The International AIDS Conference continues to provide key findings in the development of HIV treatment and prevention, but not just. It also brings clinicians, researchers, and activists together to increase collaborations. The theme for the 22nd edition of the conference held in Amsterdam between the 23rd and 27th July, 2018 (AIDS 2018) was, in fact: “Breaking Barriers, Building Bridges”. The presence of young activists and women, two key populations which unfortunately remain underrepresented in the field of HIV, was very strong and powerful. Both populations sought and demanded engagement with politicians to not only put HIV back on their agenda but to also get invited and included in the planning and decision making on policies which concern their health.
The ‘Greater involvement of people living with HIV’ principle advocating for the inclusion of people living with HIV in any policy framework targeting key populations living or at a high risk of acquiring HIV, was a resounding strong message over the five days of the conference. It is gospel truth that policies drafted together with affected key populations provide a more successful practical implementation of said policies.
Undetectable Equals Untransmittable (U=U)
(NAM)aidsmap referred to the conference as a historical breakthrough, as the “U=U (undetectable equals untransmittable) and PrEP (pre-exposure prophylaxis) Conference”. What U=U means is that: There is no chance that a person living with HIV who is on effective treatment with an undetectable viral load can transmit the virus to their sexual partners. This has been confirmed from the results of PARTNER II, the second phase study of the PARTNER study, presented at AIDS 2018.
The PARTNER study recruited both straight and gay serodiscordant couples (one positive, one negative) to find out if the person living with HIV, whose viral load is less than 200 copies/ml, can sexually transmit the virus to their partner. The results of the first phase (PARTNER I), which were presented at CROI back in 2014, showed that no one with an undetectable viral load, straight or gay, can transmit the virus.
PARTNER II, on the other hand, recruited only gay men. The results confirmed what had already been confirmed in the first phase of the study and hinted at in an earlier study (HPTN 052) that, scientifically, with confidence, there is no risk of sexual transmission when the person living with HIV is on effective treatment and their viral load has been suppressed, and this even though there were nearly 77,000 acts of condomless sex reported.
Over 720 organisations, including the Centers for Disease Control and Prevention (CDC) and the World Health Organisation (WHO), have endorsed these results and the message behind U=U.
The outcome of the studies are themselves good reason for celebration; they send a message of hope to people living with HIV, their partners and families, but not just. The results provide a powerful tool to further fight self-stigma and the stigma which people living with HIV have to face. They are also a powerful political tool for people living with HIV to demand virology tests and effective treatment which could help them become virally suppressed.
The UNAIDS 90:90:90 targets (getting 90% of people with HIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment virally suppressed and therefore non-infectious) are now even more relevant than before. A fourth 90 (90% of the people living with HIV enjoying a good quality of life) has recently been added to the original targets. Nonetheless, this will not be possible if a global political will is not present. Without the right and just allocation of resources, the message behind U=U and the targets by the UNAIDS could possibly remain an action plan on the agenda for most governments.
Both activists and researchers at the conference were unanimous in that HIV should once again be put as a priority for governments. There are 36.7million people around the globe living with HIV, with more than half (18.6 million) being women over the age of 15. Each and every single person diagnosed with HIV not only has a right to any treatment, but to aneffective treatment which could suppress their viral load. It ensures that people living with HIV enjoy a quality of life comparable to those not living with this chronic condition. Furthermore, from a public health perspective, it benefits governments and citizens alike to provide treatment since it stops both forward and vertical (mother-to-child) transmission of the virus.
Further scientific developments
Anti-Retroviral Therapy (ART), which is the treatment prescribed to people living with HIV, is a combination of three or more drug regimens. Studies presented at the conference proved that a two-drug regimen (Lamivudine and Dolutegravir) is not of an inferior quality when compared with a three-drug regimen (Dolutegravir + Tenofovir + Emtricitabine). This could potentially see a reduction in the costs of ART and also in the concerns over the side effects and toxicity levels ART leaves in the patient. Data from a study in Brazil also confirmed that putting Dolutegravir in the first line regimen (the preferred, recommended treatment) significantly increases the chances of virological suppression compared to other treatment regimens that do not include Dolutegravir.
As to a possible cure for HIV, data from the ‘River Study’ has put to test the ‘kick and kill’ strategy where an agent is used to ‘kick’ the virus in the reservoir while a vaccine is used to ‘kill’ the awoken virus. Even though the results were disappointing, the study provided further insight into the HIV reservoir. Studies and analysis are currently underway to further understand why the study failed.
Decriminalisation of sex work
Possibly one of the most vociferous groups in the conference was that of sex workers, demanding entire decriminalisation of sex work across the globe. Sex workers are ten times more likely to become infected with HIV. Legislation which criminalises the sex client and not the sex worker, so called ‘end demand laws’, was originally thought to drive a higher demand for essential services, including HIV prevention and treatment. However, two studies on Canada and France’s ‘end demand laws’, presented at the conference, showed a decrease in the demand for essential services. “If ‘end demand’ laws create new barriers to HIV prevention and care, that is a very significant concern,”Linda-Gail Bekker, President of the International AIDS Society and International Chair of AIDS 2018, said. This provokes careful reconsideration of the ‘end demand laws’ and further investigation of the impact they have on access to health care services.
A group of sex workers also interrupted President Bill Clinton’s keynote speech on the last day of the conference, demanding that he exert what political pressure he could to decriminalise sex work. They also joined other protests held at several intervals during the conference demanding that the next AIDS conference is not held in Trump’s America. Laws around sex work and drug users, together with the constant undermining of rights of transgender people, will prove to be problematic for those who would need to obtain a visa to attend the conference.
Bringing the conference home
In a plenary session, Minister for European Affairs and Equality Helena Dalli spoke about the recent introduction of gay marriage and the Gender Recognition Act allowing transgender people to change the gender on their identification documents without the need to undergo gender reassignment surgery. She also mentioned the government’s positive actions to provide a gender reassignment clinic. Even though not mentioned in the press release issued by Dalli’s ministry (PR181667),in her concluding, the Minister made reference to HIV-related issues pertaining to Malta. When asked to provide dates for the government’s action plan to provide Post-Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP) on the NHS and better treatment for those living with HIV in Malta, no concrete answers were forthcoming. the minister could not provide any concrete answers. When pressured, an accompanying ministry official stated that the changes mentioned are part of an action plan the government has and which it will implement over the next three years.
What policymakers must recognise is that the use of political rhetoric hardly ever works in health-related matters, especially in the field of HIV. People living with HIV and those affected by it (those at a high risk of contracting HIV) demand not only accurate answers but immediate implementation of effective strategies which could see their quality of life improved.
The results from separate investigations conducted by myself and a colleague of mine earlier this year on what medication is prescribed to people living with HIV in Malta and what services they are offered, show that some people are still being prescribed concoctions of pills. Some have reported taking up to six pills a day. To add insult to injury, these medications fall entirely outside international guidelines on ART; they are not even recommended to be prescribed in developing countries. Not only did the medication have to be collected from the pharmacy at Mater Dei Hospital rather than a pharmacy of the patient’s choice, but there were occasions where stock of certain medication was running low, so patients had to go back to the pharmacy to get more medication. Psychological support was reportedly not available.
As things stand, the cost of PEP, a 28-day treatment which can prevent the settling of HIV in the body following exposure to it as long as it is started within 72 hours of exposure, sets you back about €550. Even though PEP is considered to be a powerful preventative tool for HIV, it seems that making it accessible to the general public who might need it is not a priority.
The engagement of politicians with key populations is a prerequisite for any effective policies. Former President Bill Clinton, Elton John and Prince Harry, Duke of Sussex, were unanimous in stating that this is not the right time to cut down on funding in HIV and Public Health at large. They have also encouraged activists to keep lobbying and fighting for support from their politicians and international organisations. HIV is an infection which affects all parts of the world and it is only through global cooperation that the number of new infections can be reduced, with effective treatment and virological tests made available in all parts of the world.