmission of HIV from mother to child, increases the survival of infected and uninfected children and increases the survival of the mother.
Max Bweupe, PMTCT coordinator for Zambia’s Ministry of Health presented on the Zambia national plan for PMTCT coverage. There is good coverage of the women who deliver in hospital –12,000 out of the 14,000 who tested positive received a single dose of Nevirapine. The main problem, as with many national PMTCT programmes, is that many pregnant women deliver at home - in Zambia’s case 50%. There is an urgent need to strengthen the community component of these programmes to increase coverage.
A quick way to move towards universal access would be to strengthen maternal and child health and PMTCT programmes, so that families can access prevention and treatment.
3. Integration of sexual and reproductive health and HIV programmes
Despite the high level meeting in New York two years ago, and much discussion, progress is slow on a global (or regional) strategy for the integration of HIV and sexual and reproductive health.
The Alliance’s Javier Hourcade Bellocq spoke on this subject at a seminar on the integration of HIV with sexual and reproductive health. Nono Simelelu from IPPF showed examples of where IPPF had started to integrate HIV programming within some of their programmes, such as FHOK in Kenya where they provide voluntary counselling and testing via family planning clinics, and Rofamilia in Colombia where services for men who have sex with men are integrated into reproductive health provision.
4. Prevention coverage:
Despite prevention being discussed a great deal at the conference, the summary of global prevention scale-up makes sober reading:
| Prevention intervention | Global coverage |
| Access to voluntary counselling and testing |
0.2% |
| Harm reduction programmes |
4% |
| Prevention of mother to child transmission |
8% |
| Behaviour change communication for men
who have sex with men |
11% |
| Information, education and communication
for sex workers |
16% |
| Condom access |
21% |
