What most excites you about the HIV R4P conference?
I’m excited about both the process and the topic of R4P. On the process, we’re starting to be smarter about how we bring the science of the vaccine, microbicide and Pre-Exposure Prophylaxis (PrEP) worlds together. We were nervous about how acceptable this idea would be to people from different research arenas. As the R4P programme has come together, the synergies between these fields have become even clearer and the benefits of scientific integration have become even more apparent.
R4P also provides a critically important opportunity to keep the scientific momentum going at a time when there are many competing health research priorities. These conferences galvanise fields of research. Looking at the spectrum of skills and backgrounds of the people registering for R4P, you see the opportunity that this conference provides to open up a new level of dialogue between different disciplines. There is no doubt that our work would continue without R4P, but we’d be staying within our own silos, and within our own paradigms of thinking. HIV R4P offers an opportunity to stretch and grow beyond our daily interactions with our immediate colleagues.
How will R4P highlight South African researchers and research institutions?
If you look at the research from South Africa in the last 10 years, there has been increasing output in both the HIV and TB fields, which is totally appropriate given the burden of disease we carry. South African science has matured, and its researchers are now globally recognised for their scientific input and ability to implement successful clinical trials. Locating this conference in the African region offers opportunities for researchers and policymakers from the region to interact with emerging, global, scientific thinking and to see how this portfolio of work continues to build a bigger picture. The R4P leadership has worked very consciously to seek out African scientists who can present on a range of topics in basic, clinical and behavioural science. Hosting conferences in Africa always contributes to capacity building and ownership in the region.
You’ve witnessed a transformation in South Africa’s research focus and capacity across your career. How have these changes impacted the efforts to find new prevention tools for HIV?
Looking back to 1994 and our transition to a democratic government, the baseline we started from in South Africa in almost all forms of HIV research was close to zero. In my first big study — a phase II study on nonoxynol 9 — we had a study naive team, a study naive site and a study naive population. We were given a protocol and a start date. There was no community advisory board and we hadn’t yet learnt about Good Participatory Practice. At that time, clinical trial sites simply implemented studies developed in their entirety in the developed world.
When you compare this approach to a current study we are implementing, the FACTS 001 study, the change in our understanding of what’s required for a successful clinical trial is extraordinary. We’ve learned a great deal from looking at our successes, and from our past mistakes. Today, studies have better products, better study designs and better community partnerships, but there are areas where we could still improve.
There are too few independent scientists in the region who can write their own protocols and publish their research themselves and too few Africans recognised as first and second authors, even though the data is published from their own clinical trial sites. Given the multi-billion-dollar investment that has been put into African study sites, we should reflect on why we haven’t been more successful in developing independent researchers in the region. Despite developing successful north-south partnerships, there is still more that we could do to boost the number of independent scientists working in Africa.
What do you think is needed to develop new prevention tools for women on the continent where they are needed most?
We’ve got a research agenda and an innovative new product pipeline. What we sometimes lack is a transparent process for the selection of new products or the choice of new research approaches.
Secondly, this field will continue to have an inevitable mixture of failures and successes. We need to better understand how to extract the maximum amount of information from our failures, as well as our successes. The failures often seem like a death knell for the scientists, the study teams and/or the product. Yet every time we fail we learn more about basic science, the product and/or human behavior. Failure always presents an opportunity to learn, and we need to plan for those opportunities better.
We also need a bigger implementation science research agenda so that we can roll out the technologies that we have today. We have a number of new technologies that we have failed to make available to the populations that most need them. For example, why are we not doing more to ensure access to female condoms and diaphragms? Why are we not rapidly scaling up access to PrEP, or exploring its possible impact for young women? Why has circumcision taken so long to roll out? Some of these questions are just as important as those related to the next stage of basic or clinical research.
Are you optimistic about the prospects for microbicides and multi-purpose prevention technologies?
Yes. I certainly am. Studies of tenofovir gel show that it works in women who use it consistently and correctly. Yet interestingly, and shortsightedly, some commentators are saying that the days for a coitally dependent gel are over. The fact that an intention-to-treat study does not show an overall effect does not mean that the product has not been effective in those participants who, and this is key, used the product correctly. Conflating adherence in a study with the prospects for adherence in the real world can be misleading. When women go to a clinic and ask for a contraceptive, the vast majority of women will use that method for a significant period of time. Those women self-identify as being at risk for an unwanted pregnancy and they want to do something about it. This scenario is quite different from that pertaining to a clinical trial.
Women need a range of prevention products — gels, rings, injectables, multipurpose prevention technologies, and a vaccine. It’s naive to think that any one of these options will solve the problem for all women. We have a number of very promising options in development, and we need to keep all of them moving forward.
South Africa and HIV prevention
According to the United Nations Programme on HIV and Aids (UNAids) 2013 Global Report, South Africa is home to an estimated 6.1-million people living with HIV — the highest population of people living with HIV anywhere in the world. Yet, while HIV has affected South Africa as it has few other countries in the world, recent responses to the epidemic here have been equally impactful.
Domestic spending on the epidemic, and access to HIV therapy, have both increased significantly in South Africa in recent years. UNAids estimates that 81% of South African adults and 63% of children who needed antiretroviral therapy based on World Health Organisation 2010 guidelines were receiving it in 2012, and that 83% of pregnant women living with HIV received antiretrovirals to prevent HIV transmission to their children in 2012. The nation is also enhancing its focus on providing treatment to individuals living with both HIV and TB.
South Africa is one of a small number of countries that have also integrated HIV testing into community campaigns providing screening or prevention services for multiple diseases, such as malaria, diabetes, hepatitis and/or sexually transmitted infections.
As a result of these and other efforts, estimated new HIV infections in South Africa dropped by 42% overall between 2001 and 2013, from 640 000 to 370 000, and by 72% in children over a similar period. New infections in women declined by 21% between 2009 and 2012 and the percentage of men who have sex with men estimated to be living with HIV in South Africa declined from 13.2% in 2009 to 9.9% over the same period. Thanks to treatment scale-up, in 2011, life expectancy in the KwaZulu-Natal province was 11.3 years higher than in 2003.
South Africa is also a leader in HIV prevention research. South Africa — and South Africans — have long been leaders in HIV prevention research. A number of key clinical trials and research studies have been hosted, supported, designed and led in South Africa and by South Africans. According to the AVAC HIV Prevention Research & Development Database approximately 13 ongoing clinical trials are taking place in 15 different locations in South Africa currently.
Conference fast facts
HIV R4P brings more than 1 300 of the world’s leading prevention researchers, funders, policy makers and advocates for four days of exchange, debate and direction-setting for the field. The conference features:
Four plenary, and 17 symposia and roundtable sessions.
722 abstract presentations — 177 oral presentations and 545 posters.
300 international scholarships and five New Investigator Awardees.
Webcasts of all oral sessions — available within 24 hours.
The conference is chaired by Sharon Hillier from the University of Pittsburgh in the United States; Eric Hunter of Emory University in the US; Anatoli Kamali from the Medical Research Council and the UVRI Uganda Research Unit on Aids in Uganda; Helen Rees of the Wits Reproductive Health and HIV Institute in South Africa; and Robin Shattock from Imperial College London.
HIV R4P co-chair Professor Helen Rees is an internationally renowned expert in HIV prevention, reproductive health, vaccines and drug regulation. She is the executive director of the University of Witwatersrand’s Reproductive Health and HIV Institute.
Rees is the chair of the World Health Organisation’s Regional Office for Africa Advisory Committee on Vaccines and a member of the South African National Advisory Group on Immunisation, a member of the Scientific Advisory Committee of the HIV Prevention Trials Network, and the protocol chair of the Follow-on African Consortium for Tenofovir Studies (FACTS 001), the confirmatory study evaluating the safety and effectiveness of 1% tenofovir gel in preventing HIV acquisition in young women. She is the past chair of the South African National Aids Council’s Programme Implementation Committee and is co-chair of the National Institutes of Health funded Wits HIV Research Group.