Join us in warmly congratulating our Director, Prof Robin Wood, on his recently being awarded the Weber-Parkes Medal from the Royal College of Physicians, United Kingdom.
This is in recognition for his substantial contribution to the fight against tuberculosis.
The Weber-Parkes Trust Medal was founded in 1895 by a gift from Dr Hermann Weber in memory of Dr Alexander Parkes.
This endowment is a £3,000 gift awarded once every three years for major contributions to the prevention and cure of TB.
On World AIDS Day (December 1st), a high-level delegation from the European Union and European & Developing Countries Clinical Trials Partnership (EDCTP), launched Phase 2 of the EDCTP, funding from which supports some of the research at CIDRI and the DTHC.
As part of the launch, Commissioner Carlos Moedas, EU Commissioner for Research, Science and Innovation, and his delegation were hosted by Professor Robert Wilkinson [Wellcome Trust Senior Fellow in Clinical Tropical Medicine, Director of the Clinical Infectious Diseases Research Initiative (CIDRI) and Professor in Infectious Diseases at Imperial College London],as well asAssociate ProfessorGraeme Meintjes and members of the CIDRI team, at CIDRI’s clinical research site in Khayelitsha. This event was used as an opportunity to showcase the important work that CIDRI is doing to tackle HIV-associated TB.
The same delegation then visited the Desmond tutu HIV Foundation (DTHF) Youth Centre in Masiphumelele south of Cape Town, accompanied this time by the Minister of Science & Technology Dr Naledi Pandor. They were hosted by Professor Linda-Gail Bekker, Deputy Director of the DTHF and Desmond Tutu HIV Centre (research arm), and member of the IDM. DTHC’s previous EDCTP grant (2009-2012) had initiated a program in adolescent health and HIV prevention. The Youth Centre caters for youth aged 12 – 22 and offers a range of holistic development programmes, including a clinic that provides sexual and reproductive health services.
AGS Movers are platinum sponsors of the annual FIDI international conference to be held in Cape Town 29th March – 1st April. They are using this platform to promote the DTHF Tutu Tester ‘Health on Wheels’ project through a gateway www.agsmovers.com/connect
In addition to providing an exceptional online landing page, AGS are providing more than 600 conference bags containing branded golf shirts each with a DVD of the film, Children of the Light, a documentary on the life of our patron, Archbishop Emeritus Desmond Tutu.
AGS are committed to a healthier South Africa – their target is to exceed R50 000. Open www.agsmovers.com/connect and make your commitment to bring DTHF health services to our people.
Warm thanks to AGS, and to you. We appreciate your support.
Brian Kanyemba from the DTHF Men’s Division attended the Co-infections, Retroviruses and Opportunistic Infections conference in Seattle February 2015. His interest in the outcomes of the conference was to understand how new bio-medical HIV treatment and prevention interventions might be transferred from the science of clinical trials to the end user in the broader community.
During the conference he hosted two panel discussions. FACTS 001 study: What does this Trial mean to South African women? featuring FACTS core protocol chair Professor Helen Rees, founder and Executive Director of the Reproductive Health and HIV Institute of the University of the Witwatersrand in Johannesburg. See https://www.youtube.com/watch?v=xmy7a5VSZN4&feature=youtu.be
The second discussion dealt with HIV Prevention in Africa the next step, Perspectives of HIV prevention and treatment advocates featuring Associate Professor Morenike Ukpong from Obefemi Awolowo University, Nigeria. See https://www.youtube.com/watch?v=brBp6HAPKtg
The Alan Pifer Award was granted to them for excellence in research, treatment, training and prevention of HIV–related diseases and infections in Southern Africa. Their journey has taken them from the dark days of AIDS denial to an important moment in the history of the epidemic.
“What got me into this work,” says Professor Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre, “is a combination of curiosity and passion. The curiosity kicks up the questions that inform the research. The passion is never driven by pity – I am constantly overawed by the resilience of this community.” This combination has also led not only to cutting-edge research, but to some extraordinary stories from the community in which the Centre operates.
“The remarkable work of Linda-Gail Bekker and Robin Wood to fight the HIV epidemic has shown visionary and responsive leadership,” says vice-chancellor Dr Max Price. “Their work in the communities of Cape Town has made a difference in the lives of countless South Africans and their commitment to social justice and responsive research is commendable.”
The DTHF Family Planning Integration into HIV Care and Treatment Services Project (FPI Project) has launched the Contraceptive Choices Flipchart. This innovative tool was developed by the FPI Project team and is an outcome of the FP Refresher workshops that the team has been engaged in in partnership with the Western Cape Province Department of Health.
The FPI Project has been instrumental in ensuring that family planning, which has not featured prominently in the health programmes implemented by the Department – is now firmly “back on the map”. One-day FP Refresher workshops were organised throughout the Province for clinicians (doctors and nurses) as well as NGO counsellors who work in primary care facilities. Most importantly, ‘family planning Champions’ were elected at each clinic to continue to promote and extend family planning at their facilities. The team have not only initiated the integration of family planning into HIV Care and Treatment services, but they also developed tools and easily understood information materials, such as the flipchart. Every primary health care facility in the Western Cape is now equipped with these materials to assist clinicians when offering family planning options to their clients. Family planning and HIV treatment services have become a “one-stop shop” service from the clinician’s consulting room.
Ably led by Anna van Esch, the project has been very well received by all. The FPI Project has played a vital role in changing lives, especially of those women living with HIV.
Ntando Yola, Education and Community Engagement Manager at the Clinical Trials Unit (CTU) has been elected to serve as the new co-chair for the HIV Prevention Trials Network. (HPTN). The HPTN is a worldwide collaborative clinical trials network that develops and tests the safety and efficacy of interventions designed to prevent the transmission of HIV.There was stiff competition for this position. We are delighted that Ntando has received recognition for his outstanding leadership and excellent skills in communication and training. We congratulate him most warmly.
Prof Linda-Gail Bekker, has been featured in the May 2015 issue of VAX, the Bulletin on AIDS Vaccine Research, as one of five prominent women scientists from across the world, who are making a difference in the fight against AIDS.
Prof Bekker is the President-Elect of the International AIDS Society, and is the first woman from Africa to hold this position, which she will take up at the 21st International AIDS Conference in Durban in 2016.
Tom Lindsay, President of Alere Africa, has signed an agreement to sponsor the Tutu Teen Truck mobile unit (formerly the Tutu Treater). He is seen here with DTHF Youth Centre interns, Ntokoza Stofile, Phutuma Thole and Keziah Quimpe, with Professor Linda-Gail Bekker.
Currently Cape Town is experiencing not only an HIV but also a STI epidemic, especially in adolescents. We have found that adolescents are more likely to access mobile healthcare services than traditional facilities. The unit will provide a youth and adolescent friendly health service in Cape Town’s high HIV incidence communities.
Like the Tutu Tester, the unit is self-contained comprising two counselling rooms and a dispensing cubicle. A team led by a nurse practitioner is currently being recruited. We look forward to seeing the Tutu Teen Truck on the road in August and to deepening our partnership with Alere. Our grateful thanks to Tom Lindsay and the Alere team for their support.
Starting antiretroviral treatment early has substantial health benefits for those living with HIV.
The Desmond Tutu HIV Foundation (DTHF) Clinical Trials Unit has been a major participant in an important international clinical trial. The results were released on 27th May and will have a considerable impact on the management of HIV treatment in the future. The study found that individuals who begin antiretroviral treatment at a CD4 count over 500/mm3 experience substantial health benefits over those who start treatment at a CD4 count less than 350/mm3.
The Strategic Timing of AntiRetroviral Treatment (START) study tested whether there was benefit to HIV+ patients in initiating antiretroviral treatment early. More than 4, 600 men and women living with HIV were enrolled at 215 sites in 35 countries. The study was conducted by the International Network for Strategic Initiatives in Global HIV Trials (INSIGHT).
The DTHF Clinical Trials Unit enrolled 287 participants in the study, the largest number at any site. The site also served as the Site Coordinating Centre for two other South African sites, Clinical HIV Research Unit in Johannesburg and the Durban International Clinical Research Site. In total, South Africa enrolled 501 participants on the study.
Half of the study participants were randomised to start antiretroviral treatment immediately and the other half had their treatment treatment until their CD4+ cell count declined to less than 350 cells/mm3. The study found that all patients had low levels of serious illness but those that initiated treatment earlier had a clear further benefit compared to those starting late. The rates of adverse events were similar in both groups indicating antiretroviral therapy was safe. The trial started in 2009 and was scheduled to close in December 2016, but a review by the study’s Independent Data and Safety Monitoring Board recommended that results be released early as the evidence was overwhelmingly in favour of early initiation of antiretroviral therapy.
“This is a very encouraging result which will inform policy based on good quality data” said Prof. Robin Wood, Chief Executive Officer of the Desmond Tutu HIV Foundation and Principal Investigator for the site in Cape Town. “We now have strong evidence that early treatment is beneficial to the HIV-positive person.”
In the light of these findings, all our participants are being informed of these results. They will be offered treatment if they are not already on antiretroviral therapy and they will continue to be followed up on study until the end of 2016.
The Desmond Tutu HIV Foundation is a centre of excellence for HIV and TB research. The Foundation is a not for profit organisation that has operated in association with the Faculty of Health Sciences, University of Cape Town since 2004. We work in partnership with government health agencies and local and international partners to upscale and improve the management and treatment of HIV and TB and related infections.
Working from six sites and two mobile vehicles in under-resourced areas of Cape Town, community development and community support are integral to our research endeavours.
For more information see the NIH press release at:
As the 21st International AIDS Conference wraps up in Durban, South Africa, Professor Linda-Gail Bekker, incoming International AIDS Society President, talks to The Conversation Africa health and medicine editor Candice Bailey about what was achieved and what still needs to be done.
What are the three interventions or innovations that stand out at the conference in terms of taking the fight against HIV forward?
There has been exciting work about how we do treatment better to make sure we get to the 34 million who are infected. And that’s absolutely critical. We have to reach those 34 million people but we know that health systems, particularly in the sub-Saharan region, are struggling. So there was some wonderful work on differentiated models of care, how we can do business more effectively and efficiently and ways we can do the steps in the cascade more efficiently.
And I’ve loved some of the testing innovations. Addressing all the steps from testing is critical.
Secondly I’m passionate about primary prevention but I think we’ve got some gaps on how we can do it. I’m a great proponent of daily pre-exposure prophylaxis and I really think we should roll it out because it works. But I’m very excited about the prospect of what’s coming down the road in terms of less frequent dosing for pre-exposure prophylaxis.
Number three is a fresh approach to adolescents. This conference has reinvigorated the notion that we have to get adolescents to the table. We have done well, I think, in getting adolescents to be really well represented. And it works. You feel their voice.
If you could shuffle all of the homes in the world like a deck of cards so that people in wealthy countries lived side by side with people from poor countries, it would transform the world’s fight against poverty, hunger, and disease. It would be impossible for people to look away, impossible for them not to help.
I was naïve about the deep poverty in the world until I took my first trip to Africa with Melinda in 1993. Seeing the disparities with our own eyes made all the difference and inspired us to start our foundation.
Since then, I’ve continued to travel regularly to Africa, India, and other parts of the developing world. I always return from my trips humbled and inspired. My one disappointment is that I wish everyone could have seen what I did. I have no doubt it would help more people become aware of the challenges the world’s poorest people face. It would also leave them as optimistic as I am about the incredible progress the world is making in health and development.
During my trip to South Africa in July, I tried something new that I hope will allow people to experience what I have. I had highlights of my visit recorded in virtual reality. It’s still an emerging technology but what excites me about it is that it allows viewers to immerse themselves in another world. You can look up and down. Turn right or left. Listen to sounds all around you. I used to think there was no substitute to being there and seeing things for yourself. But virtual reality is a close second. It fulfills my dream of allowing people to see what I’m seeing and, perhaps, feel what I’m feeling, too.
In this video, you will hear the stories of young women living with HIV. Sit beside me as I drive from the leafy suburbs of Johannesburg to the dusty township of Soweto. Feel what it’s like to be in the center of a stomping gumboot dancing troupe. And be inspired by the power of South Africa’s youth, who will drive the next generation of innovations to create a future free of AIDS.
Pulling on a pair of virtual reality goggles can, I admit, feel like you’re blocking out the world. But I hope you’ll find that they’re an amazing tool to draw you closer to other people. Instead of separating yourself from the world, I think you’ll discover you’ve deepened your connection to it.
If you want to know more about my trip to South Africa, you can read about my visit here and here.
I also encourage you to learn more about The Global Fund, which has helped provide lifesaving treatment to millions of people living with HIV.
Cape Town alone has more TB each year than the US, Canada, UK and Germany put together. Professor Robin Wood, a leading University of Cape Town scientist, is in search of the clues as to why this is so, writes Business Day.
As a schoolboy in Birmingham, Wood once had the task of opening and closing the high windows in his classroom using a long pole. Good ventilation was considered key to sound health and a sharp mind. Business Day reports that Wood is now a leading scientist at the University of Cape Town, puzzling over why the city has such a raging tuberculosis (TB) epidemic. He spends much of his time hunting for clues on how the disease is spread, and how it has been in the past and his schooldays’ experience is still relevant.
The report says unlike European cities that exported TB to South Africa along with their colonial-era immigrants in the 19th century, Cape Town has never managed to get the disease under control. There were almost 30,000 newly notified cases of TB in 2009 among the city’s 3.4m inhabitants. The incidence of TB in Cape Town was 479 per 100,000 of the population in 2014, according to the Western Cape Health Department.
By contrast, the incidence in New York was just 7.7 cases per 100,000 in 2015. “Cape Town alone has more TB each year than the US, Canada, UK and Germany put together. The question is why,” says Wood.
The report says that Wood and his colleagues have turned to records collected by health authorities over more than a century in three cities hard hit by TB in the early 1900’s – New York, London and Cape Town. They plotted TB notification rates between 1910 and 2012 and noticed something startling. Even before the advent of the first antibiotic treatment in the late 1940’s, the rate was plummeting in New York and London and continued to fall steadily over the course of the century.
Yet, the report says, in Cape Town it remained stubbornly high and today remains at levels last seen in industrialising Europe in the 19th century. The TB notification rate hovered at about 450 cases per 100,000 between 1910 and 1945, fell briefly after the introduction of antibiotic therapy to a low of 250 cases per 100,000 in 1970, but rose again to 450 per 100,000 in 1995 and soared with the HIV/Aids epidemic to 850 per 100,000 in 2010.
Many healthy people get infected with TB but never develop the disease, but the HIV weakens the immune system and makes people more susceptible to it. Yet even among HIV-negative people, the TB notification rate in Cape Town between 2009 and 2012 was breathtakingly high: 445 per 100,000 population. (It was 6,338 per 100,000 among those who were HIV-positive). A similar pattern was observed for TB mortality rates.
The report says the period between 1950 and 1960 in Cape Town offers a clue as to why the disease remains rife, says Wood, as this was the only time when a significant fall in TB mortality was recorded. During this era the city embarked on a process known as “active case finding” in which it screened masses of people for TB rather than waiting for sick people to care. TB mortality declined by 60%. “It’s a bit of circumstantial evidence suggesting that maybe we need to think again,” says Wood.
The scale of Cape Town’s TB problem means there are large numbers of infected people spreading the disease for months before they are diagnosed and start treatment. Breaking the back of the epidemic will require breaking this transmission cycle, says Wood. “In places like the Cape Flats and the townships, people get infected multiple times,” he says. People living in these communities inhabit a veritable soup of TB, because they are exposed to hundreds of different strains of the disease, the report says.
South Africa’s TB control policies are aligned with the World Health Organisation’s and focus on diagnosing and treating patients who seek medical attention, rather than actively looking for cases. Wood says this policy is based on evidence from the West’s experience with TB and suggests the programme needs to be adapted to different circumstances. “If you are in a Pollsmoor Prison cell for 23 hours a day, with no ventilation and overcrowding at 300%, the TB control programme cannot be the same as outside or you won’t touch the epidemic. We can’t treat our way out of it,” Wood says.
Wood has also been studying the risk of TB transmission among high school children from Masiphumelele township, by kitting them out with carbon dioxide monitors and tracking their movements. Carbon dioxide is a proxy measure for shared air, and enabled the researchers to estimate where the students were at highest risk of catching TB. They found the pupils spent 60% of their time in rooms where the carbon dioxide level was above a safe threshold, the worst of which were poorly ventilated classrooms.
The report says this kind of work has made him a keen advocate for well ventilated classrooms, as better air flow would reduce pupils’ risk of catching TB. Like prisoners, they are compelled to spend much of their time in a confined and crowded space. The least the education system can do is make sure their schools don’t make them sick, he says.
It is with great sadness that we share the news with you that our friend and colleague, Professor Stephen Lawn, of the London School of Hygiene & Tropical Medicine and the University of Cape Town, has died at age 50.
Steve Lawn was very well known in South Africa and internationally for his pioneering work on the diagnosis and treatment of tuberculosis among populations affected by HIV/AIDS.
A London School of Hygiene & Tropical Medicine statement reads: “In 2014 he was diagnosed with a highly malignant brain tumour and, despite neurosurgery, radiotherapy and repeated chemotherapy, he has continued to work and teach throughout the past two years with his characteristic brilliance, warmth and humour.
“Steve Lawn has made major contributions to the diagnosis and treatment of tuberculosis among populations affected by HIV/Aids, and to reducing the burden of HIV-associated TB. His pioneering work has resulted in over 250 publications including many influential papers particularly on rapid diagnostic screening for TB, and making important contributions to World Health Organisation guidelines.
“Steve was professor of infectious diseases and tropical medicine at the London School of Hygiene & Tropical Medicine and closely linked to the Desmond Tutu HIV Centre at the University of Cape Town, where he was based from 2005 to 2012. His work was honoured by the Desmond Tutu Foundation and the government of South Africa, and awarded the Royal Society for Tropical Medicine and Hygiene’s Chalmers Medal.
“Returning to London in 2012, he continued to contribute greatly to the work and life of the school, leading the very popular HIV/Aids module, supervising PhD students, and continuing ground-breaking research on HIV-associated TB in southern Africa. He was a strong supporter and very active member of the School’s growing TB Centre.
“Above all, Steve was passionately committed to saving lives and reducing the burden of disease in some of the world’s poorest communities. He was inspired by faith and love, and was in turn greatly loved by colleagues and students alike. Our deepest sympathies and thoughts are with Steve’s family and many friends; his wife Joy Lawn is also a professor at the School, and they have two children – Tim (21) and Joanna (19).
“Steve and Joy together with colleagues in the TB Centre in London, those in Cape Town and around the world, decided to establish a Memorial Fund. This will support a lecture to be given annually, in London and Cape Town, by a leading TB researcher. In addition, there will be a monetary prize for an upcoming researcher conducting work focused on reducing the disease burden of TB and Aids in Africa.”
As well as a professor of infectious diseases and tropical medicine at the London School of Hygiene & Tropical Medicine, Lawn was an honorary associate professor of infectious diseases and HIV medicine at the University of Cape Town.
He completed his clinical training in infectious diseases in London and has previously worked as a lecturer for the Universities of Ghana in West Africa and was a research fellow for four years at the US Centres for Disease Control and Prevention, Atlanta, conducting laboratory-based research on the co-pathogenesis of HIV and tuberculosis (TB).
With funding from the Wellcome Trust, he was based at the University of Cape Town from 2005 to 2012 where he conducted clinical, epidemiological and laboratory studies on HIV-associated tuberculosis (TB) in the context of the rapid scale-up of antiretroviral treatment (ART). Recent research has focused on evaluation of new TB diagnostics for screening for HIV-associated TB and on the role of ART in the prevention of HIV-associated TB at individual and population levels.
Since 2012, he has been based in London, with ongoing research activities on HIV-associated TB in South Africa. He was the chief investigator for the STAMP Trial in Malawi and South Africa (ISRCTN71603869), which aims to reduce facility-based deaths from HIV-associated TB through use of a novel urine-based TB screening strategy.
Data is the first step to solving a problem. It sets the scene, uncovers the discrepancies, and reveals clear gaps for focus. Conversely, when something is not counted it is easily ignored. The UN proposes that this is an underlying issue facing the 1.1 billion girls living today: they are not being counted and the absence of data limits our ability to uplift and empower them. This is why the 2016 International Day of the Girl has been themed “Girls’ Progress = Girls’ Goals: A Global Data Movement”, which aims to push this missing information to the forefront and highlights the need for accelerated data collection to fill the gap in knowledge of challenges girls and young women face.
Data is not only informative, but also illustrative. Consider South African girls in 2016: Our girls are being counted as new HIV infections (2000 per week)1, instead of as high school graduates. Our girls are being counted as pregnant (18% of 10-19 year olds)2, instead of as young achievers. Our girls are being counted as sexually abused (1 in 3)3, instead of as leaders. The focus of these numbers sets the context of the situation we need to work within to bring about meaningful change to the girls that are our future.
The Desmond Tutu HIV Foundation (DTHF) works primarily to accelerate the research, treatment, training and prevention of HIV-
related disease and infections in Southern Africa; however, they retain a special focus on young women and adolescents. Six key
challenges have been identified for young women and girls, namely the high risk of HIV infection, teenage pregnancy, the high rate of school drop-outs, the absence of accessible adolescent-friendly health services, the presence of stigma and discrimination that prevents girls from accessing healthcare, and lastly the critical need to provide skills and support that aids girls in realizing their aspirations and dreams.
To combat this the DTHF runs multiple projects aimed at youth, particularly young women, in the Western Cape, which include the Masiphumelele Youth Centre, the Tutu Teen Truck, Tutu Tester, GirlPower, and other initiatives in partnership with Provincial and City Health. These programmes support an integrated and youth-friendly approach to the provision of health services. The DTHF also applauds the recent launch of the national young women and girls Campaign, which incorporates a special focus on bringing adolescent-friendly health and education services to young women and girls.
A key factor in keeping such programs successful and relevant is continuous monitoring and data collection that incorporates direct input from the young women and girls involved. Our girls need to be counted in order to see where we are and hold ourselves accountable for where we need to be.
References:
UNAIDS Gap Report, 2015
Christofides, N. J. et al. Early adolescent pregnancy increases risk of incident HIV infection in the Eastern Cape, South Africa: a longitudinal study. J. Int. AIDS Soc.17, (2014).
Artz, L., Burton, P., Ward, C.L., Leoschut, L., Phyfer, J., Lloyd, S., Kassanjee, R., Mottee, C.L. (2016). Optimas Study South Africa: Sexual victimisation of children in South Africa. UBS Optimus Foundation.
It’s 3 decades into the war with HIV/AIDS and so far 78 million have been infected and 39 million people have died, most in an untimely way (1). Yet an important battle has been won: antiretroviral therapy (ART) brought life-saving treatment to those infected, in both the developed and the developing world, and the number of AIDS-related deaths has fallen by 42% since their peak in 2004 (2). ART is even now beginning to win a second victory, this time as prevention rather than treatment; whereby endorsement of immediate initiation on ART following diagnosis allows for more rapid viral suppression, which significantly reduces the chance of transmission.
Figure 1: From a presentation at the HIV Glasgow Conference depicting global progress towards the UNAIDS 90-90-90 goals, as shown in the UNAIDS 2016 Prevention Gap Report (3).
However, in 2015 alone more than 5000 new infections are occurring every day, 40% of those living with HIV/AIDS do not know it and 62% of HIV-positive people are not virally suppressed (3). ART has been our hammer, but AIDS is not dead yet and it is time to access what else we have in the toolbox. We need a revolution, and it needs to be a primary prevention revolution!
Nowhere is this more evident than in resource-limited settings, where multiple and location-unique obstacles challenge the traditional approach of test and treat and create the need for primary prevention implementation. Unfortunately, but importantly, developing countries where the burden of HIV is high, face significant economic constraints that often force a choice to be made between HIV prevention and HIV treatment. To overcome this, any prevention scheme implemented needs to be bespoke: tailored to the country-specific key populations and layered with dual biomedical and structural interventions where the force of infection is high. In order to kick off this revolution, we need to identify the areas that ART is leaving exposed, and then we need to cover them with primary prevention.
Prevention Gap 1:
Figure 2: From a presentation at the HIV Glasgow Conference showing how different locations have different key populations (KP). This advocates for a location-population approach to treatment. Graphs taken from the UNAIDS 2016 Prevention Gap Report. (3)
“Few countries have consistently applied a comprehensive prevention approach that provides specific packages of services tailored to priority populations within specific local contexts”
The need to recognize and identify key populations is an old hat concept. Groups such as female sex workers (4% of new infections globally), people who inject drugs (PWID, 7%), men who have sex with men (MSM, 8%), transgender people (0.4%) have been prioritised worldwide for treatment and prevention (2). In areas such as Vancouver, Canada where HIV incidence among PWID is high, or San Francisco, U.S. where the MSM population carries the weight of the HIV burden, focusing all the resources towards such key population is high effective.
However, it needs to be acknowledged that key populations differ significantly between countries and do not always align with global classifications. This is particularly evident in Eastern and Southern Africa, where all the key populations combined contribute only 21% to new infections, while adolescent girls and young women alone contribute 20% (3). In such circumstances, a high focus on the key populations, while also necessary, would not lead to huge gains in eradication of the epidemic. Therefore, it is imperative that each country adopts a location-population specific approach that identifies their unique populations in crisis and responds accordingly. It is only by correct identification of the population that the correct prevention tools can be selected and applied.
Prevention Gap 2:
“43% of countries with injecting populations do not have needles and syringe exchange programs, and only 12 countries provide the requisite 200 clean needles per person injecting per year”
For PWID a significant reduction in HIV transmission can be achieved by reducing injecting risk, through primary prevention interventions such as needle and syringe exchange programs and access to opioid-substitution therapy. Vancouver, Canada saw a 76% decrease in HIV-transmission between 1996 and 2007 in the PWID population as a direct result of implementation of such programs. The introduction of universal ART (immediate initiation after treatment) in 2010 for treatment as prevention (TasP) further accelerated the transmission decline; illustrating the success TasP can achieve while working in tandem with primary prevention (4,5). If all countries with injecting populations at high risk of contracting HIV could, with sufficient resources and political will, implement both TasP and primary prevention as part of a tailored prevention package, HIV incidence in this population could be equally swiftly turned around.
Prevention Gap 3:
“Laws and policies that undermine public health need to be actively reviewed and repealed”
Legal structures, stigmatisation and discrimination are significant barriers to certain populations, limiting the prevention programs that can be provided and decreasing engagement with health services due to fear of discrimination or incarceration. MSM provides a good example of this, as globally there are still 76 countries where same-sex relationships are illegal and HIV prevention services to this group are restricted. In Malawi, where MSM face incarceration if discovered, a study found that only 9.6% of HIV-infected individuals were aware of their status and the majority of participants were first-time testers (7). In stark comparison, MSM in San Francisco, who constituted the epicentre of the AIDS epidemic in 1980s, are the largest population currently on PrEP (pre-exposure prophylaxis) and have already reached their first two 90-90-90 goals (6). This is a result of concentrated effort and political will, as well as a legal environment conducive to provision of primary prevention.
Prevention Gap 4:
“Community empowerment and other programs that have been proven to reduce stigma, discrimination and marginalization, particularly in health clinics, have not been brought to scale”
Social discrimination towards populations already vulnerable to HIV-infection increases their risk profile, especially when this stigma is carried into the clinic by health-work professionals. While social attitudes are only likely to be changed over long time periods, much can be achieved when there is community participation, empowerment, and strong community leadership. For example, in India, despite the continued illegality of brothels, 82.8% of sex workers were reached by HIV prevention programmes that offer STI treatment and free condom distribution, but which also implement structural interventions and community mobilisation to decrease stigma and remove barriers to accessing entitlement (8, 9). This combination of biomedical and structural primary prevention has successfully resulted in a steady decline in HIV-incidence in this population (9).
Figure 3: From a presentation at the HIV Glasgow Conference illustrating the “Vicious HIV Cycle” as it would appear in the world of the Simpsons. The most vulnerable group here are young girls, who become HIV-infected typically when they enter into relationships with older men or when they are exposed to high levels of gender-based violence. This figure was adapted from de Oliveira, 2016 (9).
Prevention Gap 5:
“2/3 Young people do not have correct and comprehensive information about HIV”
Sub-Saharan Africa has been particularly hard hit by the HIV epidemic, with 24.7 million people still living with HIV (UNAIDS Gap Report 2014). Key populations feature less here and a cycle of infection instead perpetrates through the general population. For instance, in South Africa young women (<25 years) sit at high risk and typically acquire HIV due to age-disparate relationships or as a result of sexual and gender-based violence (10). As these women grow up they enter relationships with HIV-uninfected men of their own age, and the virus spreads. Men, who show significant less engagement with healthcare such that they are less likely to be tested and less likely to adhere to ART, often enter relationships with younger girls and begin the infection cycle again (10).
Multiple steps need to be taken here, with particular focus on the implementation of separate adolescent-friendly and male-friendly healthcare services. An effective way of doing is through mobile clinics, which move away from crowded health facilities and into hard to reach areas, at times that are convenient both for youth and for men who work. This allows for increased access STI testing and condoms (and hopefully soon PrEP!), as well as provides a platform to promote HIV education and awareness.
Prevention Gap 6:
“PrEP coverage is < 5% of the 2020 target of 3 million people on PrEP”
Pre-exposure prophylaxis could be a prevention revolution in itself, providing protection in circumstances where condoms, ARV’s and behaviour leave large gaps. Most importantly it has the potential to allow the vulnerable to protect themselves, as for women in areas with high gender-based violence or adolescents undergoing their sexual debut, it can be difficult to negotiate the terms of safe sex. Access to PrEP during high risk periods would allow these populations to engage with primary prevention without requiring the knowledge or consent of their prospective partners. Another scenario to consider, is people in serodiscordent partnerships who require a safety bridge before viral suppression can be achieved through ART. The ADAPT HTVN 067 study with South African women showed that the majority of women would take oral PrEP daily with good adherence, if it were to be available. PrEP rollout is still in its infancy, however, if availability and access can be accelerated, it could be the primary prevention tool needed to make eradiation of this epidemic a reality.
Figure 4: A graph from a presentation at the HIV Glasgow Conference to illustrate the positive impact of cash and cash+care on HIV-risk behaviour among adolescents in South Africa. This was taken from Cluver et al., 2015 (14).
Prevention Gap 7:
“Structural drivers need to be included in the response”
In resource-restricted settings, HIV risk is often strongly associated with structural constraints, such as economic deprivation and dropping out of school. For instance, it has been shown that for every extra year of secondary school a girl obtains, her chances of contracting HIV drop by 50%. An effective way of overcoming such structural barriers is through conditional or unconditional transfers, such as paying for school uniforms and providing cash incentives for negative STI testing scores. This has been shown to reduce sexual debut, pregnancy, age-disparate sec and translational sex (12-14). Furthermore, greater reductions in HIV-risk behaviour was observed when cash transfers were combined with care initiatives, such as increasing parental, community and educational support (15). These are all examples of social prevention interventions and, particularly with adolescents, it is important that protection is seen as additive with HIV primary prevention.
Prevention Gap 8:
“Condom provision in SSA covers less than half the required numbers, and condom use is much too low across all population groups at high risk”
Condoms remain one of the most effective means of preventing horizontal HIV transmission, yet condom fatigue and low usage across all populations restricts the protection they have the potential to provide. In an attempt to make condom use sexier for the youth, Minister of Health of South Africa, Aaron Motsoaledi, this year announced that the state had “procured new coloured and scented condoms to increase condom use among young people. They provide the four maximums: Maximum pleasure, Maximum protection, Maximum quality, and Maximum number of young people making use of them.”
Prevention Gap 9:
“The number of medical male circumcisions needs to almost double in order to meet the 2020 targets”
Men living in countries where HIV-prevalence is high in the general population present a unique challenge, as they are tend to shy away from health services, harbour fears of stigma, job loss and lack of confidentially, and are less likely to be diagnosed, receive treatment, or live a long-life once infected (16,17). Therefore, ensuring primary prevention in this group is vital as once infected this population is incredibly difficult to reach and relies on specialised male-friendly services such as community based adherence clubs and incentivized mobile testing (17,18). Primary prevention is most effectively administered through voluntary medical male circumcision (MMC), which reduces HIV-acquisition by 55-65%. Modelling studies show that to achieve HIV/AIDS eradication in the next 50 years, MMC will need to be scaled up to the maximum as it provides prevention coverage on par with universal ART access (TasP) (19).
Ultimately, the AIDS epidemic is only going to conquered if primary prevention is bought up to scale. This battle can’t be won with ART alone. Viva la primary prevention revolution!
Linda-Gail Bekker
An adaption from a keynote lecture presented at the HIV Glasgow Conference 2016, entitled “The HIV Prevention Revolution in Low- to Middle-Income Countries”.
Fraser H, Mukandavire C, Martin NK, Hickman M, Cohen MS, Miller WC, Vickerman P. HIV treatment as prevention among people who inject drugs – a re-evaluation of the evidence. Int J EPidemiol. 2016; 1-13.
Hayashi K et al. Reductions in mortality rates among HIV-positive people who inject drugs in Vancouver, Canada during a treatment-as-prevention-based HAART scale up initiative: a gender-based analysis. 8th International AIDS Society Conference on HIV pathogenesis, Treatment, and Prevention (IAS 2015), Vancouver, abstract MOPEB156, 2015.
Raymond HF, Chen YM, McFarland W. Estimating incidence of HIV infection among men who have sex with men, San Francisco, 2004-2014. AIDS Behav. 2016; 20,1: 17-21.
Wirtz AL, Jumbe V, Trapence G, Kamba D, Umar E, Ketende S, et al. HIV among men who have sex with men in Malawi: elucidating HIV prevalence and correlates of infection to inform HIV prevention. J Int AIDS Soc. 2013; 16,3: 18742.
Avahan- The India AIDS Initiative: The Business of HIV Prevention at Scale. Bill & Belinda Gates Foundation. New Delhi, India. 2008.
de Oliveira T, Kharsany ABM. Who is infecting who? Community-wide phytogenetic transmission networkers reveal young women’s high HIV exposure from older men with low ART coverage. CAPRISA. 2016.
Mofenson LM. Tenofovir pre-exposure prophylaxis for pregnant and breastfeeding women at risk of HIV infection: the time is now. Plos Med. 2016; 13,9: e1002133.
Department of Social Development. Annual Report 2012-2013. Gauteng, South Africa. 2012; 19.
Handa S, Halpern CT, Pettifor A, Thirumurthy H. (2014). The government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15-25. Plos ONE. 2014; 9,1: e85473.
Cluver LS, Boyws M, Orkin M, Pantelic M, Molwena T, Sherr L. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. Lancet Glob Health. 2013; 1: e362-370.
Cluver LD, Hodea RJ, Sherr L, Orkin FM, Meinck F, Ken PLA, Winder-Rossi NE, Wolfe J, Vicari M. Social protection: potential for imporving HIv outocms among adolescents. J Int AIDS Soc. 2015; 18, Suppl 6: 20260.
Nglazi MD, van Schaik N, Kranzer K, Lawn SD, Wood R, Bekker LG. An ncentivized HIV counselling and testing program targeting hard-to-reach unemployed men in Cape Town, South Africa. J Acquie Immune Defic Syndr. 2012; 1, 59(3): e28-34.
Johnson LF, Rehle TM, Jooste S, Bekker LG. Rates of HIV testing and diagnosis in South Africa, 2002-2012: successes and challenges. AIDS. 2015; 29: 1401-1409.
Grimsrud A, Sharp K, Kalombo C, Bekker LG, Myer L. Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa. J Int AIDS Soc. 2015; 18, 1: 19984.
Smith JA, Anderson SJ, Harris KL, McGillen JB, Lee E, Garnett GP, Hallet TB. Maximising HIV Prevention by balancing the opportunities of today with the promises of tomorrow: a modelling study. Lancet HIV. 2016; 3)7): e289-e296.
“We’ve never treated our way out of an epidemic. There’s no doubt we have to have primary prevention alongside treatment in order to get HIV control, but we are not going to get HIV eradication without a vaccine. That is very clear.” Linda-Gail Bekker, Deputy Director of the Desmond Tutu HIV Foundation, explains the urgent need for an HIV vaccine in a recent interview with The Guardian. See full interview “HIV vaccine test hopes for breakthrough in combat against the virus” here: http://bit.ly/2fTn4NP .
The new vaccine trial, HVTN 702, will be launched on 30 November 2016 at the Desmond Tutu HIV Centre’s Emavundleni Research Centre in Nyanga. The trial will access the safety, tolerability, and efficacy (ability to prevent HIV infection) among South African adults. The vaccine is a modified version of the vaccine used in the RV144 Thailand clinical trial, which reduced the HIV infection rate by 31.2% – the first vaccine to ever show even partial efficacy against HIV!
Keep a look out for an update on this exciting development on 30 November when the first vaccination will be conducted live from Emavundleni. If this vaccine works it could provide the boost needed to reach the UNIADS 2030 goals of eradicating the HIV/AIDS epidemic by 2030!
Philippi Village: a new entrepreneurial development that will house the Zimele team.
This January, there was a buzz of excitement at Philippi Village as 120 new staff members arrived ready to make adifference in their community through The Zimele Project. To date, this will be the largest single project that the Desmond Tutu HIV Foundation has ever taken on, and we are now excited to share the details of this project with you.
In partnership with the Western Cape Government and funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria, the Desmond Tutu HIV Foundation is launching The Zimele Project, a unique multi-dimensional health and social intervention programme for our youth aged 10-24 years. The programme is designed for 20 000+ participants in and out of school and will run for 2 years in the Mitchell’s Plein/Klipfontein health sub-district.
The Zimele Project aims to provide comprehensive, integrated, adolescent-friendly healthcare services, together with strong educational support and social empowerment. By focusing on adolescents across the second decade of life, various programs will help adolescents come to terms with key life skills and equip young women with the skills to deal with puberty, impending adulthood and the use of education as a tool for success.
Different projects are set up for different age groups, and will include:
School-based interventions for 10-14 year olds modelled on the famous Soul Buddyz clubs
School and community-based programs for 15-19 year old girls that will build motivation to remain in school and provide important life skills, health services and educational support.
Uplifting monthly empowerment sessions for 19-24 year old women in the process of transitioning to adulthood. Aptly named Women of Worth, this program will aim to ignite these women’s dreams and provide guidance as to how to achieve them.
Teen parenting workshops, child protection services, career jamborees and community dialogues will be hosted throughout the program to provide opportunities, reinforce community alliance, and help those most vulnerable.
The provision of convenient and comprehensive adolescent-friendly mobile health services for all
At the induction, Professor Linda-Gail Bekker, who is the Project Director, said ”Zimele is a unique opportunity to see the impact of integrated, adolescent-tailored, structural, clinical and community-based interventions that aim to ensure healthy and vibrant adolescents in Cape Town”. Riaan Beukes, AcoE: Adolescent Program Manager said that this will be an exciting year, with an exciting team. ”I can’t wait to get started and work with this amazing community.”
Xolani Gambu who is employed as a Social Auxiliary Worker said that he heard about the Desmond TutuHIVFoundationfrom an NGO that he previous worked for. ‘I am excited about The Zimele Project but also working for the Foundation because of what Desmond Tutu stands for. People look up to him and respect him. I previously worked for a project called Dreams and since this project shares some similarities with The Zimele Project I was interested right away.
Emmanuel Gebashe is a Research Assistant who heard about The Zimele Project from a friend that works at UCT. He previously worked for the Department of Health and with the knowledge he gained he hopes to use this expertise while working on The Zimele Project. He said,”South Africa has one the highest HIV/AIDS infections rates and I want to work for an organisation that not only empowers young women and girls but also works to fight for a lower HIV/AIDS new infection rate.
Mziwamadoda Mampintsha is also employed as a Research Assistant, previously worked for Soul City so he has always known about the Foundation. He said, ”I am very, very excited about the The Zimele Project and this will be a whole new field of work for me, I am very much looking forward to working here”.
Zimele – through working together.
DTHF staff induction in January 2017 to welcome the Zimele team to the organisation.
DTHF received the UBUNTU Award for Social Responsibility at a gala event in Cape Town on 17th February. The evening honoured the legacy of Oliver Tambo and those South Africans who have followed in his footsteps. It was attended by President Jacob Zuma and many notable dignitaries. Tracy-Ann Finnan (Senior Finance) and Riaan Beukes (Project Leader for Zimele) graciously received the award on behalf of the Foundation.
The award recognizes “South African citizens or organizations that through excellence serve as global ambassadors of our nation. The awards celebrate South African citizens who through their Integrity, Passion, Patriotism and Humility have raised the South African flag high on an international stage.”
Riaan’s acceptance speech is notable, encapsulating the values and mission that drive the DTHF.
“Good evening Mr. President, Ladies and Gentleman.
The Desmond Tutu HIV Foundation, passionately seeks to reduce the impact of HIV, tuberculosis and related conditions on the lives of individuals, families and communities in South Africa, the region and in Africa.
Through our innovation and hard work and driven by our compassion for humanity, we strive to improve the health and wellbeing of all individuals particularly those who live in the most burdened and least resourced parts of our country.
Inspired by the example and teachings of our patron, Archbishop Emeritus Desmond Tutu, we seek to support and change, those least fortunate, hardest hit and most needy. Over many years this has included people living with HIV and TB, the LGBT community, adolescents and young women. Never daunted nor overcome, we have sought evidence-based interventions with African innovation and creativity to solve some of the most pressing health challenges facing our country today.
Some of our firsts have included: antiretroviral treatment to primary health care communities, mobile HIV and health screening, cutting edge drugs, vaccine candidates, and HIV prevention technologies.
We are greatly honoured to have been singled out with this award today and express our gratitude to our nominators and the South African community.
Desmond Tutu HIV Foundation (DTHF) strongly endorses the Prevention Access Campaign (PAC) core message: Undetectable HIV is Untransmittable HIV (U=U). Their message is condensed to the simple hashtag #UequalsU.
An HIV-positive person who maintains an undetectable viral load with the aid of regular, successful treatment cannot transmit HIV sexually (1).
Bruce Richman, a cofounder of PAC, began the campaign to share the information that undetectable HIV is not infectious. PAC emphasizes that there is scientific evidence behind this statement. This knowledge has the potential to alter negative perceptions around the disease, yet the message still hasn’t reached everyone. His motivations behind the U=U campaign are as follows:
“The U=U science has the potential to transform the lives of millions of people with and affected by HIV and to radically transform the field. It’s time to ensure this game-changing science breaks through the intersecting stigma and politics in medicine and public health to reach the people and field it is intended to benefit.”
Viral load count infographic | Know your viral load (5)
There are still many people living with HIV that don’t know that if the virus is undetectable, then they cannot transmit the virus to their sexual partners. Undetectable HIV means that the viral load is suppressed and doesn’t show up on blood tests. Richman adds that “The U=U message is an unprecedented opportunity to dismantle HIV stigma and transform lives of people living with HIV by lifting the fear and shame of transmission.”
HIV-positive people with an undetectable viral load are healthier and much less likely to infect other people. If everyone took steps to have an undetectable HIV viral count, then lower rates of transmission could help stop the spread of the virus.
UequalsU undetectable is untransmittable | Prevention Access Campaign (6)
There is a need for increased access to viral load detection tests in Sub-Saharan Africa. It is recommended that everyone get an HIV test, but it is recommended that sexually active gay and bisexual men may benefit from a test every 3 to 6 months (2). In Cape Town, the Western Cape Government will provide a free viral load test every six months at public clinics (3).This is an excellent service, however might not be enough for people who engage in high HIV-transmission risk behaviour.
Other Sub-Saharan countries, like Malawi, only recommend viral load testing every other year for persons on antiretroviral therapy (4). Guidelines like these that don’t provide timely viral load monitoring are a huge barrier to preventing the spread of HIV. Knowing that UequalsU is one step. The next is ensuring that everyone can reliably monitor their viral load.
Linda-Gail Bekker, Chief Operating Officer at DTHF, comments that “In this era of ART access for all, it is important to realize that those individuals who take their treatment and are virally suppressed are very unlikely to be infectious – and this for them is wonderfully liberating!” Loving someone is not a criminal act, although many HIV-positive people are still discriminated against because of their disease. By raising awareness that U=U we can spread the message that undetectable HIV is untransmittable HIV.
If you want to help spread awareness, then use the hashtags #UequalsU #FactsNotFear and #ScienceNotStigma.
You can also follow PAC on Facebook and Twitter using @PreventionAC.
If you could shuffle all of the homes in the world like a deck of cards so that people in wealthy countries lived side by side with people from poor countries, it would transform the world’s fight against poverty, hunger, and disease. It would be impossible for people to look away, impossible for them not to help.
Cape Town alone has more TB each year than the US, Canada, UK and Germany put together. Professor Robin Wood, a leading University of Cape Town scientist, is in search of the clues as to why this is so, writes Business Day.
It is with great sadness that we share the news with you that our friend and colleague, Professor Stephen Lawn, of the London School of Hygiene & Tropical Medicine and the University of Cape Town, has died at age 50.
Data is the first step to solving a problem. It sets the scene, uncovers the discrepancies, and reveals clear gaps for focus. Conversely, when something is not counted it is easily ignored. The UN proposes that this is an underlying issue facing the 1.1 billion girls living today: they are not being counted and the absence of data limits our ability to uplift and empower them. This is why the 2016 International Day of the Girl has been themed “Girls’ Progress = Girls’ Goals: A Global Data Movement”, which aims to push this missing information to the forefront and highlights the need for accelerated data collection to fill the gap in knowledge of challenges girls and young women face.
The Desmond Tutu HIV Foundation (DTHF) works primarily to accelerate the research, treatment, training and prevention of HIV-
ening Mr. President, Ladies and Gentleman.
