The next wave of HIV prevention progress

Gethwana Mahlase leads the field in exploring female-oriented HIV prevention options

Gethwana Mahlase leads the field in exploring female-oriented HIV prevention options

As leaders in HIV and Aids descend on Cape Town this weekend for the HIV Research for Prevention conference to discuss the way forward for HIV prevention research, their presence is a recognition of the tremendous contributions that South Africans have made to the global fight against the epidemic. 

Even through earlier years of official denial and government foot-dragging, South African communities, advocates and researchers banded together to carry out landmark research studies and lay the foundation for the world’s most ambitious HIV treatment program. Those efforts have not just saved and improved the lives of South Africans; they have served as examples and inspiration for countries across Africa and beyond. 

Now, South Africans are leading the way into the next era of HIV prevention. Clinical trials in South Africa and across the globe have produced new ways of halting HIV infection and current studies could soon produce additional advances, including vaginal gels and rings that contain antiretroviral drugs and that could help empower women to protect themselves. 

But getting new and existing options to everyone who needs them is an enormous and complex task. We have to begin engaging communities about these advances and planning for rollout now, so we can minimse the avoidable delays in access that have been all too common in the past. Vaccines, like those for Human Papillomavirus and hepatitis B, HIV treatment and HIV prevention options like the female condom and daily oral pre-exposure prophylaxis (PrEP) are all examples of life-saving tools that have not quickly reached the many who need them the most.

On some fronts, the critical work of preparing for and providing access to new options is already happening, with South Africans in a leading role. While South Africa’s HIV treatment access program is the most high-profile example of early activism and more recently implementation, progress can also be seen in prevention efforts. 

Take voluntary medical male circumcision (VMMC), for example. In 2005, a clinical trial in Orange Farm showed that VMMC can reduce a man’s chances of acquiring HIV from female partners by nearly two-thirds; a result confirmed by two additional trials in Kenya and Uganda. For the first few years after these landmark results, only a handful of countries made significant progress in scaling up the intervention — a huge and disappointing delay. 

But more recently, progress has picked up dramatically. In South Africa, nearly 1.4-million men were circumcised by the end of 2013, most of those in just the last two years. VMMC scale-up is working here because civil society, local service providers, policy makers and funders have worked together to ensure that men and boys have access to programs. This progress needs to be sustained via sufficient funding and continued partnership with local organisations as service providers, advocates and allies, so that demand for and understanding of the service is sustained and ultimately targets are met. 

With even newer prevention options becoming available, we need to repeat this same progress — but without the initial delays. 

We can start with daily PrEP, a powerful new tool that can and should be implemented now. Trials in South Africa and a number of countries show that people who consistently take PrEP daily, comprising an oral tablet with tenofovir (TDF) and emtricitabine (FTC), also known as Truvada, can reduce their risk of becoming HIV-infected by 90% or more. It is important to remember these trials showed that, like any medication and condoms, PrEP only works if you use it correctly and consistently. 

As early as 2012 the Southern African HIV Clinicians Society Consensus Committee published guidelines for safe use of PrEP for men who have sex with men. Recently, the World Health Organisation recommended that daily oral TDF/FTC as PrEP be offered as an option to men who have sex with men. 

But PrEP isn’t just for gay men — it’s been shown to be effective for heterosexual men and women and among people who inject drugs as well. If implemented effectively (and sooner than later), PrEP could help thousands of women and men stay HIV free. 

PrEP isn’t for everybody, but it should be an option for anyone at high risk of infection. And clinical trials only answer the initial questions of whether PrEP is safe and effective (which it is). Now, we must overcome regulatory, programmatic and financial hurdles so we can translate research results into actual impact on the epidemic.

In South Africa and elsewhere in the region, there is an urgent need for large, real-world projects to help us figure out how best to get PrEP to the people who can benefit most. Happily, initial projects are finally getting underway, but we must speed up the translation process. Advocates and communities can help push for well designed and funded projects, for regulatory approval, and for funding to support PrEP for people who need it and can benefit from it.

The time to do this is now — not only for PrEP in the short-term, but for helping us all learn how to introduce new options more rapidly. Lessons learned with oral PrEP will help us prepare for new ARV-based vaginal gels and rings. Just a few years ago, South African women and researchers contributed to the biggest scientific advance in this area — the Caprisa 004 trial. This was the first study to show that an ARV-based vaginal gel could lower the risk of HIV infection. A major follow-up study, Facts 001, is now under way in South Africa, with results expected early next year. If positive, it could pave the way for the gel to become available to women in this country and beyond.

Meanwhile, another two studies are evaluating a vaginal ring that slowly releases a different antiretroviral drug to prevent infection. These trials are scheduled to yield results in early 2016. 

While neither of these options is a sure thing, their potential is incredibly exciting. The need for additional, effective, women-controlled options is one of the most urgent priorities in HIV prevention today.  

Women have been waiting for new options, and we need to plan for success today. That includes defining, in advance, a core set of activities that can help us understand how best to get PrEP, gels and rings to women in need. Just as important is engaging civil society, building on the demands of women in the Caprisa 004 trial for access to an effective vaginal gel as soon as possible, and building a community of champions for these new options. For any new prevention or treatment option to make a difference, community support is essential.

Finally, we need to sustain research to create even more, and more effective, ways of preventing HIV. That includes an effective vaccine. Recent Aids vaccine science has been promising and confirms that a vaccine is possible. But the science also shows that it takes time. One of the key priorities now is to convey both the promise and the timelines, preparing advocates for active engagement as well as for possible delays, and ensuring the search for an Aids vaccine remains part of a truly comprehensive response to the epidemic.

This week’s HIV Research for Prevention conference is largely centered on research and is being attended by many of the world’s leading scientists, along with many committed civil society advocates, whose contribution is no less crucial to progress. Their commitment to research, and their ability to represent their communities, has been behind all the successful HIV research to date. 

If there’s one thing that research and experience has taught us, it is that the best prevention is about having options. People’s needs are different, and no single prevention method is right for everyone, all the time. But while there are no single or easy solutions, dramatic progress is possible. 

These potential new options — along with effective community-led responses to gender-based violence, stigma and discrimination — could help curb the alarming rate of new HIV infections in women in this country, across the continent and around the world.

Gethwana Mahlase is the founder of the Siyayifuna Campaign dedicated to the search for female-oriented HIV prevention options, and Mitchell Warren is the executive director of AVAC, a leading international HIV prevention research advocacy organisation