Track F report by Damon BARRETT
In opening the 18th International AIDS Conference (AIDS 2010) in Vienna, the conference theme played out through the welcoming remarks of Ban Ki Moon, the Secretary-General of the United Nations.
Rights here, Rights now reflected not only the importance of the international community, individual nations and communities themselves to seek and improve access to health and treatment, but also the need to ensure the respect, protection and fulfilment of fundamental human rights.
Mirrored here was not only the importance of human rights in work to achieve the “indivisible” millennium development goals, but also the importance of recognizing human rights in order to attain “health and development for all.” As Brigitte Schmied, President of the Austrian AIDS Society and AIDS 2010 Local Co-Chair would later suggest, “AIDS was never just about science, it has always been about social justice as well.”
This marriage of science and social justice was reflected also in the comments of Julio Montaner, the Chair of the AIDS 2010 conference, who indicated one of the roles the bi-annual conference plays is “to send an evidence-based message” to those that define and diffuse law and policy. A message that human rights have played a central role in our successes to date; and that, critical choices relative to rights—both here now—would continue to challenge world leaders in the year ahead.
Yves Souteyrand, of the World Health Organization, in speaking on HIV epidemiology and the challenges and implications for human rights, stated, “universal access to prevention and treatments cannot be achieved without universal access to human rights.” He illustrated this be defining some of the affronts to human rights by epidemiology, including unethical HIV surveillance, contributions to HIV transmission by violations to human rights and the failure to act on epidemiological evidence for those most vulnerable and at risk.
Reflected in a reference to Jonathan Mann provided by Paula Akugizibwe of the AIDS and Rights Alliance for Southern Africa was that “the epidemic of stigma, discrimination, and denial…[is] as central to the global AIDS challenge as the disease itself.”
Concurrently, though, there was perhaps a tendency for this human rights talk to imbue the evening with a kind of lip service that may fall short of true action. This arguably failed to convince all of those in attendance that the international community was doing everything possible to weave together health, ethics and human rights in the kind of synergism envisioned by Professor Mann when he founded the World Health Organization’s Global Program on AIDS almost 25 years ago today. That is, the kinds of synergies required to secure action over lip service for the attainment of human rights protections for those most vulnerable to HIV.
Despite the myriad of references to rights heard throughout the evenings speeches, the paths to attain the kinds of synergies and commitments required may likely remain at the very fore of the minds of the more than 20,000 participants assembled in Vienna this week.
Track A report by Guido POLI
Sharon Lewin (Melbourne, Australia) addressed the current strategies in place for finding a “cure” (either a sterilizing cure, i.e. elimination of the infection or a functional cure with complete suppression of the virus capacity to cause disease and to be transmitted). She underscored that in spite of the great benefit of today’s therapies, yet full life expectancy has not been achieved for people living with HIV, even in the best care settings. In addition, combination therapy bears important side effects and frequent diseases of the cardio-vascular system and of other organs, including a higher frequency of solid tumors. Since for every 2 people started on therapy, 5 new infections occur, we are still far from controlling and curtailing the epidemic. On such a basis, Sharon Lewin focused on the three major barriers to achieving the cure: 1. the existence of residual viral replication even under potent therapy combination, 2. the existence of anatomical sanctuaries or reservoirs (including the brain, testis and the gastro-intestinal tract) and (3) of latently infected cells not affected by current therapeutic agents. Latently infected cells can be found in a variety of T lymphocytes and also in other cell types, including astrocytes of the central nervous system, tissue macrophages and stem cells that can give rise to progenies of different infected cell types.
The feasibility of achieving “the cure” is illustrated by the case of patient affected by lymphoma who underwent total body irradiation and stem cell replacement with an immunologically concordant donor who was also homozygote for the CCR5-delta32 deletion (a mutation that does not permit to CCR5, the main HIV-1 entry co-receptor, to be present on the surface of lymphocytes and macrophages). This patient is still negative for virus replication after several months of suspension of antiretrovirals without presenting evidence of virus replication or HIV disease progression. Gene therapy approaches aiming at reducing the expression of CCR5 in a single patient may mimic such a success We need to understand what made it possible. The second case, reminded by Lewin, are elite viral controllers, who maintain very low levels of virus replication in the absence of therapy.
What strategies can be envisaged for the future? Treatment intensification, unfortunately, does not lead to changes in residual viremia or HIV DNA (i.e., the number of infected cells). However, an important study from Spain demonstrated that the inclusion of an integrase inhibitor showed an impact on these parameters. A second important suggestion comes from a French study showing that early initiation of treatment might lead to reduce HIV load. However the biggest challenge would be to tackle the viral reservoir by awakening dormant latently infected cells. In the case of T cells, their activation in a context of potent antiretroviral therapy preventing new infected cells might lead to their elimination by apoptosis or other mechanisms including immune-mediated elimination of the infected cells. A panoply of potential new drugs have proven in vitro efficacy and bear the potential to achieve this task.
Track B report by Andrew KAMBUGU
In assessing the state of the epidemic during the opening session, the highlight from a clinical science perspective was a provocative call to consider the case for a cure for HIV by Dr Sharon Lewin from Australia. While maintaining that considerable scientific progress has been made in the prevention, care and treatment of HIV, Dr Lewin made compelling arguments for a focus on a cure for HIV. The main basis for this case was the observation that despite the gains seen with HAART, the life expectancy of HIV-infected individuals on HAART does not at all approximate that seen in comparable HIV negative populations.
Finding a cure will not be easy though. Dr. Lewin highlighted 3 key challenges to this goal. First and most challenging is the persistence of latently infected cells. This latent pool according to the most recent studies is far larger than originally imagined. The pool includes; transitional memory cells, naïve T cells and multi-potent progenitor cells. Secondly, there is residual viral replication even in the presence of the most potent HAART regimens. Finally, there are anatomical barriers (the central nervous, the gut and the genital tract) which possess unique resistance to the HAART penetration.
In order to comprehend the strategies for an HIV cure Dr Lewin proposed 2 theoretic cure models. These are; the infectious diseases model (sterilizing model) where the goal is to eliminate all the HIV reservoirs from the body; and the cancer model (also the remission model) which has a less lofty goal of limiting the HIV reservoir to a bare minimum.
Turning to the current and future strategies for an HIV cure Dr Lewin proposed the following:
* Optimizing HAART through treatment intensification (citing Buzon et al-Nat Med 2010 16:460);
* Reducing viral reservoirs through earlier treatment initiation and induction of latent cells (IL-7 treatment and other compound including histone deacetylase inhibitors)
* Making cells resistant to HIV infection by induction of specific CCR5 receptors and other mechanisms. These particular strategies are at the proof of principle stage.
There are grounds for optimism for an HIV cure based on the evidence presented during the opening session even if clinical application may be a long way off. Hopefully, this theme will be amplified over the next few days
LAPC report by Nathan FORD
Hundreds of activists opened the conference with a protest against AIDS funding cuts, demanding accountability from donor governments that have broken their AIDS funding promises. Delegates marched through the conference venue from the Global Village to the Opening Ceremonies location shouting 'Broken Promises Kill', and 'You Made a Promise, Now Make It Happen'. Outside the entrance to the Opening Ceremonies, activists participated in the 'die in' under giant balloons picturing the faces of Obama, the President of Austria, G8 leaders, and key African leaders all captioned with 'Show us the money!'. Activists dropped a banner from the subway stop outside the plenary hall, and the action concluded with activists depositing a giant 'NO RETREAT. FUND AIDS.' banner on the Opening Ceremonies stage.
In his opening address, Dr Julio Montaner, President of the IAS, congratulated the leadership of the World Health Organization for putting forward treatment guidelines that reflected the latest scientific evidence in support of the broader benefits of universal access to ART. He noted that the elimination of vertical transmission of HIV was widely accepted as feasible and should be a political goal, and highlighted the growing evidence to support the impact of widespread coverage of ART on incidence. “It’s time to move on it, and move on it now”, he said. He went on to note, however, that stigma and discrimination were major barriers to an effective HIV/AIDS response, resulting in “misguided policies and misallocated resources.”
Dr Yves Souteyrand from WHO echoed this concern, stating that “human rights continue to blind our knowledge of the epidemic and challenge our ability to respond.” Dr Souteyrand outlined data showing that most at risk populations contribute almost a quarter of new infections in West Africa, and remarked that in many countries data is missing because epidemiological surveillance breaks down when people’s way of life is criminalized and engagement in research could endanger their lives. Homosexuality, for example, is criminalized in 80 countries around the world with penalties ranging from imprisonment to sentences. Souteyrand concluded with data from Ukraine that highlighted how policies supportive of human rights can impact positively on HIV. Evidence-based prevention and treatment policies (including opioid substitution therapy), have contributed to a substantial decline in the number of new cases of HIV among IDUs, from 29.9 in 2004 to 11.2 in 2008. He noted, however, that such policies have only been implemented in a third of the country, and encouraged the Ukraine and other countries to build on these results.
All speakers echoed the concerns raised by the demonstrators that donor funding for HIV/AIDS must be assured. Paula Akugizibwe from ARASA stated clearly that lack of money was not at the heart of the donor retreat from HIV/AIDS funding: "The global economic crisis is not threatening the fight against AIDS. It's a global priorities crisis that's threatening the fight against AIDS," she said