AVAC at HIVR4P 2018, Update 2: The World Is Not a Nail
October 26, 2018
Greetings from Madrid! Some meetings are a series of presentations, coffee breaks and cocktails. Others are these things plus something else -- a sense of movement towards a consensus, a new commitment. As this HIVR4P conference enters its final day, we feel like it's safe to say that this conference heralded an energized, nuanced commitment to choice.
In This Update:
As it happens, AVAC highlighted choice in our annual report, No Prevention No End, released last week ahead of the conference. We noted how politicized the world has become, and how essential it is to reclaim it in speech and more importantly in actions. HIVR4P did this in extraordinary ways. Here are a few takeaways and the sessions that brought this home:
Young women should run the world and if they did, there would be choices and much less shame about bodies and their coverings.
Throughout the conference, the Advocates Corner has been the site of vibrant, spirited engagement, much of it led by young African women attending the conference from Uganda, Tanzania, Malawi, South Africa and many other countries. Over the course of the week, they've engaged with researchers, challenged the audience in a powerful opening action, and articulated their needs and desires in creative ways. This included a "panty line" -- a powerful, visual uncovering of the hopes, priorities and demands that women are supposed to keep hidden -- like our desires. The hotel's demand that fabric panties be removed from the line, conveyed by the conference staff, prompted strong feelings and swift action. In the closing plenary, these young women took to the stage with signs, panties and pride, to great applause and a strong statement of support from the Conference chairs.
In a Tuesday session called If I Choose, Will I Use, researchers from the Quatro study and from a collaborative between RTI International and the Desmond Tutu HIV Foundation (DTHF) in Cape Town presented results from two different inquiries into what people who may someday use products want in those products. This seemingly logical step is not always taken in the context of HIV prevention -- or product development writ large -- so products don't always match people's preferences. In the next era of choice, if these presentations are any indication, they will. Here are some highlights:
Injectables have promise, based on user preferences and trial data, but also real-world challenges, including "the tail."
While the field awaits results in 2021 or so from the two efficacy vaccine trials in the field, R4P included a number of presentations on experimental vaccine approaches to creating broadly neutralizing antibodies (bNAbs). The goal of this work is to develop products that teach the human immune system to create antibodies like those being given, in pre-made form, to participants in passive immunization studies, such as the AMP trial.
There are three approaches being considered for early human trials from data now mostly in mice:
On the heels of the Resource Tracking Working Group report presented at the conference declining resources for HIV vaccine research, Robin Shattock (Imperial College London) and his colleagues presented on research from the 5-year 23 million EAVI2020 project. Working with a modest budget in the HIV vaccine world, EAVI2020 plans to design, test and manufacture multiple vaccine candidates, a model perhaps for more financially constrained times.
Finally, so much is going on in vaccine research that Julie McElrath from HVTN noted we "drowning in a sea of data."" The rise of bioinformatics has highlighted the need coordinate across networks to make data useable. Uniform assays and ultimately common criteria for down selection for clinical trials for efficacy trials are needed to conserve resources and ensure the most promising candidates move forward.
In Wednesday's plenary presentation, Raphy Landovitz and Craig Hendrix (Johns Hopkins University) embodied activist principles of naming issues and calling on specific actors to respond to concerns. Hendrix used a toolbox metaphor to take the audience through a "thought experiment" about what they'd like to have in their bedside drawer for a safe sexual life. Did people want the equivalent of a handyperson's special -- drill, hammer, wrench, pliers and so on -- or did they just want a hammer, in other words a single option. "Not everything," Hendrix remarked, "is a nail." The most important slide was his final one, in which he laid out core tasks for a range of stakeholders with power over the future of HIV prevention research. We find it so relevant and powerful that we have reproduced it here.
In an oral abstract session (OA10) titled Key to the Response: Populations, Partners and Prevention, researchers reviewed a range of familiar and essential realities: marginalized populations carry a high HIV burden, need biomedical interventions and culturally competent care along with strengthened communities and changes in criminalization laws. Studies from Brazil, Indonesia, Kenya, South Africa, the Ukraine, the US, and Viet Nam all highlighted the degrees of violence by the state, families and societies that impact adolescent girls and young women, sex workers, transgender people, and drug users -- as well as the resilience of these groups, and their essential role in designing and delivering solutions that fit into their lives.
In our first update, we noted that both words and silences matter a great deal at this moment in history -- in the world and in our field specifically. In that update, the quote attributed to Dr. Mike Cohen regarding PrEP in women did not include the full text as presented on the slide, which stated, "Concerns about potential limitations of TDF/FTC prevention in women have been noted, and will likely be clarified through ongoing studies (e.g. HPTN 082) and observational data." We should have used the precise language from the slide, and we apologize for shortening the text as every individual should be heard in the words they choose.
The concerns AVAC has raised, including at length in our AVAC Report 2017: Mixed Messages and How to Untangle Them and at a range of consultations, about the ways that daily oral PrEP is described with respect to relevance for women remain. Daily oral PrEP is less forgiving in women; close to perfect adherence is likely required for protection. This is a limitation faced by many drugs that require diligent use for efficacy. We feel that it is essential that limitations related to PrEP for women be framed as problems to solve via innovative program designs, and that suggestions that a WHO-endorsed strategy may still be require research to validate its use in women can be misconstrued as reasons to delay expanded access. Cohen did not in any way suggest a delay, and we hope the full quotation clarifies this fully. However, AVAC's advocacy partners have observed countries questioning PrEP's utility in women and using similar framings to justify their reasoning.
We will cover the closing plenary session in more detail in our final update, and it will soon be available via webcast. It was a remarkable panel of leading researchers and advocates, including the conference co-chairs and Maureen Luba, a Malawi-based member of the AVAC team who works closely with MANET+ and CEDEP. While all the presentations were on different topics, there was a single unifying theme of collaboration, choice and voice. This is a field in which we must find ways to work together and to respectfully disagree. We look forward to working collaboratively and in community with all stakeholders dedicated to scaling up today's tools and continuing investigation for new ones in the future.
[Note from TheBody: This article was originally published by AVAC on Oct. 25, 2018. We have cross-posted it with their permission.]
This article was provided by AVAC: Global Advocacy for HIV Prevention. It is a part of the publication 3rd HIV Research for Prevention Conference (R4P2018). Visit AVAC's website to find out more about their activities and publications.
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