July 21, 2009
Cape Town, South Africa -- Examinations of extremely drug resistant tuberculosis (XDR-TB) and immune control of HIV in South Africa's KwaZulu-Natal Province highlighted the strategic location of the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) in the world's most HIV-impacted country. At Tuesday's plenary session, the more than 5,000 researchers, clinicians and community leaders attending the conference also took a comprehensive look at research on biomedical interventions to prevent HIV infection and financing the long-term response to HIV amid growing concerns about the impact of the global recession on scale-up. The conference runs from 19-22 July in Cape Town.
"The XIII International AIDS Conference in Durban gave birth to the call for access to HIV treatment for rich and poor alike and the IAS has returned to South Africa as the continent stands at a threshold," said IAS 2009 Local Co-Chair Dr. Hoosen (Jerry) Coovadia who is Chairman of Dira Sengwe and Scientific Director of the Doris Duke Medical Research Institute at the University of KwaZulu-Natal in Durban. "We have made real progress since 2000 but South Africa still has the worst epidemic in the world and we once again need the leadership of scientists, political leaders, international donors and community to turn the pandemic around."
An estimated 5.7 million people in South Africa -- one in every five adults -- is HIV positive, and an estimated 600,000 patients had access to life-saving antiretroviral therapy (ART) by mid-2008. South Africa's HIV/AIDS National Strategic Plan set targets to treat 80% of people who need ART by 2011, to give 95% of women access to prevention-of-mother-to-child transmission services by 2011, and to reduce new infections by 50% by 2011.
"In light of what is at stake, we are unwilling to accept the idea that HIV funding must fall victim to the global economy," said IAS President Dr. Julio Montaner, who is IAS 2009 Chair and Director of the BC Centre for Excellence in HIV/AIDS in Vancouver, Canada. "We must always drive for an efficient response that includes rigorous evaluation, but there is nothing we can do that is more efficient in the long run than treating people early and in a sustained way."
In his plenary presentation, Dr. Ronald Gray summarized the results of the 28 completed biomedical HIV prevention trials of STD control, microbicides, pre-exposure prophylaxis (PrEP), HIV vaccines and male circumcision. Of these trials, only four, including three of male circumcision, have reported significant efficacy. According to Dr. Gray, one of the conclusions to be drawn from positive and negative results is that phase III prevention trials are difficult, expensive and time-consuming. Ultimately, according to Dr. Gray, researchers will need to more carefully screen candidate interventions prior to trials and may need to conduct fewer trials, but with a greater investment in rigor and quality. Dr. Gray is Robertson Professor of Reproductive Epidemiology in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.
Dr. Bruce Walker analyzed the roles of CD4 and CD8 T-cell responses in controlling HIV infection. Drawing from data collected from collaboration with South African researchers at a site in KZN, Dr. Walker focused on T-cell-driver immune responses in people infected with HIV-1 subtype C virus, the most common subtype. This ongoing work involves people of Zulu/Xhosa ethnicity who are chronically infected with subtype C virus. Dr. Walker explored several facets of how T lymphocytes fall short in fighting off HIV, including how genetics of the infected person affect HIV control, how mutations in cytotoxic (cell-killing) T lymphocytes can impair HIV's ability to replicate, and why specific genes in the human leukocyte antigen (HLA) system affect viral control differently in people infected with different HIV-1 subtypes. Dr. Walker is Professor of Medicine at Harvard Medical School and Director of the Ragon Institute of MGH, MIT and Harvard.
According to Dr. Stefano Bertozzi, the threats to HIV/AIDS funding from the global financial crisis will place a greater emphasis on getting value from investments, and require a shift in thinking from a short-term, emergency response to a more efficient, long-term approach. Dr. Bertozzi is Executive Director of the Center for Evaluation Research and Surveys at Mexico's National Institute of Public Health (INSP). He pointed to several tactics to improve efficiency, including strategic selection and improved targeting of HIV interventions, and better management and strategic integration of those interventions into other services. He also called for more balance between investing for long-term benefit and funding activities to achieve short-term results, including evaluation.
Dr. Prashini Moodley, Chief Specialist and Head of the Department of Infection Prevention and Control at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, examined the emergence and spread of XDR-TB in KZN, explaining the interconnections between the local TB and HIV epidemics. Based on the experience of Tegula Ferry, site of a major XDR-TB outbreak, she discussed the roles of both nosocomial spread and the increasing numbers of immune-compromised patients in the community as factors in the spread of TB. According to Dr. Moodley these findings indicate the need for a multi-pronged approach to TB control that includes active case finding through rapid diagnostic methods, appropriate and early treatment for all patients with TB, timely initiation of antiretroviral treatment for all HIV-infected individuals and appropriate hospital infection control.
A webcast of Monday's plenary will be available on the conference website later in the day.
U.S. Ambassador at Large and Global AIDS Coordinator Eric Goosby and National Institute of Allergy and Infectious Diseases (NIAID) Director Anthony Fauci yesterday addressed U.S. global HIV policy, research and implementation under the Obama Administration in a special session. Addressing the current debate over when to initiate antiretroviral therapy, Dr. Goosby noted that the science clearly shows starting treatment at CD4 cell counts of 350 is better than starting at counts of 200. He assured delegates that this science will inform discussion of whether the World Health Organization's HIV treatment guidelines should be revised, but also noted that fiscal realities of what countries can afford will be a consideration. Dr. Goosby also said that PEPFAR is committed to mainstreaming responses to gender inequality in its activities and the programmes it supports. "We know we must place a special emphasis on women and girls to address gender inequity," he said.
Dr. Fauci reviewed the current state of HIV science and U.S. health policy, noting the benefit and cost-effectiveness of beginning treatment earlier. He cited research showing that the annual cost of caring for someone who starts treatment late in the course of disease (with a CD4 cell count of less than 50) is twice as high as the cost of care for someone who began treatment earlier. Dr. Fauci also said that he is confident the U.S. entry ban on people living with HIV will be lifted, as will the ban on federal funding of needle exchange programmes operating in the U.S. Both issues are under active consideration in the U.S. at present.
The special session was chaired by Global Fund Executive Director Michel Kazatchkine.
A webcast of the session is available online.