Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

30 December 2011

Mapping Pathways 2011: The year in voices

Original content from the Mapping Pathways blog team

“We are on the verge of a significant breakthrough in the AIDS response. The vision of a world with zero new HIV infections, zero discrimination, and zero AIDS-related deaths has captured the imagination of diverse partners, stakeholders and people living with and affected by HIV. New HIV infections continue to fall and more people than ever are starting treatment. With research giving us solid evidence that antiretroviral therapy can prevent new HIV infections, it is encouraging that 6.6 million people are now receiving treatment in low- and middle-income countries: nearly half those eligible.” - Michel Sidibe, UNAIDS Executive Director, World AIDS Day report

Earlier this month, WHO and UNAIDS released a World AIDS Day report providing a snapshot of goals and progress made in 2011 toward HIV/AIDS prevention. We thought we’d provide a snapshot of the Mapping Pathways project as well – but through the voices of some of the most memorable and inspiring people we spoke with this year.

“It’s been like Christmas every day since July at the International AIDS Conference in Vienna when the CAPRISA study results came out… We’ve gotten over this first hurdle; we’ve proven that we can create new ways to prevent HIV through the use of ARVs taken orally or applied topically but now we have to figure out how to get that pill, or gel, or whatever into the right hands in the right place at the right time. We’re grappling with all the problems that come with success.” - Jim Pickett: ‘Success! Now what?’
“There is a threat – still distant but definitely visible – that we will lose this astonishing success through complacency… We can make AIDS rare – and eliminate it entirely from rich countries – using technologies that we already have. The question is whether we have the will to do it.”  - Mark Chataway: Using antiretrovirals to prevent new infections

“There’s still so much we don’t know, and these are open questions rather than being settled questions… we can’t prove that the intervention worked, and we can’t prove that the intervention didn’t work … There are still things to be learned.”  - Julie Davids: FEM-PrEP closure update – What does ‘futility’ mean exactly?

“I think whenever the field starts to go on emotion, we get into trouble… Human behavior keeps messing up the plot.”  - Dr. Linda-Gail Bekker: Of Mice, men, and microbicide trials   

 “I put the word MSM on the board, and do you know what one woman participant said? She said, ‘By MSM do you mean men who have sex with men? Yes, they must die; and if not, they must be killed!’ I was so taken aback. I thought, ‘Oh my God, this is where the advocacy has to start from.’” - Brian Kanyemba: A snapshot of advocacy in Africa

“The level of efficacy seen in the HPTN052 study is stunning, and is extremely important on several fronts. First, in terms of the potential of this strategy to reduce transmission, it is clearly an effective option… Of course, there are some issues associated with this strategy as well.”  - Dr. Joe Romano: Thoughts on the microbicide pipeline and the recent HPTN 052 results

“I believe that it is a political, economic and human tragedy that the first time our country has had a national HIV/AIDS strategy is exactly at the same time that we’re being told there are no resources to put it fully into place... We are, in significant ways, being restrained from putting our best minds and hearts at the forefront of this effort. When we get to the end of the day, there are good ideas, and then there are good ideas that are fully funded.”  - Julie Davids: The economic effect of HIV/AIDS in the US

“Sex sells. People in the commercial world use sex to sell things like cars, toothpaste, pens…almost anything! Why not use sex to sell safer sex?”  - Anne Philpott: How sexy sex can help prevent HIV transmission

“Working with vulnerable populations like transgender individuals and men who have sex with men (MSM) was really an eye opener. These are people who often have nothing to their name (often not even a roof over their head), are disowned by society and their families and are completely discriminated and stigmatized against. Yet a number of them were keen to help spread awareness about HIV/AIDS, prevention options and vaccines so that others may benefit from the information and not get infected with HIV. This degree of humanity is truly remarkable.”  - Dr. Sonali Kochhar: PrEP in India

“My sense is that many people are still very uncomfortable and not quite able to figure out why we’re talking about PrEP in the Indian context. Many senior people in the field feel the focus needs to be on TLC+.”  - Anjali Gopalan: Notes from India – concerns and challenges around PrEP

“The matchmaking started because people living with HIV don’t disclose their status to their parents. In India, when the boy is 30 or the girl is 24-25, the parents want them to get married. They start looking for partners and the person who is infected is unable to talk freely to them and say, ‘Look, I have HIV and I can’t get married.’ That’s when they come to me and ask, ‘My parents are planning to get me married to an HIV-negative person – now what do I do?’ So we say okay, we’ll look for someone for you."  - Dr. Suniti Solomon: A modern-day HIV love story

“Clearly if people abstained from sex, or had sex with partners they knew to be uninfected, or used condoms 100% of the time, we wouldn’t have the HIV epidemic. But obviously, spreading billboards all over the world has not cut it.” - Dr. Linda-Gail Bekker: Safe-sex education – too little, too much?

“Placebo controlled trials are essential for the evaluation of the safety and efficacy of new products.  The placebo control group in a clinical trial provides the means of establishing any specific safety issues with a product, as well as the effectiveness of the product at preventing HIV transmission… Once a microbicide product has been adequately shown to prevent HIV transmission, it will no longer be possible to run placebo controlled trials, and the “window” will be closed."  - Dr. Joe Romano: What happens when the ‘placebo window’ closes?

“It boggles me that I still have to make the case for understanding the relational and contextual nature of HIV transmission and the need to recognize that people and technologies are interactive and interdependent."  - Judith Auerbach: Addressing social drivers of HIV/AIDS

“Even among groups of experts, I have noticed people getting confused – misapplying data, conclusions, or assumptions...”  -  Lori Heise: Tricky Terminology in HIV Prevention – Microbicides and Oral PrEP

“Giving gay men more information about their health only empowers them to make informed decisions. The fear that gay men will take PrEP, forego condoms and become out of control disease spreaders, harkens to the days when men feared women would become crazed nymphomaniacs thanks to the new birth control pill.” -Alex Garner: Open letter Urges that PrEP debate should be based on ‘facts not misinformation’

“Firstly, we need to work out whether this result is true or not. But even if it is true, it’s quite possible that we need to balance the benefits of avoiding an unwanted pregnancy against the small increased risk of acquiring HIV infection.”  - Dr. Tim Farley: Hormonal contraceptives and HIV – the grey area

“It’s really critical we know what research is and is not being done, what evidence does and does not exist, so that we have a solid understanding of the implications of these technologies in various social, economic, cultural, and political contexts that exist in different countries. It’s only then that we can begin to think about investing in them and the best ways to implement them."  - Molly Morgan Jones: Mapping Pathways so far – the ‘literature review’

“If you’re talking about early treatment, you’ll have one person saying, ‘This is a quantum leap from where we are now, and it’s operationally impossible.’ And then you’ll have another person saying, ‘Well, if you have cancer, the doctor doesn’t wait till you’re half dead to give you the treatment, and so we should have been doing this years ago.’ And both are very valid points; it’s just how do you get those two people, who are equally important in making this happen, make it happen?” - Daniella Mark: It’s a question of ‘how’ in South Africa Part 1 & Part 2

“PrEP … is hard as hell to figure out. Hard as hell. But that’s what we have to do – we have to be right there, at the hardest place possible, trying to get the answers.” - Jim Pickett: Triumphs and Trials in 2011

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

29 December 2011

Gilead has submitted application for FDA approval of PrEP

via Bay Area Reporter, by Liz Highleyman

The company, which made the announcement December 15, has asked for priority review, meaning a decision could come as early as June. Clinicians can currently prescribe drugs "off label" as they see fit, but official approval of Truvada PrEP would have implications for public health programs and insurance coverage.

"The data from clinical trials clearly show that taking Truvada every day and using condoms can be very effective in preventing HIV for people at highest risk for infection," said Project Inform Executive Director Dana Van Gorder. "We believe in the right of HIV-negative people to choose the evidence-based prevention methods that best support their efforts to remain negative, and we urge quick FDA approval of Truvada for prevention."

PrEP trial results

Gilead's request is based on findings from a series of large international trials of oral PrEP using Truvada or the medications it contains, tenofovir (sold separately as Viread) and emtricitabine (Emtriva). Overall, results have been promising but several questions remain unanswered.

The large iPrEX trial, which enrolled nearly 2,500 gay and bisexual men and transgender women in six countries (including San Francisco and Boston in the U.S.), found that daily Truvada reduced the risk of acquiring HIV by 44 percent overall, with 36 new infections among men receiving PrEP compared with 64 among men taking a placebo pill.

Further data presented at the International AIDS Society conference this summer in Rome showed that risk reduction exceeded 90 percent for participants who had detectable drug levels in their blood, indicating good adherence.

"With 2.6 million new HIV infections occurring each year, and fewer than half of people with HIV receiving treatment, the world needs new and effective HIV prevention strategies," said iPrEx protocol chair Dr. Robert Grant from the Gladstone Institutes and UCSF. "Men who have sex with men have borne an enormous burden in this epidemic, and have also been consistently at the head of efforts to help reverse it."

Two other trials discussed in Rome – Partners PrEP and TDF2 – showed that the drugs in Truvada reduced the risk of HIV infection among heterosexual men and women in Africa by 60 percent to 75 percent.

In contrast, however, two studies of heterosexual African women have not seen a similar effect. The Fem-PrEP study of daily Truvada was halted earlier this year due to lack of effectiveness, as was an arm of the VOICE trial testing oral tenofovir alone (the tenofovir/emtricitabine combination is still being evaluated.)

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

27 December 2011

Five hundred twenty-five thousand six hundred minutes: How do you measure a year?

Original content from the Mapping Pathways blog team

Another year winds down, and it is time to take stock, to reflect on all the moments that have made 2011 an important year for the HIV prevention community – and for all those of us who hope for and work toward the end of the HIV/AIDS epidemic.

The year began on a high note: the extremely encouraging results from the IPrEx and CAPRISA trials, announced in 2010, had us “jumping up and down” as Jim Pickett (Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago, chair of International Rectal Microbicide Advocates [IRMA], and a member of the Mapping Pathways team) says in his memorable interview, Success! Now What? These results were the long-awaited proof of concept for new prevention technologies – the “first real ‘win’” after many years of hard work.

The first bump in the road was the discontinuation of the FEM-PrEP trial in April due to futility, when the trial’s Independent Data Monitoring Committee concluded that the study would be highly unlikely to prove the effectiveness of Truvada in preventing HIV infection among the study population, i.e., HIV-negative women who are at risk of infection through sexual transmission.

The unexpected development had everyone expressing their opinions and wondering about the implications – after all, what does “futility” mean exactly? Dr. Linda-Gail Bekker (an expert in the field of biomedical trials and research) cautioned against knee-jerk reactions to the trial closure in her interview with Mapping Pathways: “Wait for the evidence, I think that is the message. Extrapolate at your peril. We know only what we know, and we need to just work within that.”

Then came the HPTN 052 results – and we were jumping with excitement again! The study demonstrated that initiation of ART by HIV-infected individuals substantially protected their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission. In an interview with Mapping Pathways, microbicides expert Joe Romano captured the overall sentiment, saying, “The level of efficacy seen in the HPTN052 study is stunning, and is extremely important on several fronts.”

There was good news for India (a Mapping Pathways target country) too: a UNAIDS report stated that the rate of new HIV infections fell by more than 50% in India between 2001 and 2009, double of the average decline in the world. The PrEP debate in India continued through the year. “There is a lot of concern in the country, especially with global funding not available right now,” explains Anjali Gopalan (Executive Director of NAZ India, a Mapping Pathways partner organization), in Notes from India: Concerns and Challenges Around PrEP. Mapping Pathways also published a short post on what we’ve been hearing in India so far.

Soon after the HPTN 052 results, the FACTS 001 trial was announced in South Africa – a follow-up study to confirm the effectiveness of tenofovir and to verify the CAPRISA 004 results in “larger, more diverse populations.”

Around this time, Mark Chataway (co-chairman of Baird’s CMC, a Mapping Pathways partner organization) was in South Africa (a Mapping Pathways target country). “My visit to the country once again brought into sharp focus for me just how significant South Africa and the rest of the southern African region are in the context of HIV treatment and prevention strategies,” writes Mark in his insightful post about South Africa and the HIV epidemic.

July brought bad news: the drought in the Horn of Africa began, bringing the region into international focus as an estimated 11.6 million people struggled for basic nutrition and sanitation in the humanitarian crisis – experts have warned that this situation could have a serious effect on the health of people undergoing HIV treatment.

Prevention trials continued to stay in the news. The Partners PrEP study and the TDF2 Botswana study both showed that taking antiretrovirals can reduce the risk of HIV infection through sexual intercourse by 62-73 percent among heterosexual individuals and heterosexual couples.

As heartening news continued to pour in, the UK’s House of Lords Select Committee on HIV & AIDS gave us another reason to celebrate as they called for greater emphasis and funding toward prevention. “Prevention must be the key policy,” remarked Lord Fowler, chairman of the committee.

In the US, dollars-and-cents issues remained a key factor. “The entire HIV prevention and treatment landscape overall is also in a state of flux in the US … When we get to the end of the day, there are good ideas, and then there are good ideas that are fully funded,” explains Julie Davids (Director of National Advocacy and Mobilization at AIDS Foundation of Chicago, a Mapping Pathways partner organization) in The Economic Effect: HIV/AIDS in the US.

October brought news that rekindled an old debate: the Lancet published the results of a study conducted in Africa, which seemed to suggest that hormonal methods of contraception could lead to increased risk of HIV infection. “Now whether this is a disaster or not, that needs to be considered very carefully in context. There are huge benefits, particularly in the African region, of avoiding an unwanted pregnancy, not only for the morbidity issues but also for mortality reasons … Firstly, we need to work out whether this result is true or not,” points out Dr. Tim Farley (an expert in HIV and sexual and reproductive health) in Hormonal Contraceptives and HIV Prevention: The Grey Area.

Recently, the VOICE trial hit a speed bump: the oral tenofovir arm and the tenofovir vaginal gel arm were dropped from the study. Both decisions were based on reviews of study data, which concluded that they would not be able to demonstrate effectiveness in preventing HIV among the women in the trial (although both products were found to be safe). The reasons for this are still unclear and will be fully investigated when the trial concludes in the middle of 20112. The study continues to examine the oral Truvada tablet to determine whether it’s effective in preventing HIV in the trial population.

A recent highlight was US Secretary of State Hillary Clinton’s speech on HIV/AIDS – one that earned her both bouquets and brickbats from the HIV prevention community. On the upside, Secretary Clinton focused on scientific evidence and called for immediate action to take advantage of the “historic opportunity” to create an “AIDS-free generation.” Unfortunately, she completely omitted any reference to PrEP and rectal microbicides. The speech also failed to mention gay and MSM populations, two groups that are experiencing catastrophic rates of HIV globally.

The year wound up with IRMA’s rectal microbicide African strategy meeting and the big ICASA conference in Addis Ababa, Ethiopia in December. (Click here and here to read about some of the important developments at these events.)

All in all, 2011 has been a dynamic year: lots of excellent news as well as some troubling developments. From the Mapping Pathways blog team, here’s to celebrating our achievements, learning from our failures, and working to address the challenges.

Happy New Year!

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

21 December 2011

Pause and Rewind with Jim Pickett: Triumphs and Trials in 2011

Original content from the Mapping Pathways blog team

“PrEP … is hard as hell to figure out. Hard as hell. But that’s what we have to do – we have to be right there, at the hardest place possible, trying to get the answers.”

MP: Was 2011 a significant year with regard to new HIV prevention methods?

JP: Definitely. I think it’s been a really dynamic year. The discussion around ARV-based prevention has been heated, it’s been passionate, and it’s been very broad. The field as a whole has received so much attention this year because of all the studies that were reported, beginning in 2010. The lively discussion has put the research and advocacy that’s been ongoing for years on so many people’s radar for the first time.

MP: What were some of the biggest highlights in the prevention landscape this past year?

JP: In terms of the actual science that was reported out this year, a couple of studies were really important. The HPTN 052 trial proved beyond a shadow of a doubt that providing treatment to people can be very effective as a means of prevention as well as for treating the individual with HIV. It was something we all pretty much knew but we didn’t have a randomized controlled trial to prove it. Now we have one – and that’s really powerful.

There have also been significant results on the use of pre-exposure prophylaxis (PrEP) in heterosexual individuals. The Partners PrEP study and the TDF2 Botswana study have brought further proof that oral prevention – taking a pill every day – can work to prevent HIV, and can work quite well.

On the other side, we’ve had some confounding results as well. The FEM-PrEP trial closure, due to the fact it was unable to prove the effectiveness of Truvada in preventing HIV infection among HIV-negative women, has left us scratching our heads. The VOICE trial, which is investigating both microbicides and PrEP, had to close the tenofovir gel and pill arms due to futility – they weren’t going to be able to show these interventions work to prevent HIV.

We’ve come up against ‘futility’, and now there’s a huge question mark. We don’t yet know what is going on: Was it something biological? Was it because adherence was poor? Why did these products work in other trials? While there have been very encouraging results about PrEP, the jury is still out – for instance, is this a good intervention for heterosexuals, especially women? Both PrEP trials that have shown futility have been for women. These critical questions need to be addressed.

MP: What has the debate around PrEP been like? What are people saying?

JP: Like I mentioned, the debate around ARVs as prevention has been very dynamic. Wherever you are on the analysis of these new strategies, whether you are critical of these or really excited about them, much of the discussion has been fruitful and invigorating.

What has upset me, though, is that some people (whether they’re researchers, advocates, public health workers, or policymakers) have been drawing lines and pitting interventions against one other. For instance, PrEP, ARVs for HIV-negative people to prevent HIV acquisition, is being pitted against treatment, ARVs for HIV-positive people. There’s been a lot of discussion on who “deserves” the drugs and who doesn’t – I don’t think that’s helpful in any way. We should all be working to get ARVs to those who need them – HIV-positive people, of course, and also HIV-negative individuals who need them, can use them, and would find them very beneficial. It’s about ARV access writ large.

MP: Why do you think this has happened?

JP: This is what happens in times of scarcity and economic trauma. People say, “We can’t possibly do everything, so we should do only this and not that.” It’s not surprising, but it’s still disheartening. We need to think broadly, globally and not dismiss new interventions because they’re challenging or bring up lots of questions. PrEP does bring a ton of issues: It’s brand new, it’s just out of the box, we’ve never done this before, and it’s hard as hell to figure out. Hard as hell. But that’s what we have to do – we have to be right there, at the hardest place possible, trying to get the answers. That’s where we should be spending our energy.

When the female condom was first introduced, it wasn’t given the attention and support it needed and a lot of people dismissed it. I think that really hobbled its potential for a long time. I don’t want to see PrEP in the same place – being disparaged before we’ve had a chance to explore and fully understand its potential.

MP: How can the Mapping Pathways project help in this context?

JP: The Mapping Pathways project will be offering a synthesis of literature, real-world experience, and key stakeholder opinions from vastly different perspectives and regions of the world. This is going to be extremely helpful because we know that just having great science isn’t going to get any of these interventions rolling. This project is helping create and disseminate information that countries, regions, states, and cities can use to make informed decisions about how they engage with these new prevention technologies – or not. I think the key word here is “informed”. What we’re all hoping is that these decisions are made based on a combination of science, feasibility, and acceptability in each region.

The fact that we’re going to be able to play a role in that process is very exciting. Wearing my Mapping Pathways hat, I’m really proud of the work we’ve done this year. The first wave of data collection is done – we’re now analyzing our literature review, our survey results and stakeholder interviews, and results from our ExpertLens process. I’m very excited about the data and analysis that we’ve been able to pull together as a multinational team. And now we get to start sharing these great insights with the world!

Jim Pickett is the Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago. He is chair of IRMA (International Rectal Microbicide Advocates), and a member of the Mapping Pathways team.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

19 December 2011

The Treatment Action Campaign (TAC) Shapes AIDS Policy in South Africa

via The Guardian, by Pierre de Vos

boy hiv medication south africa
"The TAC case thus illustrates how social and economic rights can be used by civil society groups to mobilise public support for a worthy cause – even before a court is asked to adjudicate on what will often be very complex legal and moral issues – and that it can enhance democratic engagement and participation."

Shortly after Thabo Mbeki, the former South African president, began his flirtation with Aids dissidence in 2000, the Treatment Action Campaign (TAC) was created to respond to the HIV crisis in the country and the government's reluctance to deal with it.

Although closely aligned with the ANC government, the TAC engaged politically and launched various court challenges to force a change of heart on the part of the government and, ultimately, in order to ensure that every HIV-positive person who could not afford it was provided with antiretroviral (ARV) medicine by the state.

The TAC ran a brilliant and strategically astute campaign to mobilise the public, trade union organisations and other civil society groups behind its cause. Its trump card in this campaign was section 27(1) of the constitution , which states that everyone has the right to have access to healthcare services, including reproductive healthcare.

Like other social and economic rights contained in the South African bill of rights – including the right of access to housing, sufficient food and water; and social security – the right to healthcare is not absolute. It requires the state only to take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of each of these rights.

At the time of the drafting of the bill, some politicians and academics opposed the inclusion of these rights, arguing that it would not be possible for judges to enforce these claims as they would be required to make policy choices best left to the democratically elected branches of government. But given the vast discrepancies in wealth – often based on race – caused by apartheid and the fact that many citizens did not have access to basic services at the dawn of democracy, the drafters of the constitution believed that it was imperative to include not only traditional civil and political rights in the constitution, but also justiciable social and economic rights. Otherwise the very legitimacy of the constitutional enterprise would be at risk.

South Africa's constitutional court at first dealt cautiously with the interpretation and application of these rights, making it clear that it would not be feasible to interpret the rights in a way that provided individual claimants with a right to demand specific goods and services from the state.

The court was in a difficult position as it had to respect the separation of powers doctrine and could not dictate to the government how to allocate its budgets. At the same time it was required to ensure that the social and economic rights did not remain rights on paper alone, but were interpreted in a way that signalled their enforceability.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

17 December 2011

Mapping Pathways at ICASA: Generating interest, creating buzz

 Original content from our Mapping Pathways blog team

Two Mapping Pathways team members – Molly Morgan Jones from RAND Europe and Jim Pickett from the AIDS Foundation of Chicago – recently presented two project posters at the 16th International Conference on HIV/AIDS and Sexually Transmitted Infections in Africa (ICASA) held in Addis Ababa from December 4-8. This was the first time preliminary project findings from the literature review, online survey, stakeholder interviews, and ExpertLens were officially shared with the wider HIV prevention community on such a large scale. The semi-annual ICASA is Africa’s largest gathering on HIV/AIDS. This year it brought together approximately 7,000 delegates from more than 103 countries. Check out the two Mapping Pathways poster presentations here. The daily poster exhibition showcased posters on research findings, best practices, and innovative strategies in the response to HIV/AIDS in Africa.

“Molly and I had a lot of fun,” says Jim Pickett. “In general, the focus of the conference wasn’t so much about new prevention technologies, so it was important for us to get out there and get the word out. We stood in front of the posters and had some really great discussions – people were  not only interested in the science behind some of these ARV-based prevention strategies, but also understanding the various viewpoints from stakeholders ‘on the ground.’ I think Mapping Pathways generated a real buzz.”

At this year’s ICASA, concerns about funding took center stage. According to a conference write-up, “Underlying the encouraging atmosphere, participants, presenters and conference organizers shared concerns about recent announcements regarding cuts in much needed life-saving funding for HIV, AIDS, tuberculosis and malaria. The financial blow of the Global Fund, which suspended normal disbursements until 2014, comes at the worst moment – when the use of antiretroviral drugs for treatment and prevention has dramatically reduced mortality from the virus and reduce transmission of AIDS.” Read the rest of this synopsis on the conference here: ICASA 2011 Closes with a Call for a Sustainable HIV Response

Apart from discussions on funding, other conference presentations included promoting gender equality (a high-level task force “Women, Girls, Gender Equality and HIV for Eastern and Southern Africa” was launched); strengthening health systems and showcasing the additional benefits the AIDS response has had for the broader health and development; and committing to the elimination of new HIV infections in young children. Pickett co-chaired a session on HIV and LGBT issues in the African context as well, which was standing room only.

On the last day of the conference, delegates gathered together to discuss how to deliver on the 2011 United Nations Political Declaration on HIV/AIDS for Africa, which was unanimously adopted this June. The declaration calls for universal access by 2015. Read more here.

Check out the Mapping Pathways posters here. And let us know what you think. You may leave a comment here, or send us an email at:

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

16 December 2011

A Defining Moment in HIV Control

via The Lancet, by Salim S Abdool Karim, Quarraisha Abdool Karim

A defining moment in the global AIDS response has been reached. The discourse is no longer about HIV prevention or HIV treatment; it is now about HIV control through the implementation of antiretrovirals as key components of combination interventions. Barely a year ago, visions of HIV control would have been considered far-fetched. The impetus for this change in mindset, which has been building since the XVIII International AIDS Conference in Vienna last year, emanates from the compelling evidence that antiretroviral drugs prevent HIV infection in the general heterosexual population, which is released this week and presented at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Rome by the Partners PrEP1 and Botswana TDF22 trials.

The Partners PrEP trial,1 involving 4758 HIV discordant couples from Kenya and Uganda, found that daily oral tenofovir disoproxil fumarate (TDF) and TDF-emtricitabine reduced HIV transmission by 62% and 73%, respectively. The Bostwana TDF2 trial,2 in 1200 heterosexual men and women from the general population, found that daily oral TDF-emtricitabine reduced HIV transmission by 63%. These findings follow close on the heels of the CAPRISA 004 trial3 of tenofovir gel, the iPrEX trial4 of oral TDF-emtricitabine in men who have sex with men, and the HPTN 052 trial5 of early antiretroviral treatment as HIV prevention. Importantly, these new findings fill a critical gap in HIV prevention with a readily available antiretroviral approach to prevent heterosexual transmission in both men and women (figure). Women benefit from a new prevention option under their control, which is particularly important for those not assured of their partner's fidelity or willingness to use a condom. The hope these studies add to HIV prevention is further bolstered by the recent step taken by the pharmaceutical company Gilead Sciences Inc to lodge TDF and emtricitabine with the UNITAID patent pool,12 thus enabling lower cost versions of the drugs to be manufactured and thereby facilitating wider access in poor countries.

 There is now no doubt that antiretroviral drugs prevent HIV infection. However, important scientific questions remain. Does the inclusion of emtricitabine in pre-exposure prophylaxis (PrEP) formulations provide sufficient additional benefit to warrant the additional costs and side-effects? Are levels of effectiveness and safety similar for daily use and use-with-sex of PrEP? Do the safety, effectiveness, cost, and acceptability profiles of oral and topical PrEP merit implementation of both formulations? Does PrEP lead to masking of HIV acquisition that is then revealed once PrEP is withdrawn? Can the new results be generalised to the type of hyper-endemic settings (HIV incidence more than 5% per annum) where the FEMPrEP trial13 was done? Since inadequate drug levels may not have been responsible for the lack of effectiveness observed in the FEMPrEP study,14 the search for an explanation for this intriguing and contrary result needs to be pursued with vigour.

There are also many practical questions about implementation: how to increase uptake of HIV testing;15 how often to monitor HIV status in people on PrEP; how to achieve high coverage in those at highest risk; how to maintain high levels of adherence; how to reduce the risk of migration away from condoms (behavioural disinhibition); and how to monitor the risk of drug resistance. While attempts are being made to obtain data to address these questions and to generate data to guide effective implementation, the development of normative guidance by WHO/UNAIDS and submissions for regulatory approvals of TDF and TDF-emtricitabine as PrEP for HIV infection are key next steps.

As antiretroviral drugs take a key role in the global effort to control the HIV epidemic, there is much to be learned from the contraceptive field where multiple technologies, approaches, formulations, and dosing options were developed to enable and maximise user choice and increase levels of uptake, coverage, and adherence and thereby improve the public health impact.

Beyond the questions of implementation, the future scientific challenge looming large for PrEP is finding a drug or class of drugs with a resistance profile that does not interfere with existing first-line and second-line AIDS treatment. Treatment of HIV-positive people for HIV prevention and PrEP and microbicides for HIV-negative people are two sides of the same coin, and cannot be viewed in isolation from each other. Although research on treatment for prevention, PrEP, and microbicides has mostly occurred in separate silos, their findings converge into a single focus in HIV prevention and necessitate guidance on how to use all three strategies synergistically for maximum benefit depending on the nature of the HIV epidemic. There is no magic bullet for the HIV epidemic. Treatment for prevention will be dependent on the extent to which couples establish their HIV status, whether the HIV-positive partner in a discordant couple adheres to therapy, and whether the HIV-negative partner maintains fidelity within the partnership. PrEP will be dependent on the extent to which people seek to establish and regularly monitor their HIV status and those on PrEP adhere to their regimen and clinical monitoring. Hyper-endemic communities, such as those in South Africa where HIV prevalence in the community is high, may require both interventions jointly and synergistically: treatment of people infected with HIV to reduce risk of transmission within the discordant couple, and PrEP to reduce the HIV-negative partner's risk of HIV acquisition from outside partners.

Therein lie the three most complex policy, implementation, fiscal, and ethical challenges generated by these new findings. First, how to scale up HIV testing, a key prerequisite in settings with stigma and discrimination. Second, how to extend antiretrovirals for both treatment and prevention when many of Africa's health systems are already struggling to cope with patients with AIDS and are not able to initiate antiretroviral therapy in everyone who currently needs it for their survival. Third, in the context of limited resources how best to ration and prioritise the limited available implementation capacity.

In this defining moment in the response to HIV, a global commitment to increased financial resources for implementation, health systems strengthening, and greater implementation efficiency is imperative. Anything less will crush the hope and promise that antiretroviral drugs can change the course of the HIV epidemic.
We were the co-Principal Investigators of the CAPRISA 004 trial of tenofovir gel. QAK is co-Principal Investigator of the HIV Prevention Trials Network, which is undertaking HPTN 052 trial of treatment for prevention. SSAK is an executive committee member of the Microbicide Trials Network, which is undertaking VOICE trial of oral and topical PrEP.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

PMTCT with combination of nevirapine and cotrimoxazole

via Aidsmap, by Carole Leach-Lemens

"Policy makers can now make informed decision regarding the WHO 2010 prevention of mother-to-child (PMTCT) guidelines and the combined use of nevirapine and cotrimoxazole prophylaxis for extended periods of time. Such use is critical in these settings where frequent monitoring is challenging, and where the difficulties of travelling long distances and the high costs of transportation make regular clinic visits difficult."

Use of nevirapine with cotrimoxazole prophylaxis in HIV-exposed uninfected infants (HIV-EU) until six months of age in Zimbabwe and Uganda was safe with no immediate or long-term adverse effects, researchers on behalf of the HIV Prevention Trials Network (HPTN) 046 protocol trial report in the advance online edition of AIDS.

The findings from this secondary data analysis have important policy implications for HIV-exposed but uninfected infants in resource-poor settings.

The HPTN 046 protocol, a prospective randomised placebo controlled trial, looked at the safety and efficacy of nevirapine prophylaxis against HIV transmission in breast milk with infants followed for 18 months.

Policy makers can now make informed decision regarding the WHO 2010 prevention of mother-to-child (PMTCT) guidelines and the combined use of nevirapine and cotrimoxazole prophylaxis for extended periods of time. Such use is critical in these settings where frequent monitoring is challenging, and where the difficulties of travelling long distances and the high costs of transportation make regular clinic visits difficult.
The guidelines are based on evidence of the effectiveness of the extended use of daily nevirapine in reducing breast milk transmission of HIV. Daily use of nevirapine prophylaxis in HIV-exposed but uninfected infants for PMTCT from birth until one year of age, or until the stopping of breastfeeding (whichever comes first), is recommended.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

15 December 2011

HIV Researcher Dr. Robert Grant named Time "Person of the Year"

via Time, by Alice Park

People Who MatteredDr. Robert Grant has been a quietly powerful force in HIV research for years. In the early 2000s it was Grant, a professor of medicine at University of California, San Francisco, and Gladstone Institute of Virology and Immunology, who pushed to test the potential of antiviral drugs — normally used to treat people who already have HIV — as a way to protect healthy, uninfected people from acquiring the virus. His first study of the medications in gay men wasn't popular — why test the drugs in healthy people when millions of HIV-positive patients didn't even have access to the medications? — but proved successful, lowering new infection rates among men taking the antivirals prophylactically.

But it wasn't until 2011 that Grant's true influence on the battle against AIDS finally emerged. His initial research set the stage for further studies of the treatment-as-prevention strategy in other populations. This year a groundbreaking study found that treating the uninfected partner in heterosexual couples — in which one person had HIV and the other did not — dramatically reduced the risk of transmission. Another study found that giving antiviral drugs to heterosexual men and women also cut their risk of infection. The findings are crucial, since it is the heterosexual population that currently bear the heaviest burden of new HIV infections around the world. With hopes for a vaccine continually receding and safe-sex campaigns of limited value, Grant's idea (along with other emerging prevention strategies, like male circumcision) has the potential to halt the AIDS epidemic by stopping infections from occurring in the first place

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

14 December 2011

Update on IRMA’s Project ARM – Africa for Rectal Microbicides Strategy Meeting in Addis: Dedication and passion are paving the way forward

  Original content from our Mapping Pathways blog team

“It was an amazing group, and one that moved me to near tears on a number of occasions”

Our colleague Jim Pickett from the AIDS Foundation of Chicago, a Mapping Pathways partner organization, just returned from an inspiring week in Addis Ababa, Ethiopia, where he led a strategy meeting for the International Rectal Microbicide Advocates (IRMA) and then attended the ICASA 2011 conference (read more about both here and here). We checked in with Jim for an update on IRMA's Project ARM (Africa for Rectal Microbicides) strategy meeting, which was held in Dec 2 and 3 (click here for a fact sheet on Project ARM).

The meeting, which was the result of 18 months of planning and coordination, convened about 40 individuals - both invited speakers and guests, including 16 individuals who secured scholarships to attend (out of 145 applicants.) The meeting participants represented countries including Ethiopia, Rwanda, Cameroon, Kenya, Nigeria, Zambia, Malawi, Zimbabwe, South Africa, Uganda, Canada, United Kingdom, and the United States  -researchers, advocates, LGBT people, heterosexual people, and those representing sex workers, prison populations and more.

“It was an amazing group, and one that moved me to near tears on a number of occasions,” says Pickett, who explained that the aim of this meeting was for people to come together and create a strategy, a road map, around rectal microbicide research and advocacy specific to the African context. “I've been to many, many meetings – too many –  in my day and I think the Project ARM meeting was, by far, one of the most productive, inspiring, exciting, energizing, and emotionally moving ones I've ever had the privilege to attend. Yes, I am obviously biased - but it isn't often that events like these make me misty-eyed and put a lump in my throat – repeatedly.”

The journey to getting all these people together for this meeting was not easy, as many faced multiple challenges securing the required visas for travel to Ethiopia. Says Pickett, “There was this incredible energy in the room. We’d been planning this meeting for the past 18 months, and it has been a long journey for all of us to make this happen. A number of the people attending went to extraordinary lengths to get to Addis Ababa. They had to make so many trips to embassies and consulates for visas, so many obstacles were placed in their way to dissuade them from attending, but none of them took no for an answer. The incredible perseverance they exhibited simply to show up was extremely moving.”

The participants spent the two days together getting informed – including sharing the latest updates on rectal microbicide science, rectal microbicide advocacy, issues around LGBT crimininalization, anal sex prevalence, the gay/MSM epidemic, and more. “But we didn't just passively listen to others speak - we broke out into small groups a number of times to unpack what we learned and to come up with priorities and plans for moving forward,” says Pickett.

Four advocacy-focused items and four research-focused items were prioritized, and action steps were developed for each. These included expanded rectal microbicide scientific research activities in Africa, expanded research into anal sex behaviors among African straight and gay/MSM populations, communication/education efforts, and the birth of  the Global Lube Access Mobilization (GLAM) campaign called "And Lube" to support increased access and availability of condom-compatible lubes throughout Africa. Current lubricant access across the continent is absolutely abysmal.

What especially surprised and moved Pickett was the level of enthusiasm and positivity in the room. “A lot of these people come from countries that have seriously troubling environments and where advancing HIV prevention and advocacy is met with extreme homophobia. So I thought that a lot of the discussion would be on the challenges and obstacles-- I mean, so many of the countries we were focusing on are settings where you can’t even think of doing a microbicide trial, let alone discussing sexuality openly without worrying for your safety – yet the participants didn’t get stuck on these negatives. These are men and women who are brave and strong and are committed to fighting for better health and civil rights for the people in their country. It was extraordinarily fulfilling to witness their passion and energy first hand; to see them standing up and doing this work despite the numerous challenges and obstacles in their way.”

Dr. Ian McGowan, co-principal investigator of the Microbicide Trials Network (MTN) attended the meeting, presenting the latest in rectal microbicide science. He also addressed some of the questions regarding the recent closure of the VOICE trial’s study arm testing tenofovir gel. The decision was made due to futility – while tenofovir gel was found to be safe, the trial was not able to prove the gel worked to prevent HIV. See the statement from the MTN for more information. Previously the trial had to drop its tenofovir tablet arm due to futility as well. The Truvada tablet arm in the trial is continuing. “There was a lot of speculation in the room about why it was closed,” said Pickett. Many of the people present speculated that a lack of adherence might have been a factor, said Pickett. “But of course, it’s all speculation at this point, we don’t know what happened, and we won’t till the end of next year likely.” He added that McGowan confirmed that it is still important to move forward on both vaginal and rectal microbicide research and to keep exploring ways to create a more diversified microbicide pipeline (learn more about the microbicide pipeline here and here).

For Pickett, another big highlight was McGowan’s strong validation for Project ARM’s objectives. McGowan, a highly respected veteran in microbicides research, publicly offered MTN support for future Project ARM activities and commended the participants for their collective intellect and passion. Said Pickett, “Ian participated in many of the small break-out groups, and I think he was impressed by the high quality of thought, curiosity, and energy in the room. And to have that kind of validation from someone who is one of the key rectal microbicide researchers on the planet… it was a really big moment for us. There isn’t a doubt in my mind now that Africa is squarely on the rectal microbicide map.”

Pickett also felt that an interesting backdrop to the IRMA meeting was Hillary Clinton’s speech that formalized the Obama administration’s prioritization of LGBT rights globally, helping to bolster rights’ groups on the ground in their fight against discrimination. “At the end of the day,” said Pickett, “if people aren’t free to be who they are, wherever they are, they won’t be able to make use of any prevention technology, let alone rectal microbicides. There’s no point in having a really great microbicide on the shelf if people are not safe, and therefore unable, to access it.”

Jim Pickett is the Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago. He is chair of IRMA (International Rectal Microbicide Advocates), and a member of the Mapping Pathways team. A full report from the Project ARM meeting in Addis, laying out a rectal microbicide research and advocacy strategy for Africa will be released at the Microbicides 2012 conference in Sydney in April 2012. Until then, find updates here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

12 December 2011

To End AIDS, We Need a Plan!

via Huffington Post, by Mitchell Warren

Last Thursday (December 1), on World AIDS Day, President Obama threw the full weight of the U.S. government behind a vision that would have seemed outlandish until now: The end of the global AIDS epidemic.

Over the past few years, a string of HIV prevention research breakthroughs has put that ambitious goal within sight for the first time. Voluntary medical male circumcision is the most powerful, under-utilized biomedical HIV prevention strategy available: with a single surgical procedure, men's risk of HIV from female partners is reduced by more than 60 percent. Treatment for HIV positive individuals is also potent prevention -- reducing risk of transmission by up to 96 percent.

These two strategies are the cornerstone of a new era of HIV prevention, and it is critical that the president continue to be a supporter and leader of the chorus of advocates, health and political leaders who are saying "Yes, we can end AIDS."

Now the question is: How will we achieve this goal? What are the priority actions to take today, tomorrow, and years from now?

First and foremost, the resource commitments need to match the strength of the scientific data. Funds are needed to ensure that the most effective prevention is put in place for the people who need it, in programs that meet their needs, with rigorous evaluation of impact so that no dollars are wasted.

President Obama's commitment to expand access to HIV treatment for two million more people by 2013 is a wonderful first step. But his call to the leaders of the world to match the US commitment must be heeded.

Last week, the Global Fund to Fight AIDS, Tuberculosis and Malaria - which supports HIV treatment programs in resource-poor countries along with PEPFAR - announced that it has been forced to curtail new grant-making until2014. The Fund pointed to a drop-off in contributions from governments in the face of the global economic crisis.

There's no question that economies are hurting. But global AIDS programs are among the smartest investments in history: they've saved countless lives and have shifted the course of the epidemic so that annual HIV infections are on a slow but steady decline. In most cases, these efforts represent a tiny share of donor countries' national budgets - for the U.S., it's well under one percent. It is precisely at this moment, when the potential dividends are greatest, that the world's modest AIDS investments should be sustained.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

09 December 2011

Successes of Second Line Treatment in Sub-Saharan Africa

via aidsmap, by Carole Leach-Lemens

Study Shows Malawi AIDS Deaths Drop 10 Percent"The authors conclude, “in ART programmes [in sub-Saharan Africa] switching patients to second-line regimens based on WHO immunological failure criteria appears to reduce mortality, with the greatest benefit in patients switching immediately after failure is diagnosed.”"

Mortality was reduced by about 75% among adults experiencing immunological failure according to the World Health Organization (WHO) criteria who switched to a second-line regimen compared to those who remained on a failing regimen in two public sector ART programmes without access to routine viral load monitoring in Zambia and Malawi, researchers report in the advance online edition of AIDS.

Additionally in this collaborative analysis Thomas Gsponer and colleagues on behalf of the Southern African region of the International epidemiological databases to evaluate AIDS (IeDEA-SA) showed the less time spent on a failing regimen the lower the risk of death, HR:0.70 (95%  credible intervals (CI): 0.44-1.09), p=0.11 for each six months of shorter exposure.

An estimated 6.6 million people are now getting ART in resource-poor settings. As access to treatment increases so does the number of people experiencing treatment failure with a corresponding increase in the use of second-line treatment regimens.

Cost and the absence of the necessary laboratory infrastructure preclude the regular use of viral load monitoring in resource-poor settings, especially in rural areas.

Without viral load monitoring immunological (CD4 cell counts) and clinical criteria are used to determine treatment failure. However, the accuracy of such criteria to detect virological failure is poor. This may lead to unnecessary switching with many health care providers reluctant to switch using these criteria. So people are switched later and at lower CD4 cell counts compared to programmes where viral load monitoring is available, note the authors.

The authors chose to examine further the effect of switching to second-line ART on mortality in settings without viral load monitoring.

All adult patients experiencing treatment failure according to WHO immunological criteria from two public sector ART programmes in Lusaka, Zambia and Lilongwe, Malawi were included in the analysis. Clinical and immunological monitoring was done every three to six months. In both sites viral load testing is limited because of cost and operational difficulties.

Criteria for inclusion: all patients 16 years of age and over with immunological failure after January 1, 2004 based on any of the three WHO criteria: 1) CD4 cell counts staying persistently under 100 cells/mm3 2) a fall of CD4 cell counts below the baseline count and 3) a fall greater than 50% from the peak value.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Complexity of Changing Behaviors

So, what have we learned about prevention?

Inform, plead, scare them straight—HIV-prevention messages have covered it all.

Those working in prevention thought that if they gave people information about the disease, it would help protect them, according to Dr. Jennifer Lauby, a researcher at the Public Health Management Corporation.
"We found out that it's more complicated than that," she said.

Her colleague Lee Carson agreed. "Education alone doesn't equal behavior change," Carson said. "We see that in smoking and things like that."

Prevention has to be more comprehensive, Lauby said.

"There're really a lot of factors that go into making people at risk for HIV, including social factors, community factors, access to care," she said. "We have to look at all of those factors when we talk about HIV prevention."

Focusing on specific groups

To get a better sense of those factors, researchers such as Lauby and Carson started looking at specific groups with very high infection rates. One such group is African American men who have sex with men—and women.

Andrew Jackson, who helps out with a research project involving this group at the Public Health Management Corporation, said it is hard to reach this population because the men are very secretive about their lives and sexual activities.

Jackson is African American, gay, and HIV positive. Growing up in an Ohio steel-mill town, as a member of the Baptist church, secrecy became part of his life early on.

"You had to be all man, you couldn't divulge if you had a secret that you didn't want to give out," Jackson said.

Mum is the word not just when it comes to the behavior itself, but also when it comes to HIV, said Philadelphian Douglas Van Lue. And that puts men at risk.

"If nobody is talking about it, then nobody is asking about it, and then there's just the sexual behavior going on," he said

Both Van Lue and Jackson help spread the word about the research project.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

07 December 2011

AIDS Battle Risks Being Derailed by Global Financial Crisis

via Nature, by Meredith Wadman

Thirty years after AIDS was first recognized as a human scourge, major recent gains in treatment and prevention risk being derailed by the global financial crisis.

On 23 November, the Global Fund to Fight AIDS, Tuberculosis and Malaria announced that it will not fund new grants for prevention and treatment until 2014, owing to “substantial budget challenges in some donor countries”. The fund's HIV activities run the gamut from counselling and testing pregnant women in India to providing medications to infected children in Kenya.

And on 7 December, a report from Policy Cures in Sydney, Australia, a group that monitors global research and development for neglected diseases, showed that public and private funders last year cut their commitments to HIV/AIDS research targeted at the developing world by US$67.5 million, or 5.9%. The decline was due entirely to cutbacks by wealthy nations, which slashed spending by $72.6 million; poorer countries actually increased funding by $5.1 million. Where research is concerned, “AIDS had a bigger drop in dollar terms than any other disease”, says Mary Moran, the executive director of Policy Cures and the lead author on the report.

The threat comes even as US President Barack Obama last week promised that the United States will step up its worldwide attack on AIDS. Breaking the White House's past reticence on the issue, he urged nations to honour their unmet pledges to the Global Fund.

“Countries that have committed to the Global Fund need to give the money that they promised,” he said on 1 December, World AIDS Day. “Countries that haven't made a pledge, they need to do so,” he added, singling out emerging nations such as China that are recipients of funds “but now are in a position to step up as major donors”.

The United States has given $6.1 billion to the Global Fund since 2004, and last year pledged to contribute $4 billion between 2011 and 2013. Congress approved $1.05 billion in 2011, meaning that allotments must increase substantially in 2012 and 2013 to honour the pledge. Obama has asked Congress to provide $1.3 billion in 2012, but Senate lawmakers have so far resisted the increase.

Obama pledged to increase by 50% — to 6 million — the number of people receiving antiretroviral therapy (ART) worldwide by 2013 through the President's Emergency Plan for AIDS Relief (PEPFAR), the nation's major global treatment and prevention programme. He also said PEPFAR would aim to provide ART to an additional 1.5 million pregnant women with HIV in the next two years. The international promises came with no new money immediately attached. But Obama has asked Congress to provide nearly $7.2 billion — a 6% increase — for PEPFAR in 2012, part of the unfinished budget bills still being debated.

Advocates said that his speech marked a significant turning point. “This is the first time he's signalled that he's going to champion global HIV in this way,” says Jennifer Cohn, an assistant professor of infectious diseases at the University of Pennsylvania in Philadelphia, and a policy adviser in Nairobi for Médecins Sans Frontières (MSF; also known as Doctors Without Borders). “Whether or not this gets translated into the president's 2013 budget request, or what Congress chooses to protect during the 2012 budget negotiations — that's what I'm waiting to hear.”

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

05 December 2011

Mapping Pathways presents two posters at ICASA 2011 in Addis Ababa

Original content from our Mapping Pathways blog team

On December 5 Molly Morgan Jones and Jim Pickett from the Mapping Pathways project (left, top picture) presented two posters on our findings at the ICASA 2011 conference taking place now (through December 8) in Addis Ababa, Ethiopia.

The world has made great progress in fighting HIV/AIDS since the late 1990s. While incidence rates in sub-Saharan Africa have fallen, most of the world's new infections still occur there. A portfolio of approaches – or 'pathways' – to prevention is needed. Recent trial data shows great promise in four antiretroviral (ARV) prevention strategies.

The Mapping Pathways project used four separate methodologies to access diverse stakeholder perspectives and assess the evidence base, looking specifically at South Africa, India and the USA. 

We employ an adaptive approach to policy development around ARV-based prevention strategies. The project has engaged various stakeholders from India, South Africa and the United States in surveys, interviews and iterative exchanges to understand local perspectives and the empirical evidence needed to develop appropriate policy pathways for different contexts.

What will these pathways look like, how do we navigate them and where will they lead?

Please check out our posters - below - to learn more. And let us know what you think. You may leave a comment here, or send us an email at

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Pleasure Matters for Females Too!

"Female students placed a premium on the pursuit of pleasurable sex in and of itself. This was especially evident in the manner that they spoke about their sexual experiences. One student made it clear that she, and not her boyfriend, had initiated many of their sexual encounters, while another student matter-of-factly explained that condoms interfered with her full enjoyment of the sexual act: ‘Condoms are too clinical! I know that there isn’t much of a difference between sex with a condom and without, but I like to know that it’s just me to him, not me to him through some plastic!’" 

"The absence of recent research on ‘the joys of sex’ - with the exception of Sylvia Tamale's African Sexualities Reader  - reflects societies’ general discomfiture with young women’s sexual desire and sexual freedom more than it does the actual absence of the phenomena. Indeed the observation by sexologists Gagnon and Simon that ‘the idea of female sexual freedom is intolerable in most societies’  holds true today in many parts of the world, including Africa, as it did of nineteenth century America that they were writing about. Therefore, as we work towards making this years World AIDS Day theme of ‘Getting to Zero’ a reality, HIV interventions will need to be bolder and seriously take into account young African women’s actual sexual experiences and their lived sexual realities, however unsettling these may be for us in the HIV prevention community."

During fieldwork for my doctoral thesis in anthropology in 2007 I recall a female student at a university in Zimbabwe’s capital Harare saying to me, ‘Girls should stop acting as if they don’t like sex…from what I have seen from girls here on campus, they look forward to that [sic] more than guys do’. This statement caught me off-guard, not only because of the contempt with which it was uttered, but also because it was made by a young, unmarried African woman, in the presence of her best friend (another young unmarried woman) and was addressed to me, a virtual stranger. This was my second meeting with the two female students and already, both had stunned me with their frankness around sexual issues and especially around their own sexual experiences. In earlier discussions the two students had been quite vocal on the issue of sex and, in response to a question I had asked, one of them had declared that she never had reason to turn down her boyfriend’s sexual advances: ‘If he asks for sex, I give him. Why not? It’s not like girls don’t enjoy sex. They do!’ 

I was conducting ethnographic research on the relationship between ‘campus sexual cultures’ and female and male students’ HIV risk-taking behaviour and I found this openness by young Zimbabwean women both intriguing and refreshing. It is rare to read about young, heterosexual African women’s positive and pleasurable pre-marital sexual experiences. Often, the policy and academic literature portrays African women in one of two ways: as sexually passive and unwilling participants in the sexual act, or as sexually ‘immoral’ and ‘loose’ if they show any interest in sex at all. Neither of these portrayals fully capture the totality of young, unmarried African women’s lived realities. The views and experiences of the young women I encountered during fieldwork challenge these stereotypical portrayals, and suggest that in reality sex is not always something that is ‘done’ to young women. Neither are young women always passive and reluctant participants in sexual encounters. Feminist scholar Carole Vance, who championed a mini-revolution around women’s sexual pleasure in the US in the late eighties, poignantly observed that ‘danger and pleasure are ever-present realities in many women’s lives’. She further argued that focusing wholly on pleasure or danger oversimplifies women’s actual sexual experiences, which, in reality, are more complicated and unsettling. Dichotomies, as we very well know, are problematic in that one can only ever be one or the other— never both, and certainly never something else entirely.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Medical Male Circumcison's Potential Yet to Emerge in Practice

via The Financial Times, by Andrew Jack

A mural promotes the benefits of circumcision at a clinic in KenyaTzameret Fuerst whips two plastic rings out of her handbag and prises them together around her forefinger with a black rubber band, simulating a simple way to carry out male circumcision that she hopes will soon be widely adopted across Africa.

“This is a safe, simple, non-surgical device that needs no anaesthetic and is scaleable in resource-limited settings, using nurses to carry out the procedure in tents in rural areas,” she says. “It’s virtually painless, completely bloodless and does not require a sterile setting.”

The PrePex device that her company Circ MedTech has developed is one of a growing number of experimental tools in search of a market that has the potential to help radically reduce HIV transmission.
But circumcision is also a practice that – despite the evidence – has yet to be adopted as much or as fast as experts had hoped.

Many years after observational studies indicated that circumcised cultures had lower HIV prevalence, progress remains extremely slow. In 2005, the results of the first carefully randomised controlled clinical trials in Orange Farm in South Africa demonstrated that sexual transmission was reduced by 60 per cent in men who were circumcised.

A recent estimate published by UNAids highlighted a jump in adult male circumcisions, especially in Kenya, South Africa and Zambia. But with 555,000 interventions in men aged 15-49 across sub-Saharan Africa by the end of last year, less than 3 per cent has been achieved of a target of 21m set for 2015 to reduce significantly new infections in the region.

“It’s going to be a big challenge to reach this target,” concedes Gottfried Hirnschall, head of the World Health Organization’s HIV programme.

International organisations have publicly endorsed the importance of circumcision, and a number of guidelines have been established, but the response so far has been haphazard and funding remains modest.

Read the rest.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]