July 31, 2012
Writing recaps of events such as the 19th International AIDS Conference -- which took place last week in Washington, D.C. -- one always poses the risk of overshadowing brilliant, but small incremental steps by spending most of the time highlighting the big themes. When it comes to AIDS 2012, however, I'm in no danger of doing that, because aside from an almost robotic repetition of the phrase "AIDS-free generation," and the official slogan "turning the tide together," there was no big news or overarching theme.
Revolutionary science was in short supply, though there were some hopeful glimmers, which I'll get to in a moment, but Obama was a no show. Instead we got a Clinton sandwich, our current Secretary of State near the opening and her husband, the former President at the closing, both peddling an optimistic view of the future that had noted AIDS journalist Laurie Garret asking, "What are they smoking?"
Media stories on the conference seemed even more scant and pallid here at home than in the past, especially considering that the conference took place in the United States for the first time in 20 years. Thus, the power of these conferences to force the world's attention, for at least several days, towards the realities of the AIDS pandemic appears to be significantly diluted. And so, one has to wonder -- did it make a damned bit of difference that we collectively spent millions of dollars to fly nearly 25,000 people from all over the globe to our nation's capitol to talk about HIV for a week?
As I did not and could not attend every plenary, workshop, satellite session, talking circle and performance that took place I can only give my own opinion and acknowledge that it comes from a limited place. That place is as a treatment and prevention science advocate focused predominantly in the United States. For me, and the work that I do, it was worth it, but only just. Here are my big takeaways, from the most hopeful to the most discouraging:
I am probably biased, as cure research is one of the areas I'm most involved in, but I believe that studies presented in this area represented some of the most intriguing and exciting science of the entire week. The International AIDS Society (IAS) released a new strategy document for cure research two days before the conference started at a pre-conference titled "Toward a Cure." I attended this pre-conference and most of the cure-oriented sessions during the week that followed.
With each presenter, there was always a stated caveat that we are at the very beginnings of a true search for a cure, but the baby steps we have made so far are impressive, especially considering that many of them were initiated only once word got out that we'd actually cured someone of the disease a couple of years ago.
Much remains to be done. While many acknowledge that a sterilizing cure -- where every trace of HIV is removed from the body -- will likely take a combination approach and at least a number of years further research, there is evidence that at least in some rare cases we might be able to achieve a cure more simply. There was evidence that simply getting people on ARV therapy within days of infection could help approximately five percent of those individuals ultimately go back off treatment later without losing control of the virus -- and that they might be able to remain off treatment for life.
We also learned of two individuals with HIV and cancer who received bone marrow transplants and in whom researchers have not been able to find traces of HIV for at least a couple of years. Further tests will need to be conducted to look more deeply for the virus in this lucky pair. Also, since these individuals remained on antiretroviral (ARV) therapy throughout their transplant and up to the present, the real test will be safely interrupting their treatment and seeing what happens. In the meantime, these brilliant steps forward will undoubtedly keep hope and enthusiasm for cure research alive.
There were also a number of reports showing that expanding HIV testing in a targeted fashion and offering people with HIV treatment earlier than in the past, both for their own health and to prevent ongoing HIV transmission, can not only be cost effective, but in some cases cost savings. Some have objected to the great push toward treatment as prevention (TasP), citing concerns that people might feel coerced to start treatment for prevention reasons when they don't need it themselves. Numerous studies and posters, however, confirmed that allowing the virus to reproduce, even when a person's CD4 count is high, can cause all kinds of damage to the body. In fact, the IAS published its own guidelines during the conference, recommending treatment for all, regardless of CD4 count. A large study is ongoing to prove conclusively whether earlier treatment will be beneficial. In the meantime, however, the weight of the evidence appears to support it.
One thing that left me feeling cautiously optimistic was a pledge announced by Secretary of State Hilary Clinton to develop a blueprint for an AIDS-free generation. While grand pledges are no guarantee that we will achieve the goals set out in plans of this sort, we have already witnessed the ways in which having a National HIV/AIDS Strategy has begun to transform our own domestic response to the epidemic. This pledge also came with a promise of additional funding to focus on special populations, including men who have sex with men (MSM), sex workers and drug users. This is critical, as the tremendous stigma and criminalization of these populations has resulted in some countries devoting almost nothing to reach individuals in these risk groups despite the fact that they often bear a disproportionate burden of the epidemic.
Along these lines, I was impressed that the conference is finally giving a more central focus and space for exploring the epidemic in gay men and other MSM who are at highest risk of HIV in a majority of countries worldwide. MSM, particularly MSM of color have often received the least resources while having the highest HIV infection rates. Efforts to overcome the systemic homophobia that drives research and programming for MSM into the shadows is finally bearing fruit.
While I am pleased with this greater focus, we must now make up lost time. This is particularly true for black gay men and other MSM in the United States. New research presented at the conference has begun to outline some of the predominant reasons that black MSM remain at highest risk of HIV infection in the United States. Even though black MSM appear more likely to use condoms than other MSM, they have poorer access to health care (whether HIV-negative or HIV-positive). Also, because so many black MSM are already infected with HIV, it means that one slip-up in condom use is vastly more likely to result in HIV infection than for other MSM whose partners come from groups less likely to carry HIV. To make good on this new research we will need to quickly translate it into action.
While not a panacea, the Affordable Care Act (ACA) offers a great opportunity to expand sexual health and HIV care to more individuals. Further work must also address structural factors, such as aggressive racially biased law enforcement policies (think "stop and frisk") that result in high incarceration rates among young MSM of color and also incredibly high rates of unemployment. Lastly, evidence-based interventions to help young MSM of color remain resilient in the face of racism and homophobia are also urgently needed.
When former President Bill Clinton closed the conference he urged us all not to despair over funding shortfalls at a domestic and global level. He insisted that as long as we (governments and civil society organizations) demonstrate that our programs are effective and cost efficient, "the money will be there."
I would very much like to believe him, and perhaps this is where my views part ways with some others who attended the conference and expressed a more hopeful feeling upon leaving Washington, D.C. Yes, we have some very powerful tools to tackle the epidemic: 1) rolling out more aggressive testing efforts; 2) expanding treatment coupled with adherence support to more individuals, both for their own health and for the prevention benefits that would follow; and 3) offering combination prevention including PrEP for those at particularly high risk of infection.
Researchers have found that under certain cases, each of these can be cost effective, and at times, cost saving. Also, health care systems and non-governmental organizations have been retooling for the past several years to ensure that money is spent on high-impact, evidence-based programs. We're doing exactly what Clinton outlines.
Yet, these are the realities on the ground:
These are just a few of the things that keep me up at night and that also leave me worried that just as we have gained the tools to turn the epidemic around we may find ourselves without the resources to implement them.
International conferences can function like revival meetings, getting us fired up and reenergized to tackle our problems with new vigor. Some have publicly lauded this conference and expressed renewed optimism about the field. I think we'll only come to understand AIDS 2012's value and legacy in future years. What I most hope, however, is that we will watch our governments carefully and hold them accountable for the promises made. Perhaps this conference will ultimately be seen as the moment when we actually did turn the tide on the epidemic. Over the past 30 years of the epidemic we have, in fact, made epic accomplishments that many skeptics argued would be impossible. I'm not giving up hope, but I am watching and witnessing the promises made this year and I will do everything I can to ensure that those who made them are held accountable if they never come true. I hope you will join me in that task.