The social drivers of HIV: In conversation with Charles Stephens Part 3

Original content from our Mapping Pathways blog team

"I'd like to see us...reflecting on our successes. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes."

In the final part of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the successes in the HIV prevention landscape and some of the challenges faced by people in rural areas. Read part one here and part two here.

MP: What are the things being done well in the HIV prevention landscape?

CS: Models like the Mapping Pathways project excite me. The process of collecting data from a variety of different experts and stakeholders on the field and using that data to make a strong case is an excellent model. Other interesting models are AVAC’s HIV prevention research advocacy working group, which I’m a part of, and the community education and research advocacy work of the Black AIDS Institute. Most importantly, stakeholders and leaders within communities are trained and supported to go back to their communities with new biomedical HIV prevention information to disseminate it within their communities.

One of the things I’d like to see more of is reflecting on our successes and planning how to build on the victories we’ve seen over the last few years. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes. Also from the community perspective we have achieved certain successes like reducing stigma, mobilising communities and providing support networks and services. I’m extremely interested in finding out how we can build on these successes.

MP: What are some of the challenges individuals and communities face in rural areas?

CS: Capacity is one of the main challenges in rural areas. I find that the doctors on the ground are often very knowledgeable, passionate and committed, but the problem that is there just aren’t enough doctors and medical resources. 

Transportation is another huge barrier in rural areas. People have a hard time getting to their doctors, as the transportation infrastructure isn’t always in place. Some people have to travel three or four hours to get to their physicians.

Addressing these barriers has been a challenge, but there have been some innovations like telemedicine, where doctors can remotely provide medical information and check in with their clients from a different location.

MP:  Are there any trial results that came out recently that you have followed closely? Are there any upcoming trials you are interested in?

CS: The HPTN 061 study, which looked at 1553 black, American MSM, shared initial results at AIDS 2012 that reinforced what a lot of us had been seeing on the field. One of the most startling projections of the study was that unless improvements are seen, more than half of all young black gay men who are gay or bisexual will be infected by HIV within the next decade.

Other upcoming trials I will be following with interest are the HPTN 073 study which looks at ways to optimise PrEP adherence in black MSM and the HPTN 069 study, also called NEXT PrEP, which seeks to assess the efficacy of four ARV drug regimens used as PrEP to prevent transmission of HIV in a population of at-risk MSM.

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The social drivers of HIV: In conversation with Charles Stephens Part 2

Original content from our Mapping Pathways blog team

"HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors." 

In the second of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the social drivers of HIV and its impact on vulnerable communities. Click here for part one.

MP: According to the Centers for Disease Control and Prevention (CDC) figures, men who have sex with men (MSM) accounted for 61% of all new HIV infections in the U.S. 2009. There was also a 48% increase in HIV incidence figures among young black gay men (aged 13-29). Why has the HIV epidemic seemed to have disproportionately affected this demographic?

CS: I think there are a number of researchers right now investigating that question. I feel we are still at the stage of trying to figure out what questions we should be asking. For example, a number of researchers have done work that suggests that black gay men don’t necessarily engage in any higher sexual risks or drug-taking risks than white gay men. However, there is a higher incidence of HIV among black gay men – so why is that?

One argument is that there is a higher prevalence of HIV within existing black, gay male sexual networks, which leads to higher incidence numbers. There is also some thought about ways that poverty, stigma and other social factors can play a role in driving the HIV epidemic among black gay men.

HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors. One of most exciting conversations I’ve witnessed in the research and advocacy realm is ‘What are the social drivers of HIV and how do those social drivers disproportionately impact some communities over others?’

I think researchers should be looking at lot of areas. But more importantly, considering the impact of HIV among young black gay men in particular, I think its important that researchers, policymakers and community members all come together in grappling with this really severe epidemic.

MP: Can you elaborate on some of the social drivers you talked about?

CS: Some of the questions we have to ask are: What is the role of housing or joblessness? What are the roles of social class, stigma and homophobia? These questions force us to think about HIV in a very intersectional way. By intersectional, I mean the challenge and issue of HIV is also connected to these other larger social issues.

An intersectional approach forces us not to operate in silos. It forces us to be very innovative in how we think about grappling with HIV. It’s impossible to think about HIV without some analyses of social issues because very often those social issues reinforce the impact of HIV, particularly in vulnerable communities.

Ultimately, it is important to look at communities that are most vulnerable. But what we seem to find is that communities vulnerable to HIV are also vulnerable to a number of other social issues, which means that we have to think very critically about the role that these other social drivers of HIV play – particularly in the lives of young black gay men.

MP: What are some of these challenges and issues that young black gay men seem to face in particular? What makes them so vulnerable?

CS: I think that, again, is a research question. There needs to be a research agenda around young black gay men, particularly in the context of HIV, that asks those very questions. Some of the questions to be asked are: How do we understand the vulnerability of this population? What are some of the forces that contribute to this vulnerability?

The research agenda should bring together researchers from multiple disciplines and approaches. This research agenda requires diverse methodologies, skillsets and worldviews. In effect, this would not just be a research agenda but a research and advocacy agenda, with the research helping drive the advocacy.

Current vulnerabilities include, but are not limited to, joblessness, poverty and stigma. We talk about stigma, in particular, as a barrier to someone accessing prevention or care services. Someone might be unwilling to get an HIV test because they don’t want to be seen going to an AIDS service organisation because of the stigma associated with HIV. Someone diagnosed with HIV might not tell people and thus fail to build a support system around them.

Lack of healthcare access is another vulnerability in this population. Communities that are marginalised because of race, class or gender sometimes don’t have access to the best healthcare resources, which contributes to negative health outcomes.

A number of steps have been taken to make HIV testing as accessible as possible. There are efforts to bring HIV testing to communities and one sees HIV testing events at community centers and mobile testing.

Stay tuned to the blog as we bring you part three of our conversation with Charles, where he speaks about some of the challenges faced by people living with HIV in rural areas and shares his thoughts on the good work being done in the HIV prevention landscape. 

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

A World Without AIDS, Still Worlds Away

via the New York Times, by Lawrence K. Altman

WASHINGTON — Is the world on the verge of ending the AIDS epidemic and creating an AIDS-free generation, even though a cure and a vaccine are still distant hopes?

Yes, roared enthusiasts among the nearly 24,000 participants at the 19th International AIDS Conference here last week. Their hopes are based on the extraordinary scientific gains made since the conference was last held in the United States, 22 years ago, when an AIDS diagnosis was a sure death sentence.

Among those gains: antiretroviral drug combinations for women to prevent infection of their newborns; drugs to treat and prevent infection with H.I.V., the virus that causes AIDS, among adults; and evidence that voluntary male circumcision can reduce the risk of female-to-male transmission by 50 to 60 percent.

Today, H.I.V. has become a chronic disease that, if treated appropriately, can be held at bay in a newly infected young adult for decades — if the patient adheres to the rigid daily drug regimen.

Michel Sidibé, the executive director of the United Nations AIDS agency, said that the opportunity to end AIDS will “evaporate” if governments do not show greater political will and increase investments to make gains available to millions more people.

“All that can stop us now is indecision and lack of courage,” he said.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

Dr. Grant Colfax is Appointed Director of White House Offices of National AIDS Policy Position

via PR Newswire

San Francisco AIDS Foundation applauds President Obama's selection of Dr. Grant Colfax to become director of the White House Office of National AIDS Policy. Dr. Colfax is uniquely suited to continue the momentum established under his predecessor, Mr. Jeffrey Crowley, in advancing the ambitious goals outlined in the president's National HIV/AIDS Strategy and moving us closer to an AIDS-free generation.

"Dr. Colfax has been instrumental in the decline of new HIV infections in San Francisco in recent years," said San Francisco AIDS Foundation CEO Neil Giuliano. "His unique blend of experience serving on the front lines of the epidemic, implementing the national strategy at the local level, working as a direct service provider within the Ryan White CARE system, and conducting cutting-edge research makes him the right person at the right time to lead the Obama administration's efforts to end HIV/AIDS in the United States."

The Office of National AIDS Policy provides essential leadership in addressing the U.S. HIV/AIDS epidemic. As director, Dr. Colfax will be required to take a fresh look at how resources can be targeted to reduce HIV infection rates, increase access to treatment, and decrease HIV-associated health disparities related to sexual orientation, race, gender, and socio-economic status in hard-hit communities across the country. His track record in San Francisco demonstrates he is well suited for this challenge.

"Dr. Colfax will play a critical role over the next several years to ensure the implementation of the Affordable Care Act and HIV service integration to address the health care needs of people living with HIV," said Ernest Hopkins, director of legislative affairs at San Francisco AIDS Foundation. "Having worked closely with him on complex issues and having seen his consensus-building skills among diverse populations, including communities of color, I am confident that the AIDS community will have a strong advocate within the administration. I know Dr. Colfax will work to ensure that the coming changes to our health care system are made thoughtfully, carefully, and with a strong focus on improving the health status of the most vulnerable people."

As director of the HIV Prevention and Research Section at San Francisco Department of Public Health, Dr. Colfax elevated the role of community-based health research in local planning and funding decisions and instituted innovative, evidence-based HIV prevention tools, such as measuring and mapping community viral load and enhancing HIV testing and linkage to care, making San Francisco's HIV prevention planning and service system a model for jurisdictions across the nation. When developing the city's most recent HIV prevention plan with diverse stakeholders, Dr. Colfax was mindful to ensure its consistency with the emerging National HIV/AIDS Strategy. Throughout his career, he has maintained his role as a physician at Ward 86 at San Francisco General Hospital, the nation's first HIV/AIDS-specialized clinic.

San Francisco AIDS Foundation stands ready to work with Dr. Colfax, the White House, and other community partners across the country to reduce new HIV infections, increase access to care for all people living with the disease, and reduce HIV-related health disparities.


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

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.]

AVAC Realeases Its 2011 Report: "The End?"

via AVAC

This AVAC report presents a three-part agenda for ending the AIDS epidemic. It is intended as a vision and a challenge to the field, and a first step in holding all of us—civil society, researchers, governments, and funders—accountable for progress.

Each of the major priorities below demands action now—but the dividends will come in the short, medium, and long terms.

1. DELIVER today’s proven strategies at scale for immediate impact

• Model combination prevention programs to identify the parameters that are essential for scale-up to have a major impact on infections
• Mobilize demand for new tools among people who could benefit, through social marketing and other efforts
• Reprogram existing resources when evidence shows they could be used to greater effect
• Fund evidence-based scale-up today—and save money in the future—through substantial increases in commitments from U.S., European and developing country funders.

2. DEMONSTRATE and roll out newly available HIV prevention tools, including PrEP and microbicides, for even greater impact in 5 to 10 years

• Plan for the introduction of PrEP and microbicides in the next several years, and for follow-on research needed to address questions that remain unresolved in trials to date
• Pilot these interventions through demonstration projects that help define their optimal use and real-world impact
• Prioritize the use of these interventions in populations, and in combinations, where the potential benefits are greatest

3. DEVELOP long-term solutions—including an effective vaccine and a cure—that will enable us to close the door on AIDS

• Sustain funding for research, to capitalize on recent scientific insights that have begun to revitalize the search for a vaccine, while pursuing new leads that may eventually result in a functional cure for HIV infection.

Read the full report here.

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

Secretary Hillary Clinton on Creating an AIDS-Free Generation: Bouquets and Brickbats

* Original content from our Mapping Pathways blog team

“An AIDS-free generation would be one of the greatest gifts we could give to the future.Let's make it happen.”

On November 9, US Secretary of State Hillary Clinton delivered a speech on HIV/AIDS at the National Institutes of Health in Bethesda, Maryland – a speech that has triggered mixed reactions from people in the HIV/AIDS treatment and prevention field. Take a look at some excerpts:

“Today we are making major investments in the search for a vaccine; for tools like microbicides, which give women the power to protect themselves; and other lifesaving innovations.”

“… our efforts have helped set the stage for the historic opportunity the world has today: to change the course of this pandemic and usher in an AIDS-free generation.”

“… creating an AIDS-free generation has never been a policy priority for the United States Government until today, because this goal would have been unimaginable just a few years ago … It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other.”

“America's combination-prevention strategy focuses on a set of interventions that have been proven most effective: ending mother-to-child transmission, expanding voluntary medical male circumcision, and scaling up treatment for people living with HIV/AIDS.”

“… we now know that if you treat a person living with HIV effectively, you reduce the risk of transmission to a partner by 96 percent.”

“Treating HIV-positive people before they become ill also has indirect economic benefits.It allows them to work, support their families, and contribute to their communities; and it averts social costs, such as caring for orphans whose parents die of AIDS-related illnesses … In other words, treating people will not only save lives – it will generate considerable economic returns too.”

“… we need to let science guide our efforts. Success depends on deploying our tools based on the best available evidence.”

“An AIDS-free generation would be one of the greatest gifts we could give to the future. Let's make it happen.”

A number of HIV/AIDS activists have applauded Clinton’s “bold” speech, pointing out her emphasis on the prioritization of the fight against the epidemic, her focus on scientific evidence, and her call for immediate action to take advantage of the “historic opportunity” to create an “AIDS-free generation.” Many hope that this kind of public statement will help boost activism to preserve domestic and international funding.

On the other hand, while Clinton mentioned vaginal microbicides for women, she failed to talk about pre-exposure prophylaxis (PrEP) and rectal microbicides. These two prevention strategies are meant to protect uninfected people from the HIV virus – they have been the subject of numerous recent trials, with substantial success being demonstrated in many of them. (Take a look at our blog post on some of these studies.) Some feel Clinton’s decision give these new prevention technologies a miss can be attributed to political, financial, and social reasons.

“The omissions were disappointing but not surprising,” says 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. “Her audience was international, which means predominately heterosexual, so I suppose it made strategic sense that she would steer clear of PrEP, which has been shown to be effective for gay/bisexual men but has produced conflicting results for heterosexuals. Nonetheless, with gay men and other men who have sex with men experiencing catastrophic rates of HIV the world over, it remains disturbing to me that this group was not even mentioned, whether in conjunction with PrEP or not.”

Another possible reason for the omission of PrEP is the fact that the global jury is still out on the feasibility of rolling out PrEP interventions while there are HIV-infected people who do not have access to treatment – a problem made all the more complex because of the crippling HIV/AIDS funding constraints over the last few years. However, Pickett firmly believes that the either/or stance taken by those nixing promising preventive technologies is dangerous and close-minded. “We’re continually working to get enough information and data to answer the big questions we’re grappling with – questions about efficacy, accessibility, funding, prioritization, and acceptability. These questions are extremely challenging, but it’s imperative that we work on solving them,” says Jim. “It’s not an option to stick our head in the sand. To turn the dream of an AIDS-free generation into a reality, it is absolutely clear that we must expand access to effective ARV drugs for all those who need them – whether they are HIV-positive or HIV-negative.”

To know more about Secretary Clinton’s speech and the responses to it, read the AIDS Foundation of Chicago’s story and Science Magazine’s article. You could also check out this letter to Secretary Clinton – a blog post written by an IRMA member.

You can read the entire speech here.

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