XVIII International AIDS Conference July 18 – 23 Vienna, Austria (also called the “Caprisa conference”)

1. XVIII International AIDS Conference July 18 – 23 Vienna, Austria (also called the “Caprisa conference”) Overview and personal observations

3. Introduction • The International AIDS Conference: • gathering for those working in the field of HIV • policy makers • PLWHA • Assess where we are, evaluate recent scientific developments and lessons learnt, and collectively chart a course forward • Major push for expanded access to HIV prevention, treatment, care and support • Global economic crisis threatening funding • Helps to keep HIV on the front burner • AIDS 2010 highlighted human rights and HIV • Vienna historical role in bridging Eastern and Western Europe divide - examination of the epidemic’s impact in Eastern Europe.

4. Introduction • 10 650 abstracts received; 6128 accepted - abstract-driven presentations • 20 000 delegates from 185 countries • Symposia • Bridging sessions • Plenaries • Other: Global Village, satellite meetings, exhibitions and affiliated events • Professional development and networking.

5. Plenaries • Opening Plenary: Sunday 18 July • Yves Souteyrand, Coordinator of Strategic Information Unit of the WHO; Dr Thomas Rehle from HSRC in CT co-author • State of the epidemic: HIV Epidemiology – Progress, Challenges and Human Rights Implications • Violations of human rights are a barrier to knowing your epidemic • HIV epidemic has stabilized globally • Annual numbers of deaths declining from 2.2 m (2004) to 2 m (2008) • Due to impressive scale up of HIV treatment – 5 m • Around 2.7 million new infections each year. • Paula Akugizibwe (SA) of AIDS and Rights Alliance of Southern Africa • greatest barriers to achieving universal access are social, economic and political challenges

6. Plenaries • Others: Bill Clinton, Bill Gates, Kgalema Motlanthe • Tuesday, 20 July • Dr Anthony Fauci, (USA), National Institute of Allergy and Infectious Diseases at the National Institutes of Health on New Concepts in HIV/AIDS Pathogenesis: Implications for Interventions • Dr Aaron Motsoaledi, (SA Minister of Health), outlining commitments and initiatives by SA gov, HCT campaign, etc – very well received! • Friday, 23 July – Closing plenary • Rapporteur sessions • Call for relook at human rights • Vienna indicated support for Global Fund • Messages from Barack Obama, Hilary Clinton and Desmond Tutu

8. Abstracts Track A: Basic Sciences Track B: Clinical Sciences Track C: Epidemiology and Prevention sciences Track D: Social and behavioural sciences Track E: Economics, Operations Research, Care and Health Systems Track F: Policy. Law, Human Rights and Political Science Youth

9. Track A: Basic Sciences • Track A - only rapporteur session and some pleneries: • HIV life cycle – road map for anti-HIV drug • Very potent ART drugs – target key enzymes in HIV life cycle • Copernican revolution – finding of CCR5 and other entry inhibitors that target the host rather than the virus – some important findings • New findings in the field of LNTP and elite controllers – important for vaccine development • HIV persistence and how to address latent infected cells

10. Track B: Clinical Sciences • Track B – • New drugs and new treatment strategies • Simplification of treatment possible • When to start treatment – many debates • Greater tolerability and efficacy • Earlier treatment debate: • Earlier treatment for patients with TB (CAMELIA study), patients with 350 CD4 and children • Resource limited settings: immediate IPT needed for TB patients • Need to look at cost-effectiveness for when to start treatment • West vs Africa • Clinical benefits vs available resources

11. Track C: Epidemiology and Prevention sciences • Highlight of conference: presentation of the CAPRISA 004 trial results • Vaginal microbicide that contain antiretroviral Tenofovir • Conducted in KZN, SA amongst HIV negative women • First trial of microbicide that has a statistically significant protective effect against HIV infection – 39% (BUT lower band 6%) • 51% protective against HSV-2 – herpes virus – encouraging! • Intravenous drug users – high prevalence rates throughout EC and Russia – strong evidence of cost-effectiveness of needle based programmes but policies and laws block these • Male circumcision studies in Kenya • Rapid scale-up feasible and safe • But no sign of reduction in HIV incidence yet • ART as prevention – proven biologically and mathematically but is it sustainable?

12. Track C: Epidemiology and Prevention sciences • Still high rate of HIV infection at birth in Africa • Combination prevention, UNAIDS defines combination prevention = the simultaneous use of different classes of prevention activities, biomedical, behavioural, structural, to respond to specific needs of particular populations, and to make efficient use of resources • Avahan study – India funded by Bill and Melinda Gates Foundation – long exposure to intervention programmes and increased condom usage – HIV prevalence reducing from 20% to 16.4%

14. Methods – Caprisa study • Proof of concepts, double-blinded, randomized, placebo controlled trial • Enrolled high risk HIV uninfected women reporting 2 coital acts in past 30 days – known high risk population from pre-trial feasibility studies • Endpoint driven trial (92 HIV endpoints) • HIV infection is primary safety & effectiveness endpoint • Intent-to-treat analysis except for adherence analysis • Effectiveness of Tenofovir gel in preventing HIV infection demonstrated – 39% lower HIV new infection rate in Tenofovir group Source: Caprisa trial presentation

16. Conclusions – Caprisa study • Women and young women in particular bear the brunt of the HIV epidemic in Africa • Tenofovir gel potentially adds a new approach to HIV prevention and the first that can be used and controlled by women. It could help empower women to take control of their own risk of HIV infection. • The Caprisa 004 study is the first step – additional studies are urgently needed to confirm and extend the findings of the Caprisa 004 trial. • Once confirmed and implemented, Tenofovir gel has the potential to alter the HIV epidemic. It is estimated that this gel could prevent 1.3 millions new HIV infections and over 800 000 deaths in SA alone. Source: Caprisa trial presentation

17. Global Village and condomize

18. Track D: Social and behavioural sciences • Combination prevention strategies – highest potential impact • Mental health – depression, food insecurity and other interventions • Important study by Lucy Cloover follows 1000 children over 4 years – mental health deteriorates much more for AIDS orphans • Studies on the family based approach – treating children and their families • Integrated approaches called for everywhere • Study showed no disclosure to children of their status; also low take-up on treatment • Studies showed less than 50% of women receiving treatment • Key words: Evidence based interventions, bottom-up approach, structural, family based

19. Track E: Economics, Operations Research, Care and Health Systems • Role of health systems to provide quality care to all in need • Less than 50% coverage by ART in low and middle income countries of those in need • Lack of adherence – falling off ART – need systems designed that will ensure adherence rather than spend enormous resources on getting people back on treatment • Financing of the health systems • Both commitments and disbursements have flattened • Cannot predict future spent • Lobbying for more global funds • BUT need more cost-effective interventions and programmes • Operations research on systems and finance • New WHO guidelines will increase costs • But cost of death is much higher – therefore avert this cost = savings • Potential cost-savings of different strategies analysed

20. Track E: Economics, Operations Research, Care and Health Systems

21. Track E: Economics, Operations Research, Care and Health Systems • Massive reduction in cost of drugs in Brazil: • Negotiations with manufacturers • Licensing • Local production • Collaboaration with Thailand and India • Cost-effectiveness of facility based vs outreach interventions – Rwanda – significant improvement if outreach • Community based health insurance vs performance based financing • Kenya – 51 000 people over 7 days – 80% of targeted population • Cost-effectiveness of averted deaths • Integrated with other diseases

22. Track E: Economics, Operations Research, Care and Health Systems • Big problem: good at developing ideas - proof – concept – randomized controlled trials – published • BUT – cannot implement and scale up • “We’ve also seen a lot of models about prevention and treatment but the models and evidence based interventions held hostage by effectiveness of systems in which they are implemented.” • Attrition a big problem – cannot monitor effectiveness due to high fall off • Quality improvement gaining strength • Utilize existing resources - lots of NGO’s, knowledge and resources but uncoordinated • example: Kedar Mate study in SA • Increase in mothers on HAART from 22% - 55% over 9 months due to coordination of central strategy • Integration of care: • Integrating ante-natal care with PMTCT • Integrating TB care with general care • Prevention and treatment strategies need to be cost-effective and should be designed for real life health systems • NGO and funder collaboration to capacitate national health systems

24. Track F: Policy. Law, Human Rights and Political Science • Need to address human rights abuses stigma and discrimination and channel funding to address these • Criminalization blocks implementation of policy on street • Legal aid, legal empowerment, legal literacy needed • Corruption and ART procurement in Ukraine • Provider initiated testing and counselling – abuse of human rights? • Vienna declaration and “Right here, right now” • Track G introduced: Leadership and accountability • Youth track as well • Wide-spread support for findings and direction from conference – Obama, Clinton and others