Before Diane Havlir, MD, professor of medicine at the University of California, San Francisco (UCSF) and the chief of the UCSF Division of HIV/AIDS and Positive Health Program at San Francisco General Hospital and Trauma Center (SFGH), heads to Washington, D.C., where she will serve as co-chair of AIDS 2012, the XIX international AIDS Conference, she answered some questions about what’s to come this week.
Q: What can we expect at the AIDS 2012 conference?
Well, the big theme at AIDS 2012 this year is going to be talking about how we begin to end the AIDS epidemic. The conference theme is “Turning the Tide Together,” and there is going to be emphasis on the how: how are we going to start to begin the end the AIDS epidemic? And there's going to be emphasis on the together: who's going to finance this, and what partners do we need to bring to the table?
Q: Speaking of partners, tell me a little bit about how the conference comes about. Who organizes it, and how did you become co-chair this year?
The conference is sponsored by the International AIDS Society, which is the largest body of HIV professionals in the world. There is a chair and co-chair selected for the conference, and I was selected to be the co-chair of the conference as a representative of the United States, the host country of the conference. The conference is organized by a group of individuals who represent permanent partners of the conference, which includes global organizations such as UNAIDS, the World Health Organization, the World Bank and community organizations.
And that's really one of the beauties of this conference. It brings together people working on the AIDS response from all sectors. It includes the scientists, it includes the front line providers, it includes policy makers and high-level politicians. It includes global organizations such as the UN, and very importantly it includes the HIV community.
In fact, the conference is organized into three components and tracts. There's the scientific tract, there's a community tract and a leadership tract. There are sessions that focus uniquely on those aspects of the AIDS response, but probably the most important sessions of the conference are what we call bridging sessions, when we bring those groups together to talk about how we're going to solve problems.
Q: In the past, what sorts of advances have come out of these bridging sessions?
Well, I think that there are many examples. Let's just take mother-to-child transmission. The scientists provide the data on how treatment can prevent mother-to-child transmission. Then we ask who's going to pay for that? What kind of systems do we set up? So at a bridging session, you'll have the data, and you'll have the countries that are supporting AIDS programs to talk about how to target funding for this effort. And then the community comes into play. What brings mothers to care? Why are they not coming into care? What makes them drop out of care, what's important to them when they go for care, and then how can non-government organizations and community groups support mothers and their children to eliminate mother-to-child transmission?
I think that's one example of a topical area. Bringing all these groups together is much more effective than the scientists having their own meeting, the community having its own meeting, and the policy makers being in the policy centers and capitals of the world.
Q: So what are the bridging topics that will be dealt with this time?
There'll be a wide range of bridging topics. We'll be talking about combination prevention. Right now we have some really exciting new data about different ways we can prevent HIV disease. So the data will be presented, and the policy makers, the cost of this will be put forth, and they'll talk about who is going to pay for these approaches.
Diane Havlir, MD
And then the community will provide their perspective. I think this is a particularly good example of where bridging sessions, once again, are important. Because some of the new data have to do with offering therapy to populations we think are most going to benefit before they get infected with HIV.
When one delivers that kind of therapy, called PrEP, pre-exposure prophylaxis, in order for it to be effective and to reduce the downsides, there have to be programs in place that permit frequent testing of those individuals and support adherence. Because if those things are not done, then we can see the downsides of that approach, which would include, for example, the selection of drug resistant virus.
Q: What other advances? You mentioned TB. There are new TB drugs on the horizon, correct?
I think combination prevention is a big topical area for the conference. Another big area is going to be affected populations. We have had this series of scientific breakthroughs over the last three years, but we are not going to be able to yield the full benefit of those unless we reach affected populations.
And the question is, what do we mean by affected populations? Well, certainly, let's just start here in San Francisco. Men who have sex with men. Twenty-three percent of men who have sex with men in San Francisco are living with HIV. So this is an example of the disproportionally affected population in San Francisco.
Other affected populations that we think about are people who use drugs. Sex workers. Women are affected populations, because there are often power imbalances, which prevent them from accessing care and treatment. So that is a second big topical area the meeting is going to cover.
A third big topical area the meeting's going to cover is financing — creative financing approaches. We're in a tough time globally with economics, so one of the questions is going to be who's going to pay for AIDS prevention and treatment. The United States has been a very generous donor, as has been some European countries. Now we're seeing the participation of some of the highly affected countries.
South Africa is really stepping up. At the conference, the Bricks [Brazil, Russia, India and China] countries will be talking about their contributions. And even some countries such as Zimbabwe will be talking about innovative financing approaches that they have already put in place, which include an AIDS tax levy.
A fourth area that's going to be covered at the conference is new drugs. We are going to be hearing new information about some new HIV drugs, which we always need to continue improving on to stay ahead of the virus. There will also be new data, long in coming, about some new drugs for tuberculosis and how these drugs interact [with HIV drugs] and how we can give them along with HIV therapy. Because whenever a person has both TB and HIV, one must treat both infections at the same time. We can't do them one after the next.
And finally, I think, a very exciting topical area at the conference is going to be talk about the HIV cure — where are we with that research agenda. There's going to be an announcement before the conference about a new global strategy to work towards the HIV cure, and we'll see a lot of great discussion about that.
Q: How do the conference organizers work with the people who put on the satellite sessions, and also with organizations that are making major announcements or government agencies?
Well, I think a fundamental goal of the AIDS community is to share information among ourselves as rapidly as we can, so we can discuss it, so we can debate it and so we can act on it. So we have a very open policy in the conference. Of course, there is the central group that's administering the conference.
There's a communications effort, and as new announcements are going to be made we encourage from both ends. From the conference end, we work with media to talk about what's going to happen at the conference, and when folks are going to make major announcements. We encourage them to share that at the conference. The website includes a listing of many of these important satellite symposiums that occur at the conference that are official, conference-affiliated events.
But there are many events that will occur all over Washington, which we encourage, where people leverage the time of this meeting in order for their groups to meet no matter how big, no matter how small, to really advance the knowledge of how we can all best respond to the AIDS challenge.
Q: Can you talk a little bit about this theme of turning the tide? Is this something that brings together all those pieces that you mentioned before, the cure, combination, prevention, funding, etc.?
It absolutely brings together all those pieces. All those components are essential. As I’ve mentioned over the last couple of years, we've had breakthroughs in AIDS, mostly in the prevention area which include treatment as prevention, adult male circumcision having sustained benefits, pre-exposure prophylaxis, and data showing that early treatment benefits the individual.
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So the way I like to explain it is that we need to think about the short- and medium-term strategies and the long-term strategies. Clearly, in the short-term, we need to put into action these new scientific findings. At the conference, we are going to have a lot of discussion, dialogue and debate about the ‘how.’ How do we best do this? What are the programs that we need to set up? Very importantly, we are going to focus on efficiency and effectiveness. And of course, this brings in the money angle, because we need to have a clear understanding of how much money is needed and what we get from that financial investment.
Ramping up test and treat and PrEP and circumcision can potentially, if we act, have a huge impact on reducing the number of new infections and keeping people healthy. But most everyone in the AIDS response believes that we are going to need a cure, a vaccine, or both, to fully end the AIDS epidemic. This is where continuing a strong and robust investment in those research agendas is absolutely critical.
So that brings together all the major themes that are going to be discussed at the conference.
Q: It's impossible to put a price tag to how much it's going to cost to develop a vaccine or a cure, because we don't know how long it will take, how feasible it's going to be, etc. But when you think about treatment, when you think about prevention, can you put a price tag to how much it will cost to turn the tide on the epidemic using those tools?
Great question. That’s something that's going to be featured in one of the plenary talks at the conference. When we think about finance — over the last one to two years, as these scientific breakthroughs have come forth, people have begun to model the exact question you are asking. Remember, models are all estimates. A good thing about HIV is that things are constantly changing; we constantly get new information, better ways to do things.
There's something UNAIDS and the WHO put together as an investment framework strategy, and they modeled out the approximate amounts we would have to invest to really turn the tide in terms of new infections. They published a report about a year ago, and it was somewhere in the 20-to-30-billion dollar range over the next five to six years, if we put into action what we know.
Whether that number is right or wrong, or how off it is, the most important aspect of that particular investment framework is that it shows that by investing now, the overall price of what it takes to take care of people living with AIDS and trying to prevent this disease, this becomes cost savings as early as eight to ten years from now.
That's really profound. So what that tells us is that if we do a surge now in investment, we are going to be saving money, if money is all we're concerned about, for decades ahead. But of course, this is an ethical obligation that we put into action. What we know can help save lives and preserve health.
Q: So speaking of turning the tide, it's also the theme of the declaration. I want to ask you about the declaration. Can you tell me a little bit about the history of these declarations? We've heard about them in the past. The Durban Declaration, Vienna Declaration. So is there always one of these? How do they come about, and what do they seek to do in a general sense?
I think the power and the impact of the declarations that have been associated with the International AIDS Conference first became apparent to all of us with the Durban Declaration.
Believe it or not, in 2000 there was still, with all the evidence available, people who were still questioning whether HIV causes AIDS. The scientists felt it was extraordinarily important that we band together, and we, in a very succinct way, make a statement to say that HIV causes AIDS. It seems rather absurd, just saying it out loud. But it was extremely important, and had a lot of influence on the individuals — the president of the country, at that point, who was saying publically that HIV did not cause AIDS.
So declarations are used as a moment for an audience, when the world's attention is focused on the International AIDS Conference, to say something very, very important. And we think in 2012 we have something very, very important to say, and that is that we now for the first time ever — we've never really said this before — we think we can begin to end AIDS. That's what the declaration is about, and in the declaration we outline nine points. I'm not going to list them all here, but I can tell you in broad strokes what those are, of what we need to do to begin to end AIDS.
In essence, we need to ramp up testing, treatment and prevention that we know works. We need to do this, and we need to reach out to the most affected populations who are often the most difficult to reach.
We absolutely have to tackle the looming problem of HIV and tuberculosis, and we can eliminate mother- to-child transmission in a very short horizon in the next few years if we really put our mind to it. We need investments to do this, we need to use those investments wisely.
I think those are some of the main components of the declaration. We also point out in the declaration that we need every group at the table. All the groups are welcome to contribute. They may not all agree on exactly how to do it, but we need their contributions. And we are hoping to get massive global support for the declaration. We're hoping to get massive sign on during the International AIDS Conference.
We're also looking to all sectors of society. At the meeting, we're fortunate to have many high-level government officials from UNAIDS, from the WHO, and Bill Gates will be there. From the entertainment world, we have Elton John, and Whoopi Goldberg. When these individuals speak up about our ability to begin to end the AIDS epidemic, it can have a profound effect. And it can be a profound inspirational moment for everyone, both to people working on it, and to bring new people into the fight.
Q: Why translate the declaration into multiple languages?
We need everybody around the globe to be signing on. It's great that it is in English, of course, which many people speak. The purpose to putting it in many languages is to be inclusive. The AIDS response is all about being inclusive, and to include the communities and provide them the opportunity, to declare their commitment to help in whatever way they can to begin to end AIDS.
Q: I understand your own group is presenting quite a lot of research. Can you tell me what that's about?
Sure, I would love to. When we talk about beginning to end the AIDS epidemic, one of the predominant strategies that has gained a lot of traction, that we are looking at, is something called test and treat. What that means is that we find people who are HIV infected, and we offer them treatment.
It seems rather basic and simple, and it is. But the benefit serves a dual purpose. First and foremost, by putting people on treatment, we preserve their health. Now we know there's a huge secondary benefit of putting people on treatment and that is reducing forward transmission of HIV.
An average person untreated with HIV has about 10,000 viral particles in about a teaspoon of blood. We can reduce that to a level that's undetectable, and a person with undetectable virus has less of a chance of transmitting that virus forward. So we find people and test and treat. In San Francisco, two years ago here in our clinic, we were the first clinic in the world to offer treatment to everyone which then became adopted as our public health policy -- to offer treatment to everyone regardless of the CD4 cell count.
What we had done in the past is would wait for peoples' T cells to fall down until they had gotten to a certain level of their illness, in order to avoid toxicities of the drugs, and then we would start HIV therapy. Well, now we know the virus is doing harm and destruction even earlier. And the harm of the virus, the toxicity of the virus, outweighs the toxicity of the medicines.
We've seen progress, and we'll be presenting a little of this at the conference Earlier in the decade, maybe one in ten people in our clinic with high CD4 counts were in treatment; now in our clinic, one in two people are on treatment. So our group also has been working over the last two years of the concept of test and treat in rural Africa with our African colleagues in Uganda and in Kenya.
What are the challenges in that? The challenges are that in the United States, about 20 percent of people don't know their HIV status who are already infected. In Africa, that's way higher. That's probably about 70 percent of the people are unaware of their status.
What we are going to present at the conference is a series of projects that we have done to show proof of principal. That test and treat is worth going forward because it could be feasible, and it could provide gains well and beyond the health benefits. Our first presentation is going to be a community health campaign.
We went to a very, rural area in Uganda, and we offered not only HIV testing, but also testing for other infectious diseases such as malaria and screening for tuberculosis, as well as non-communicable diseases such as diabetes and hypertension. We'll show how successful this was, and how much the community embraced this particular approach, and how many individuals we found that never knew that they were living with HIV, diabetes or hypertension and how we link them to care.
In a test and treat approach, one of the other key questions to ask of people who feel healthy, is ‘are they interested in taking HIV medications’? So we'll also be presenting data at the conference which show that when we asked people that question in this rural area in Uganda, 98 percent of the people said, yes, they would be interested in taking medications. We'll share in those data why people were interested in taking medication.
A third presentation, with some data that we just finished in May of this year, is a follow up of our community health campaign. The first community health campaign was to measure the number of virus in this community of people living with HIV, and look at how many people had suppressed their virus, which is considered the success of therapy. We are going to report what occurred in that community one year later, after we did the first look in terms of the viral load of the community.
During this one-year period, there was a lot of acceleration of people taking therapy for a whole variety of reasons that we are going to describe at the conference. What we're going to show is what you can do to a community level viral load. It’s really very exciting and extraordinary, when we ramp up therapy.
And finally one of the things that's really important when one thinks about a test and treat strategy, is that ministers of health in countries are going to be excited if we show there's benefit to the health of the country. The minister of finance is probably the one who's going to make the decision if that money is going to be invested. The minister of finance needs to see data beyond health, in other sectors and other venues of what this investment is going to bring. We have economists who work in our group, and we are studying, at a very detailed level, the economics and education of this very rural community. That's essential to a community in working towards this test and treat approach.
We'll present data that are looking at the benefits families and children get from staying at work, and having kids stay in school, when one maintains health by finding people early and not allowing them to progress to illness, so they end up in the hospital, and then we have to rescue folks with therapy. I think that will be a very, very important and interesting dimension to this test and treat story.
Q: And that's a lesson that you've demonstrated here in San Francisco, correct?
Absolutely. We know by finding people early and keeping them healthy, we stop the cascade of getting sick, dropping out of work and ending up in the hospital. The worst case scenario is ending up in the intensive care unit, which sadly still happens in this day and age, in a city such as San Francisco/
Q: Now what about the rest of the country? Have other cities followed suit in terms of early treatment, test and treat strategies?
Yes. We announced in 2010. New York announced earlier last year that they were going to adopt offering universal treatment. Washington D.C. recently announced that it’s also the official policy of that city, which as many people know is highly affected by HIV with an overall 2.7 percent prevalence on the population level. And we have heard that Georgia also is likely to move as a state to make that a policy.
Q: I know that in some areas of medicine, there are well-documented lags between the technology and the adoption of that technology. Are things different in this field? Are people generally aware of recommendations and is there a faster uptake when things come down the pike?
Well, the answer to that question is yes and no. I think when there are just transformative breakthroughs such as HAART, when we change HIV from a fatal to a chronic disease, there is rapid, rapid uptake. But the reason why I'm going to say no to your question is because in the recent report that came out of the CDC from the United States, only 28 percent of people living with HIV have viral suppression.
If there was a rapid uptake of finding people with HIV and putting them on therapy, that number would be much, much higher. So the point you make is really an excellent one, and there's a whole new field that has emerged over the last couple of years called implementation science, which strives to characterize the obstacles and the solutions that permit scientific advances to be put into action.
That, in fact, is something that all fields of medicine, HIV included, need to improve upon.
Q: And that’s also going to be part of the conference?
Absolutely. When we talk about combination prevention, the how, the implementation science of combination prevention and treatment, will be the focus of many discussions at the conference.
Q: Looking ahead, what happens after the conference?
We're going to ask and challenge every single person who comes to the conference to leave with at least one new thing they've learned and one new direction. It's amazing what happens at the conference. The exchange of information that occurs across countries, across disciplines, helps people recharge and go back to do their work better.
People are inspired at the meeting. It reenergizes people. It affects the support of people working in AIDS from other people around the world who are not working in AIDS. I'll just give you one of the most important ones in terms of what happens afterwards. After the Durban conference, essentially we had the green light. Before Durban, people were saying, "We can't treat people in Africa — it's $30,000 per person." After that, PEPFAR was born, the Global Fund was born, and there was a global commitment after Durban. That was the ‘break the silence’ conference, which I think really is a result of that moment to go forward.
In terms of what's going to happen after this meeting — what we would like to see is a cascade of events that happen in place to seriously address the question of how to begin to end the AIDS epidemic.
Photo by Marco Sanchez/UCSF DMM Photography