| |  |  | Tuesday 19 July 2016 | | |
International AIDS Conference opens with renewed call for commitment 
Treatment access march in Durban. Photo by Jan Brittenson, hivandhepatitis.com The remarkable
gains in HIV treatment and prevention since 2000 could be lost unless
stakeholders commit to renewed funding and dedicate themselves to the human
rights of at-risk populations, the
opening ceremony of the 21st International AIDS Conference (AIDS 2016) in
Durban, South Africa was told. The theme of the conference – Access Equity
Rights Now – recognises that there are still significant obstacles to
equitable access to HIV care, treatment and prevention, including pre-exposure
prophylaxis (PrEP).
The conference was
last held in Durban in 2000, when it acted as a springboard for expanded access
to antiretroviral therapy (ART) in low- and middle-income countries.
By the end of
2015, according
to UNAIDS figures, an estimated 17 million people were receiving ART
globally. However, over half of those in need of ART are still not receiving
treatment.
Speakers at the
opening ceremony stressed the importance of reaching and addressing the needs
of populations especially vulnerable to the epidemic – women and girls, men who
have sex with men (MSM), transgender people, sex workers, people who inject
drugs. A focus of this year’s conference is how to put recent breakthroughs in
treatment and prevention into practice – but this will require fundamental
cultural, social and legal changes in many settings.
There has been
impressive progress towards achievement of the UNAIDS 90-90-90 target (90% of
people living with HIV diagnosed, 90% of people diagnosed taking HIV treatment,
90% of those on treatment achieving viral suppression). But these achievements
are being imperiled by withdrawal of funding by major donors, and low- and
middle-income countries lack the resources to make good the shortfall.
This year’s
conference features over 2000 scientific papers and 18,000 delegates are
attending from across the world. The event also includes a number of integrated
‘pre-conferences’, focusing on progress towards a cure, MSM, trans women with HIV,
and a leadership summit for the global network of people with HIV.
Achieving the 90-90-90 target 
UNAIDS Executive Director Michel Sidibé presenting at AIDS2016. Photo by International AIDS Society/Marcus Rose Reduced
commitment from donors is undermining efforts to achieve the 90-90-90 target,
according to speakers at the conference.
Delegates were
told that the target is achievable, but donor retreat is the biggest threat to
progress.
The 90-90-90 target (90% of people
living with HIV diagnosed, 90% of people diagnosed taking HIV treatment, 90% of
those on treatment achieving viral suppression) – is key to achieving the
aspiration of an end to AIDS by 2030.
A report released
by UNAIDS on Sunday showed that real progress is being made towards the
achievement of this target, including 17 million people taking HIV treatment by
the end of 2015; globally, over half of people with HIV are diagnosed, with 46%
of those aware of their status on treatment and 38% of people on treatment
having a suppressed viral load.
However, the data
also revealed disparities between world regions, with eastern Europe, central
Asia and western and central Africa falling behind the progress made elsewhere.
Funding required
to achieve the 90-90-90 target will peak at over US$19 billion next year, but
fall to $18 billion in 2020. However, last year there was a $600 million
reduction in the funding provided by major donors.
UNAIDS Executive Director Michel Sidibé told aidsmap.com that if funding continued to fall it would be
impossible to achieve the targets. Rather than ending AIDS by 2030, the epidemic will rebound and rates of new infections
will once again increase.
Sidibé said that political leadership, a commitment to
testing campaigns, reduced medicine costs and new ways of delivering services
had been key to making
progress towards the 90-90-90 target.
Speakers provided details of their experience of
providing services at each stage of the cascade – diagnosis, treatment, viral suppression.
PEPFAR (The US President's Emergency Plan for AIDS Relief) Ambassador Deborah Birx warned of the
consequences of failure to meet the 90-90-90 target, highlighting the risk of
an upsurge in new infections and a reignited epidemic if transmissions were
not controlled.
Progress towards a cure – very early treatment has promising results 
Thumbi Ndung’u presenting at AIDS 2016. Photo by International AIDS Society/Rogan Ward
A cure for HIV remains a research priority and was the
focus of a two-day meeting before the formal
opening of this year’s conference.
A particularly interesting
study involved 24 young South African women who started ART within 15 days of acquiring
HIV.
Aged between 18 and 23, the participants were recruited to the study when they
were HIV-negative but identified as being at high-risk of acquiring HIV. As part of the study, the women were offered
condoms and advice on HIV prevention.
Very frequent testing (twice a week) enabled
researchers to identify participants with very recent HIV infections. Very
early treatment resulted in much lower peak viral load during acute HIV
infection and 30 days after infection, viral load had fallen to undetectable
levels. Early treatment also preserved CD4 cell count. The function of key
immune cells normally disrupted by HIV infection was also preserved.
Many of the women did not develop antibodies to HIV,
even though intensive testing revealed very low levels of HIV infection in
cells.
The women are to remain on treatment for at least another two or three
years. A decision will then be made on whether or
not to interrupt antiretroviral therapy (ART) to see if the participants maintain control of HIV without
the need for treatment. Another research priority will be to see if it is
possible to eradicate the very low levels of HIV infection observed in these
women.
PrEP – delivering to those in need 
Linda-Gail Bekker presenting at AIDS 2016. Photo by International AIDS Society/Steve Forrest/Workers’ Photos
One of the most important recent developments in HIV
prevention has been the introduction of pre-exposure prophylaxis (PrEP), which if taken properly provides HIV-negative
individuals with a very high level of protection against HIV.
A pre-conference meeting was
told that providing access to PrEP to those who would benefit from it is now an
important priority.
The World Health Organization (WHO) will soon be
issuing PrEP implementation guidelines. This wide-ranging document will address
the concerns of political leaders, medicine regulators, community regulators,
public health officials and clinical and other front-line medical and testing
personnel.
WHO also suggests that people and groups at high risk
of HIV should be offered PrEP.
Their new document has advice about how this should be
implemented, recommending a three-step approach:
- Consider
the local context – epidemiology, geography, demographics, behaviour and
culture.
- Provide
PrEP services in areas where HIV transmissions are occurring.
- Offer
PrEP to individuals who are at risk and who wish to start PrEP.
WHO also recommends that PrEP should be part of a
wider package of HIV prevention measures.
Delegates heard that there was a PrEP ‘cascade’ – a
model based on the well-established treatment cascade for people living with
HIV.
Steps in the PrEP cascade comprise:
- Improve
supply of PrEP – develop services to make PrEP accessible to those in need.
- Increase
demand for PrEP – strengthen awareness of PrEP and positive attitudes towards PrEP,
as well as individuals’ perception of their personal vulnerability to HIV.
- Support
adherence to PrEP.
TB and HIV 
Aaron Motsoaledi, South Africa's Minister of Health, presenting at TB2016. Photo by International AIDS Society/Marcus Rose
Tuberculosis (TB) is a significant cause
of serious illness and death in people with HIV, and was the subject of one of
the pre-conference meetings, TB2016.
In 2004, Nelson Mandela issued a call to fight TB as
well as AIDS. But the
pre-meeting was told of a disappointing lack of progress, with TB remaining
the main cause of serious illness and death in people with HIV, and with TB
undetected in almost half of people with HIV who die as a result of TB.
Lack of funding and disappointing progress in the
development of new anti-TB drugs were highlighted.
The meeting heard a call for action, and it was
stressed that countries needed to address the root causes of the HIV and TB
epidemics – poverty, malnutrition, poor housing, stigma and a lack of basic
human rights.
Also presented at the TB2016
meeting, new research shows that a shortened course of therapy is effective for
the treatment of children with multidrug-resistant TB (MDR-TB).
The nine-month course of therapy achieved good results
in 83% of children and adolescents with TB resistant to rifampicin, a key
first-line drug.
Therapy consisted of the so-called 'Bangladesh regimen'
which has previously been shown to be highly effective in adults with
drug-resistant TB.
The Bangladesh regimen is made up of four months of
kanamycin, moxifloxacin, prothionamide, isoniazid, clofazimine, ethambutol, and
pyrazinamide, followed by five months of moxifloxacin, clofazimine, ethambutol
and pyrazinamide.
Results of the present study involving children and
adolescents in a number of resource-limited settings showed that the regimen
was successful in 83% of cases.
Separate research showed that the drug levofloxacin
was safe as part of a TB regimen for MDR-TB in HIV-positive and HIV-negative
children. The most common side-effects were vomiting and disturbances in liver
function. No child stopped treatment because of an adverse event.
Equal access, free choice 
Eight global HIV advocacy groups have released a consensus statement setting out basic principles for provision of HIV treatment and pre-exposure prophylaxis (PrEP). Please read it, sign it and share it.
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