Michel Kazatchkine

A call to action for comprehensive HIV services for men who have sex with men

Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Time to act: a call for comprehensive responses to HIV in people who use drugs.

The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. We review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.

AIDS: lessons learnt and myths dispelled

This article examines the AIDS epidemic and what the international community has gotten right what we have done wrong and why we need to urgently dispel several emerging myths about the epidemic and the global response to it. It suggests that we have to identify how to finance a sustained response to AIDS for another several decades develop long-lasting links with broader efforts to strengthen health systems continue to invest in research and development and put a more serious effort into tackling stigma and discrimination.

The global response to HIV in men who have sex with men

Gay, bisexual, and other men who have sex with men (MSM) continue to have disproportionately high burdens of HIV infection in countries of low, middle, and high income in 2016. 4 years after publication of a Lancet Series on MSM and HIV, progress on reducing HIV incidence, expanding sustained access to treatment, and realising human rights gains for MSM remains markedly uneven and fraught with challenges. Incidence densities in MSM are unacceptably high in countries as diverse as China, Kenya, Thailand, the UK, and the USA, with substantial disparities observed in specific communities of MSM including young and minority populations. Although some settings have achieved sufficient coverage of treatment, pre-exposure prophylaxis (PrEP), and human rights protections for sexual and gender minorities to change the trajectory of the HIV epidemic in MSM, these are exceptions. The roll-out of PrEP has been notably slow and coverage nowhere near what will be required for full use of this new preventive approach. Despite progress on issues such as marriage equality and decriminalisation of same-sex behaviour in some countries, there has been a marked increase in anti-gay legislation in many countries, including Nigeria, Russia, and The Gambia. The global epidemic of HIV in MSM is ongoing, and global efforts to address it remain insufficient. This must change if we are ever to truly achieve an AIDS-free generation.

The Global Fund's leadership on harm reduction: 2002–2009

Injecting drug use is a major driver of the HIV epidemic globally. Whilst robust evidence points to the effectiveness of harm reduction programmes to halt and reverse injecting drug use driven epidemics, uptake of these programmes in developing and transitional countries has been slow. In part, this slow uptake stems from inadequate financial resources for harm reduction; legal, socio-cultural and medical barriers leading to stigmatisation; and weak health systems unequipped to manage marginalized groups. The Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002, has become the major multilateral source of external funding for harm reduction programmes in countries experiencing concentrated HIV epidemics driven by injecting drug use. Between 2004 to end of 2008, the Global Fund invested around US

Maximizing the benefits of antiretroviral therapy for key affected populations

180 million in harm reduction programmes in 42 countries. This funding has helped to initiate and scale up harm reduction programmes in settings where domestic funding was lacking. In addition to financing harm reduction programmes globally, the Global Fund has stimulated a strong dialogue between vulnerable groups and governments. Furthermore, the Global Fund has engaged in a dialogue with countries to encourage an evidence-based approach to policy-making that recognizes the immense value of harm reduction in HIV prevention and control.

Rational vaccine design for HIV should take into account the adaptive potential of polyreactive antibodies.

Scientific research has demonstrated the clinical benefits of earlier initiation of antiretroviral treatment (ART), and that ART can markedly reduce HIV transmission to sexual partners. Ensuring universal access to ART for those who need it has long been a core principle of the HIV response, and extending the benefits of ART to key populations is critical to increasing the impact of ART and the overall effectiveness of the HIV response. However, this can only be achieved through coordinated efforts to address political, social, legal and economic barriers that key populations face in accessing HIV services.

Advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals: the International AIDS Society—Lancet Commission

The long-standing quest for the development of vaccines that confer protection against highly mutable viruses such as HIV, hepatitis C, and influenza has elicited numerous structural and functional studies on virus-neutralizing human antibodies. These studies have aimed at translating the knowledge acquired on broadly neutralizing antibodies to the design of better immunogens for the induction of specific and protective immune responses. The last few months were marked by several seminal articles that investigate HIV-neutralizing human antibodies. These studies have characterized essential mechanistic details of the neutralization of HIV and imply that both exquisite specificity and degeneracy of the specificity of antibodies may be equally important for HIV neutralization. In this Opinion, we highlight and further discuss the potential of polyreactive (promiscuous) antibodies in defense against promptly evolving viruses. Despite having been somewhat neglected by mainstream immunologists in the last 20 years, polyreactive antibodies may come to light as new weapons against HIV.

Drug use, HIV, HCV and TB: major interlinked challenges in Eastern Europe and Central Asia

Author(s): Bekker, Linda-Gail; Alleyne, George; Baral, Stefan; Cepeda, Javier; Daskalakis, Demetre; Dowdy, David; Dybul, Mark; Eholie, Serge; Esom, Kene; Garnett, Geoff; Grimsrud, Anna; Hakim, James; Havlir, Diane; Isbell, Michael T; Johnson, Leigh; Kamarulzaman, Adeeba; Kasaie, Parastu; Kazatchkine, Michel; Kilonzo, Nduku; Klag, Michael; Klein, Marina; Lewin, Sharon R; Luo, Chewe; Makofane, Keletso; Martin, Natasha K; Mayer, Kenneth; Millett, Gregorio; Ntusi, Ntobeko; Pace, Loyce; Pike, Carey; Piot, Peter; Pozniak, Anton; Quinn, Thomas C; Rockstroh, Jurgen; Ratevosian, Jirair; Ryan, Owen; Sippel, Serra; Spire, Bruno; Soucat, Agnes; Starrs, Ann; Strathdee, Steffanie A; Thomson, Nicholas; Vella, Stefano; Schechter, Mauro; Vickerman, Peter; Weir, Brian; Beyrer, Chris

The expanding epidemic of HIV-1 in the Russian Federation

Eastern Europe and Central Asia have the largest drug epidemic globally and the fastest and still expanding HIV epidemic. The Russian Federation and Ukraine together account for over 90% of the reported AIDS cases in the region. If small in absolute numbers, the epidemics are however significant in prevalence rate in most countries of Central Asia. Most heroin and many of the new synthetic or home‐made drugs are injected, which has led to high prevalence levels (up to 90%) of HCV infection in people who inject drugs (PWID). The two epidemics of HIV and HCV are in turn interlinked with TB and MDR‐TB that are highly prevalent among marginalized populations in the region. Despite progress in the last two years, access to antiretroviral treatment remains far below global levels and increases more slowly than new reported cases of HIV. Access to prevention is limited with low coverage of needle exchange programs and very low or inexistent access to opioid substitutive therapy. There are few exceptions to this situation, including Ukraine where harm reduction programs are being scaled up together with significant peer outreach programs for PWIDs. This is likely to be the reason why the epidemic curves in the Russian Federation and Ukraine are now diverging. The region faces many structural, cultural, societal and political obstacles in responding to these quadruple epidemics. Without a significantly expanded and strengthened response, these epidemics will remain major causes of illness and premature deaths in the region.