Craig McClure

Antiretroviral Therapy in Prevention of HIV and TB: Update on Current Research Efforts

There is considerable scientific evidence supporting the use of antiretroviral therapy (ART) in prevention of human immunodeficiency virus (HIV) and tuberculosis (TB) infections. The complex nature of the HIV and TB prevention responses, resource constraints, remaining questions about cost and feasibility, and the need to use a solid evidence base to make policy decisions, and the implementation challenges to translating trial data to operational settings require a well-organised and coordinated response to research in this area. To this end, we aimed to catalogue the ongoing and planned research activities that evaluate the impact of ART plus other interventions on HIV- and/or TB-related morbidity, mortality, risk behaviour, HIV incidence and transmission. Using a limited search methodology, 50 projects were identified examining ART as prevention, representing 5 regions and 52 countries with a global distribution. There are 24 randomised controlled clinical trials with at least 12 large randomised individual or community cluster trials in resource-constrained settings that are in the planning or early implementation stages. There is considerable heterogeneity between studies in terms of methodology, interventions and geographical location. While the identified studies will undoubtedly advance our understanding of the efficacy and effectiveness of ART for prevention, some key questions may remain unanswered or only partially answered. The large number and wide variety of research projects emphasise the importance of this research issue and clearly demonstrate the potential for synergies, partnerships and coordination across funding agencies.

Executive summary: Opportunities for action and impact to address HIV and AIDS in adolescents.

Introduction:The global HIV epidemic in adolescents is not controlled, and this group has not received sufficient attention in programming and research efforts addressing HIV prevention, treatment, and care. Methods:A global technical consultation on adolescents and HIV addressing services and research gaps was convened by United Nations Childrens Fund and the London School of Hygiene and Tropical Medicine in July 2013. Proceedings from this meeting are presented in this issue of the Supplement. Results:Several reviews highlight poor levels of coverage of critical HIV prevention, treatment, and care interventions for adolescents, disparities in HIV prevalence among adolescent girls, and low-risk perceptions associated with risk behaviors among key risk groups. Others underscore the significance of clear national targets and strengthening data, government involvement, enhanced systems capacity and policy, engagement of community and adolescent social networks, and of mobile and internet technologies to the success of interventions for adolescents. Finally, reviews identified several efficacious interventions for adults that could benefit from operational research to inform optimizing implementation in adolescents and how to do so with maximal cost efficiency and impact on the epidemic. Conclusions:Addressing the adolescent gap in the response to the HIV epidemic is essential to a more sustainable and effective response and is critical to overall adolescent health and well-being. The global community has the means and the responsibility to put measures in place to make AIDS-free survival the reality for children in this second decade of life.

The role of HIV research in building health system capacity in developing countries.

Purpose of reviewThere is growing recognition that greater investment in research is needed to expand our knowledge and understanding of how to scale up HIV programmes effectively and equitably in the context of weak health systems. Current debates acknowledge that there remains a gap in evidence on how HIV resources can best be managed to contribute to building health system capacity; how to integrate HIV interventions into primary healthcare systems; and how HIV scale-up is affecting other disease programmes. Recent findingsFindings suggest that global health initiatives, including HIV/AIDS programmes, should allocate a set portion of funding for research and knowledge generation in improving health system performance. Forms of HIV research with potential for building health system capacity in developing countries include clinical research, implementation and operations research, quality improvement research, economic evaluation and cost–effectiveness, HIV surveillance and population-based surveys, and monitoring and evaluation. SummaryIn this review, we present an overview of the imperative for HIV research in building health system capacity, provide examples of current trends and the forms of research with potential for enhancing health system performance, and highlight priorities for enhancing the role of HIV research in building health system capacity.

Lesotho’s Minimum PMTCT Package: lessons learned for combating vertical HIV transmission using co-packaged medicines

Mother‐to‐child transmission of HIV can be reduced to<5% with appropriate antiretroviral medications. Such reductions depend on multiple health system encounters during antenatal care (ANC), delivery and breastfeeding; in countries with limited access to care, transmission remains high. In Lesotho, where 28% of women attending ANC are HIV positive but where geographic and other factors limit access to ANC and facility deliveries, a Minimum PMTCT Package was launched in 2007 as an alternative to the existing facility‐based approach. Distributed at the first ANC visit, it packaged together all necessary pregnancy, delivery and early postnatal antiretroviral medications for mother and infant.

Strengthening accountability in the global response to HIV

As the world turns its attention towards Mexico City for the XVII International AIDS Conference (AIDS 2008) the International AIDS Society and its organising partners are taking steps to use their influence at the conference to track progress on international commitments and to strengthen accountability for those commitments in key areas. The conferences and its themes have served as milestones in the global response to HIV. The theme of Access for All (AIDS 2004 Bangkok) signaled an emerging consensus that the goals established in the 2001 UN Declaration of Commitment on HIV/AIDS would not be realised without substantially greater political leadership and resources. The treatment advocacy that dominated AIDS 2004 would culminate in the 2005 commitments to universal access by 2010 made first by G8 leaders and subsequently by the international community at the UN World Summit. Time to Deliver (AIDS 2006 Toronto) reflected growing impatience with the slow pace of scaling up HIV programmes and with the resistance of governments to addressing the needs of the populations most at risk. This resistance-exemplified by the 2006 Political Declaration on HIV/AIDS which failed to mention men who have sex with men injecting drug users and sex workers-was challenged by scientific and civil society leaders at AIDS 2006 who argued forcefully that public-health imperatives must take precedence over political expediency. The AIDS 2008 theme is Universal Action Now to emphasise the urgent need to increase the pace of scale-up. It is also an important reminder that the epidemic does not exist in a vacuum-collective action to protect human rights and end stigma and discrimination in addition to rolling out biomedical interventions is required to halt the epidemic. Recent claims that HIV-targeted funding is to blame for weak health systems in poor countries ignore the fact that establishing new laboratories and clinics building stronger management systems for the supply chain and strengthening the training of health-care workers is having a broader positive effect on under-resourced health-care systems. HIV professionals have long understood the need to work in collaboration with other health advocates and to ensure that HIV programmes are integrated with other health services. In Mexico there will be many opportunities to further strengthen such alliances and to make the case that delivery of HIV programmes can catalyse other areas of the health-care system. AIDS 2008 will also be an opportunity to reflect on the June 2008 UN High-Level Meeting on AIDS. Progress reports released in advance of that meeting indicate that most countries are far off -target to reach universal access goals. At AIDS 2008 civil society and scientific leaders will join government officials to assess progress as equal partners in the response. The International AIDS Society and its partners will later issue a peer-reviewed impact report on the conference which will analyse the new science programmatic experience and lessons learned from AIDS 2008 including implications for policy and practice. Over the next 2 years the conference will also explore how as an organisation we can adopt a more targeted approach to holding stakeholders accountable. By tracking progress on a few key interventions we hope to increase the likelihood that political commitments are translated into action. (full-text)

Commentary: Innovations in programming for HIV among adolescents: towards an AIDS-free generation.

Ultimately achieving an AIDS-free generation might rely more than we thought on developing adolescent leaders as agents of change -- not simply behavior change but societal and legal change. Innovative programming may be expanding adolescents’ social networks and engagement increasing their HIV-specific knowledge and increasing demand for HIV testing and treatment; but what is to meet this demand; and how will the effects of these programs be rigorously measured? Technology companies and mobile host sites are not clinicians or experts in evaluation. Even dizzying advances in technology are useless if adolescents have no access to them or are not able to access health promoting information services or networks. Moving forward technology and social innovators -- young and old -- must task themselves with removing barriers to testing and treatment that will reduce the sheer numbers of HIV infections and AIDS deaths in this population. Innovations must support adolescents’ access to a wider array of confidential testing options available in the community and through the health sector link them to biomedical and other prevention services of proven efficacy such as antiretroviral therapy medical male circumcision and to specific harm reduction interventions. In the years to come it is network disruption -- of entrenched social mores stigma attitudes and discriminatory practices -- that will constitute true innovation. (Excerpts)

G8 funding for HIV universal access: a new opportunity for transparency.

This article discusses the commitment of the Group of 8 (G8) countries to help meet the funding needs of universal access to AIDS treatment prevention care and support by 2010. It states that most G8 countries have not committed their fair share in this effort and have not been transparent enough in their reporting. It provides suggestions for improvement in donor transparency and reporting.

Beyond the first 25 years: The International AIDS Society and its role in the global response to AIDS

Dr. Pedro Cahn, International AIDS Society (IAS) President and Mr. Craig McClure, IAS Executive Director, provide their thoughts and analysis on the current and future role of the IAS as part of the global response to HIV/AIDS.

Addressing and improving the continuum of care for HIV-affected children: challenges and solutions.

In 2011, Ambassador Eric Goosby of the U.S. President’s Emergency Plan for AIDS Relief and Michel Sidibe, the Executive Director of the Joint United Nations Programme on HIVand AIDS, announced a Global Plan for eliminating new HIV infections in children and keeping their mothers alive [1]. The elimination of maternal-to-child transmission (EMTCT) or Global Plan calls for three topline goals – decreasing new pediatric infections due to vertical transmission by 90%, halving maternal deaths, and halving pediatric deaths from HIV and AIDS by 2015 [1]. In June 2011, all United Nations member states committed to these targets. The Interagency Task Team, a 32-organization partnership coconvened by the United Nations Children’s Fund and WHO, is charged with coordinating technical support to countries, developing supportive guidance and tools and monitoring progress, with an emphasis on 22 countries that account for 90% of the total annual number of new HIV infections among children. This series of 11 articles addressing pediatric HIV care and treatment was created by the nearly 60 members of the Interagency Task Team Child Survival Working Group.

eJIAS: The Journal of HIV/AIDS Science and Medicine in the Developing World.

On behalf of the International AIDS Society (IAS), Medscape, and our editors, we are pleased to introduce eJIAS: eJournal of the International AIDS Society , a new peer-reviewed journal dedicated to the science and practice of HIV/AIDS medicine in the developing world. And, on the occasion of the largest international gathering of HIV/AIDS scientists and healthcare and public health workers in 2 years, we are privileged to present the official online abstracts of the XV International AIDS Conference (Bangkok, Thailand; July 11–16, 2004) in this inaugural issue of eJIAS . (Published: 15 July 2004) doi:10.1186/1758-2652-6-3-56 Full text: BioMed Central: http://www.biomedcentral.com/1758-2652/content/6/3/56 PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738662/