ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

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This morning I attended the Oral presentations for HIV/STI testing and management, looking at different studies around HIV risk.

Brendan Harney from Melbourne presented his study: Risk of HIV following repeat sexually transmissible infections among men who have sex with men in Victoria, Australia. 

This presentation was a retrospective study questioning, if MSM have repeat positive STI diagnoses, are they at an increased risk of HIV transmission? 

Out of 8941 MSM (median age 29, Australian born) surveyed at a busy Melbourne Sexual Health Centres, 2.5% were diagnosed as HIV positive.

Although repeat Chlamydia and Syphilis notifications were common, Rectal gonorrhoea was found to be the highest, with 13.5% of those with a repeat positive gonorrhoea rectal infection becoming HIV positive.

Conclusion? Repeat Gonorrhoea infections are strongly associated with a HIV infection, and that this data is key to looking at PrEP inclusion criteria and why we target specific groups and behavioural activities for PrEP enrolment studies. 

 

 Aboriginal & Torres Strait Islander Health (ABSTI) – HIV & STI’s in the Australian ABSTI health context.

 Presented by A.Prof. James WARD and Prof. Gracelyn Smallwood and other eminent panellist discussed these contemporary health issues with Australia’s ABSTI people.

 HIV – double the rate of Non- Aboriginal people

                   With 60 % - Men that have sex with Men (MSM)

                             20% - Injecting drug users

                             20% - Heterosexual     

                                                                                                                                                               Please note that  -  20 % of HIV Diagnosis are Women and 12% live in remote and rural & communities.                                                                                                                                                                                                                                                       33% late diagnosis with 21 % having advanced HIV. In the general Population – 90% are diagnosed.

MEDICATION and adherence and co-morbidities are a huge burden.                               Mental Health/ depression – 12% report feeling depressed, with 9.6% of the general population report this.

The social determinates of health – ABSTI have poorer general health with unique challenges in addressing ABSTI HIV care and treatment. Medication burden.             Complex health.

 the effects of ongoing racism and discrimination.

 Feel “SHAME” and their spirits is low.

 Stigma from HIV.                                                                                                                                                                             Need to trust clinicians and respect for clients confidentially is utmost important.  

  

Needle Syringe Program (NSP) – 

ICE/Crystal has become a big issue.  

We can’t wait for an outbreak to occur, so we need to increase access to NSP services, such as in outreach programs.  

 Health and Community Partners/organisation to work with the community needs, in culturally appropriate ways, including not driving it (program & service health delivery) with experts  without consulting, involvement & input from respected key community stakeholders.

Partner’s organisations needs to ask local people to teach cultural norms. 

PANEL DISCUSSION –

90 % of the general population know HIV Status

80% of the ABSTI know their status (20% don’t!).

Reduced life expectancy (estimates 20 years compared to non-aboriginal Australia people).

need a grass roots approach, need to empower the local people by using their knowledge and expertise about their own local communities and support solutions at local levels.

Funding been cut by Governments with 75 % of Funding is going to non-grass roots, such as University Research & government bureaucracy.  

3% population in jail, 

                                                                                                                                          

food prices are increasing in local and remote communities 

Poor sanitation

No jobs, lack of career pathways

 

Cairns Doctors advised that the syphilis epidemic came first, then linked with HIV.  

Recently 1 female and 4 males (MSM) aged from 18-25 years HIV +                                  young mobile, homelessness (is a major barrier), couch surfing, staying with Aunties, not taking medication as forgets due to constant moving. Finances - Centrelink – cut off.

 Aboriginal Medical Service (AMS) – Aboriginal controlled services across Australia -      there can be an issue of taking blood in ABSTI Peoples.                                                          Non-Aboriginal Health care workers need to provide better cultural translations -           explanations as to why blood is needed (MEDICALLY) to be taken.

With young people there is a better acceptance of outreach programs that deliver rapid testing for Syphilis.  

Issues in screening STI’s in prisons

Aboriginal Community Health Workers – not getting paid and recognised properly.

Some Clinicians can be uncomfortable offering a HIV Test.

Clinicians needs to be flexible in care delivery. Work to ‘hold confidence’ with Clients.

How can Services be friendlier to ABSTI Peoples?

Building good working and trusting relationships is everything. Keeping rapport and people engaged.

Service providers need to become more effective!

Burden of disease/s, reluctant in accessing care, complex family dynamics, isolation.

Family worries, social issues, turning up for appointments and reminders.

Shame aspect – needs to be taken out of HIV. Of not having housing, which prevents people from becoming stable and stay on treatment.

 

 

 

 

 

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A.Prof. James. WARD - Aboriginal Health Perspectives.

A Predicted divergence of what is happing in Aboriginal and Torres Straits Islanders community’s in relation to HIV and STI’s.

  

New diagnosis of HIV in remote communities due to young mobile population.

Risk Behaviours such as sharing NSP Equipment, with a background of increasing prevalence of STI’s.

 Failure to engage Treatment as Prevention (PrEP) as need to take other medication (pill burden) for multiple health conditions/comorbidity.

 10-24 years age group, increasing Chlamydia and Gonorrhoea -                                                                  This highlights the inequities and lack of access to care.

 

Hep C – mostly transmitted through injecting drug use (IDU).  

Hep C has increased 43 % in 2011 – 2015.  

It effects the youngest 15-24 years old.

Hep C has 8 times the incidence in Aboriginal people (than non-Aboriginal People).

 

Rural and Remote Communities – need more access to Aboriginal Primary healthcare for testing and treatment and treatment as prevention (PrEP).

HIV in Cairns, QLD – young Aboriginal & Torres Straits Islander men in 2014-2016 had 50 % increase in HIV. This also effects bi-sexual men and men that don't dentify as gay.

NO access to NSP. Difficulties in approach to NSP and harm minimisation.

(Treatment as Prevention) TASP.

Prof. Ward said that we could learn from Canada’s first nation’s people in Saskatchewan that have a background of unresolved grief & intergenerational trauma. 

Increased of IDU and STI’s = HIV !

We need to prevent an outbreak occurring in our rural and remote Aboriginal and Torres Strait Islander (ABSTI) Communities. Health services are already limited and they would also not be able to cope with a major outbreak occurs. This would devastating to these communities.

ABSTI – vulnerability of population.

Need to increase the workforce in meaning work and career options

Need timely surveillance data, to be able to respond quickly    

Medicare to cover costs

Need to advocate ‘outside and ‘raise our voices’ (to Governments and the Australian people to increase awareness and be able to act/prevent). Especially non-Aboriginal People need to stand up and raise their voices about concerns and issues of our ABSTI People.

Increase the current low testing rates for HIV.                                                                                                                                                             Use a diversity/combination of strategies include - strengthen Aboriginal and cultural appropriate Primary care.

 Currently on 32% of people with STI’s are offered HIV Test. This needs to be offered 100%.

 Community itself needs to be interested and engaged.

 

 

 

Professor Gracelyn Smallwood 'Aunty' delivered a highly emotional discussion about the realities faced by many Aboriginal People and Communities across Australia.

Most of the Closing the Gap money (75%) is not going to grassroots level of the people.

it is been swallowed up by university research, and provides jobs to non-aboriginal people.

Gracelyn said that poverty is widespread and needs to be cleaned up.

Many don't have running water and sanitation is poor. 

Food is marked up 200%

Most are unemployed and on Centrelink benefits.

ICE/ substance/drug use is high, including injection.

Concerns about HIV reaching remote and rural communities.

High rate of imprisonment  

Aboriginal Health & Community Services need culturally appropriate programs.

Non-Aboriginal people involved in programs deliver need to go into communities before and consult and talk with keys players/stakeholders and elders. 

Local grass root program delivery don't have to cost lots of money,                                                             such as the 'deadly program' and 'grog kills skills' delivered on a  shoe-string budget. 

Gracelyn talked about her us of the (world famous) Condom man.

This health promotion/prevention strategy was used successful and widely as a healthy alternative to the scary 'grim reaper' advertisements to assist combating HIV/AIDS. 

 Non-Aboriginal People need to speak out more and advocate for ABSTI People by keeping it on the agenda.

Australia needs to reconcile with the past and the ongoing injustices against Aboriginal and Torres Strait Islanders People's. 

Please read Gracelyn thesis which she addresses these multilevel issues in Australia's Indigenous People. http://www.atsiwlsnq.org.au/reports/Gracelyn_Smallwood_2011_thesis.pdf

Thankyou Aunty, your inspirational presentation. It was the highlight of the conference for me and together we can all individually and collectively help to improve the health and lives of Australians Aboriginal and Torres Strait Islanders People. 

 

 

 

Day 4- Increasing the demand for HIV testing

Mark Stoove discussed innovative ways to improve HIV testing.  50-70% of HIV transmission among GBM are attributed to undiagnosed infection. There were policy and regulatory changes in 2012, which revolutionised HIV testing in Australia. Rapid HIV testing was introduced and there was an increase in HIV testing in community settings. The uptake of rapid HIV testing has been modest. Barriers may include funding, lack of government subsidy and some services feel testing can be time and resources heavy. The majority of HIV testing continues to occur in primary health care settings using serological laboratory testing

Community based HIV testing services such as ACON provide a comfortable, peer based service which clients find very acceptable.  ACON in Sydney provides a peer based testing model, which is supported by nursing staff. Peer based clinics have successfully attracted first time testers that were classified as ‘high risk’. Rapid HIV testing has increased testing in urban areas but more needs to be done for those living in rural areas. We need to expand the geographical reach of HIV testing. The Terence Higgins Trust provided funding to increase testing in the UK. In a 14-month pilot study over 17,500 testing kits were posted and 10,410 specimens were returned. There was a positivity rate of 1.4% and this testing was welcomed by participants with 97% reporting that they would test this way again. Self-testing kits are available in the UK and the uptake has been excellent with over 27,000 units sold between April 2015 –Feb 2016. Half of the test kit users have never had a HIV test before.

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

-Funding may be a barrier for services offering HIV testing. Government subsidies could improve rates of HIV testing

 Vickie Knight spoke about the effect a[TEST] clinics has had on HIV testing among gay and bisexual men. It was found that the clinic on Oxford Street in Sydney has increase testing and also increased the frequency of testing. Factors that make this clinic user friendly include short wait times, the service is free, CASI is used which means intrusive sexual health histories are not taken by health professionals.

 

Key messgaes

This model works and has increased testing among GBM.

 

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Day 4’s morning session was focused largely on PrEP, making it interesting and relevant to the Australian context.

 

Chloe Orkin (from the Royal London Hospital) began by providing a brief summary of the current situation and future prospects for PrEP.

 

She noted the current use (as PrEP) of standard antiretrovirals; the development of new compounds from existing classes (e.g. EFdA [NRTI]; dapivirine, MIV-170 and IQP-0528 [NNRTIs]; cabotegravir and MK-2048 [IIs]; and entry inhibitors [vivriviroc, 5P12-RANTES, PIE-12, nifviroc and trimer-D-peptide]); as well as new compounds from new classes (VRC01 and griffithsin [Neutralising antibodies]).

 

She also mentioned novel means of drug formulation that’re being developed: rings, inserts, suppositories, gels, films, soft implants, injections and douche/enema.

 

 

Sheena McCormack (University College London) presented an update on the evidence for PrEP effectiveness.

 

She began by presenting the a summary of currently available evidence as below, reminding us that overall (especially in MSM) PrEP is very effective; that adherence was a major factor in many of the studies where effectiveness was less good (particularly in young black MSM in the USA and in heterosexual populations).

 

She focused on the PROUD (continuous truvada as PrEP; immediately or deferred) study which looked at effectiveness, risk compensation and STI rates This study showed an effectiveness of 86% (90% CI 64-96%), with NNT = 13 (90% CI 9-23) – Dr McCormack commented that this compares favourably with other medications (such as statins) that’re approved for preventive measures. She also commented that some of those in the immediate intervention (PrEP) arm had significantly more unprotected anal intercourse than those in the deferred arm, and that rates of unprotected anal intercourse in both arms were relatively high. In that study, a rectal STI indicated a 1 in 6 risk of HIV infection in the following year.

 

Australia’s EPIC study was mentioned, particularly with regard to the fact that it targeted those at high risk of HIV.

 

She provided a summary of worldwide PrEP demonstration projects between 2011-2015:

-       32 projects in 16 countries

-       8478 participants with 7061 cumulative years exposure

-       Total HIV seroconversions n=67

à Highest rates in MSM 18-25 years (7.7/100 person-years)

à However available intracellular data showed undetectable or very low tenofovir levels in nearly all of those with seroconversion while on PrEP.

 

Episodic vs daily dosing – the importance of choice to effectiveness

HPTN 067/ADAPT study was mentioned: this study compared the use of daily, twice weekly (and another tablet after sex) and episode-driven PrEP in 3 populations (Harlem MSM/TGW; Bangkok MSM/TGW; Cape Town WSM). It showed that in the Bangkok population (who were generally better educated and suffered less social disadvantage) there was little difference in effectiveness between treatment arms, whereas adherence was much poorer for event-based PrEP in the other two arms (compared with continuous PrEP). This suggests that a choice of event-based or continuous PrEP may be useful depending on the population in question, and that if a population is likely to be adherent to episodic PrEP, this may produce cost-savings (less drug used overall).

 

 HIV infection despite PrEP

Those two cases of HIV being contracted despite good adherence (and adequate drug levels) were mentioned, including the “Toronto case” and the second case recently reported of a MSM acquiring a strain of resistant HIV. This reinforces the importance of reminding those on PrEP that it is not 100% effective.

 

Possible use of maraviroc as PrEP

HPTN 069/ACTG 5305 (Phase II Study of Maraviroc-Based Regimens for HIV PrEP in MSM) was discussed. In this study of n=406 MSM, people were randomised to oral maraviroc (MVC) only; MVC+FTC; MVC+TDF or TDF+FTC. 5 seroconversions occurred (4 in MVC-only arm), but in 4 of those plasma drug levels were low or undetectable.

 

Dapivirine-impregnated vaginal ring as PrEP

ASPIRE (n=2629; 27% risk reduction) and Ring (n=1959; 31% reduction) studies. Both in Africa.

However risk reduction was 60% in women >25 years of age; based on further data from the studies poor adherence was thought to be responsible for the poorer effectiveness in younger women.

Dr McCormack also mentioned the possibility of including contraceptive drugs in the PrEP vaginal ring to provide combined PrEP/contraceptive effect.

 

Conclusions

-       Overwhelming evidence of effectiveness of biological efficacy of TDF+/-FTC – which is not compromised by STI or risk compensation.

-       Population effectiveness not compromised by resistance (to date)

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-       Heterosexuals have a choice of drug; MSM have a choice of regimen; women will soon have a choice of delivery method.

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Glasgow HIV 2016 has just opened.

It was interesting to hear new-comers to this meeting reflect on the three excellent presentations in the opening: Clarity, different perspectives, and reflections mixed with predictions. The sessions will be up on the Conference website shortly.

Tony Fauci, giving the Joep Lange and Jacqueline van Tongeren Memorial Lecture. Ending the HIV/AIDS pandemic: follow the science, reflected on the changes that have come about since he entered the field in 1981, following the publication of seminal articles in the MMRW. Fauci indicated that this is when he decided to change his career trajectory and concentrate on the, as then un-named, phenomenon which would become HIV.

Fauci sprinted through 30 years of HIV to focus on the more recent research which has redefined ending HIV. Namely the recognition that treatment reduces virus which in turn reduces transmission and that knowing ones status allows for interventions. But he did not stop there. He went on to cast and eye to the horizon and identified two areas where science has significant contributions to make.

HIV persistence, or stopping persistence, is a holy grail. This comes in two forms, eradicating HIV where HIV is made dormant while treatment is administered, yet re-emerges when treatment is stopped or controlling rebound, where interference at binding or replication sites reduces proliferation. This individualised therapy has shown to be useful in this strategy in cancer treatment and it has potential in HIV.

HIV vaccines, whether therapeutic or preventative are of course what everyone is hoping for. Fauci presented some realistic steps which are being made to transition vaccines from 32% effective to more like 50% effective, a point which he suggested could make significant inroads in reducing transmission, particularly in endemic settings and in combination with other strategies. He also discussed a number of new vaccine initiatives.

He ended with neat summary of why vaccinologists have not yet been rewarded. This I thought was a poignant rationale for continuing with vaccine development in the absence of any hitherto prizes. Most vaccines mimic the actual process of disease and immune response. That is not the case in HIV, so the vaccinologist needs not to copy the virus, but be much smarter than it.

 

Andrew Hill

Spoke about the potential to improve treatment access through the greater use of generic drugs. I can’t help thinking every time I hear Andrew talk that he is simplifying something in the greater economics and practicalities of capitalism or financial markets. But his arguments are very compelling.

Interestingly Andrew inserted discussion about Australia’s funding for hepatitis C treatment. Having just come from the USA where I was asked about details of the same, it seems to me that there are very different mechanisms in place in different countries which can result in very different approaches to price setting.

Two years ago at this meeting Andrew suggested it might be in the interests of the NHS budget to make a two pill (rather than single pill) regimen available to the UK public through the NHS. This brought criticism from at least one senior Australian clinician and commentator who thought that it would be unacceptable to expect patients to take a less convenient regimen.

Linda-Gail Bekker

As always presented clearly and passionately about the current experience of HIV in Africa and was able to compare and contrast this to other global settings. She is able to mix population and locational differences and introduce a third dimension of how these interact.

Adolescents were for a long time not a priority in HIV prevention. Key affected populations, are largely characterised as being “the-non-majority population”. While recognising this, she introduced an emerged KAP in Africa and that is adolescent women.

Linda-Gail was able to focus on trends which demonstrated changes for the good. It was very interesting to see a map where Australia was pink (on a blue to red scale) for increasing or sustained new infections. While our numbers might not be big they seem to be somewhat intransigent. Many African states have seen dramatic improvements. While more developed settings seem to be finding it difficult to make changes to address persistent, comparatively low-level, new infections. Something which Fauci also recognised in the USA. It would be interesting to see Andrew Hill’s economic assessment of the cost of these different interventions.

A great opening session which augers well for the coming days.

Levinia

 

 

Anthony Fauci from the National Institute of Allergy and Infectious Diseases (NIAID) & National Institute of Health (NIH), Bethesda, USA, presented an excellent keynote lecture on ending the HIV/AIDS pandemic.

He started by taking us through a timeline of HIV infection. Starting in the 1980s, when the mean life expectancy of a newly diagnosed 20 year old (not on ART) was ~12 years. We followed the science through time and today, over 35 years later, the mean life expectancy of a newly diagnosed 20 year old (on ART) is ~53 years.

What we've learned since the 1980's regarding the etiology, virology, pathogenesis, treatment and prevention have given us a better understanding on how all these advances should continue to be used in conjunction in order to end the HIV/AIDS epidemic.

We've discussed treatment as prevention (TasP) and looked at a traid of pivotal ART studies regarding the treatment of individuals with HIV infection:

  • The SMART study showed that episodic ART is inferior to continuous ART
  • The HPTN 052 study showed that early ART reduces HIV transmission to uninfected sexual partners by 93%
  • The START study showed that early ART reduces serious illness or death by 57%

 

We are all aware of the continuum of care when our patients have a positive HIV test results, but we should also be very proactive in the continuum of prevention in those who test negative.

Despite our 90/90/90 targets, the numbers of newly diagnosed HIV infection have plateaued globally since 2009.

Continuing to improve access to ART and HIV prevention strategies, such as pre-exposure prophylaxis (PrEP) could dramatically decrease HIV-related deaths and the rate of new HIV infections.

The efficacy of PrEP has been proven in multiple studies and most recently the San Francisco Strut PrEP program showed no new HIV infections in >1200 men on PrEP in nurse-lead intervention over nearly 1.5 years. There were 82 new infection at that clinic among men not enrolled in the PrEP program.

The two main remaining scientific challenges for HIV identified are:

  • Addressing HIV persistence
    • eradicate the reservoir - classic "cure"
    • control viral rebound - sustained virologic remission
  • Development of a safe and effective preventative HIV vaccine 

Towards a HIV vaccine:

  • The first signal of efficacy (31%) in a HIV vaccine clinical trail - RV144, was seen in: Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. S Rerks-Ngarm, et al. For the MOPH-TAVEG investigators. N Engl J Med 2009; 361:2209-2220. Dec 3, 2009
  • Additional work since this study has lead to a large-scale HIV vaccine trial that will launch in November 2016 in South Africa: HVTN 702 modifeid RV144 prime-boost regime
  • More work is also being done on Neutrolising Monoclonal Antibodies, discovered since 2009.

 

Conclusion:

Treatment + non-vaccine prevention + vaccine = durable end of the HIV/AIDS pandemic

African Vaccine Dreams

Everyone's intrigued by it, every country is keen for it, apparently even the CIA wants it. The room brimmed with academic excitement as we gathered to hear a panel discussion on the prospects of an HIV vaccine and how "vaccines are needed to conclusively end HIV/AIDS and TB".

Six major trials have been conducted in the past, looking at potential HIV vaccines, but so far the results have been disappointing. The most successful vaccine trial was the RV144 study in Thailand, but this vaccine was only modestly protective against HIV infection.

The HVTN 702 trial is due to commence in South Africa towards the end of 2016, but scientific research is expensive and a phase three vaccine trial costs approximately $135million.

It's proving difficult to produce a vaccine for HIV. There are not only challenges with the science, but also with policies, politics and funding. We need international collaboration if we're ever going to create an HIV vaccine that works.

We already have a vaccine for Tuberculosis but it's more than 95 years old and not very effective. There's been little interest, investment or pharmaceutical support for a new TB vaccination and the research already performed has only yielded disappointing results.

Ruth Labode (Parliamentarian of Zimbabwe) was asked if politicians are growing cynical of ever getting an HIV vaccine and is this affecting TB and HIV research. She responded that when she hears a church minister saying "let's pray that we find a vaccine for HIV", she thinks the minister should be praying “for those who are on treatment, to stay on treatment".

She has a point. It’s important to plan for the future, but remember we already have medication that works - let's use it.

Ruth Labode stated “African countries need to come together as an informed community to collaborate with their international partners”. Her opinion is that Zimbabwe is not investing enough money into scientific research and development. “We always worry about money, but at the end of the day the epidemic is not in recession".

The panel was asked their opinion about how to get people excited about a vaccine, but continue to have a measured scientific approach. Peter Godfrey-Faussett (UNAIDS) passionately responded by saying “everyone’s talking about the UN's 90/90/90 targets for HIV, now even TB has a 90/90/90 target, but sometimes we don't quite understand what we're talking about. When we're talking about HIV we really need three ZEROS - zero HIV-related deaths, zero new infections and zero HIV-related stigma".

"Our current 90/90/90 targets relate to HIV treatment and it's working because we're seeing that the number of people dying from HIV is reducing. Some countries are nearly at 90/90/90 targets. Australia has recently announced that they're already at 90/90/90, but in some areas of the world HIV diagnoses are going up. 90/90/90 is a popular catch phrase, but people forget that it's only one of 10 targets the UN has mentioned. Millennial goals have become sustainable goals, but now we need a specific target for TB".

Peter Godfrey-Faussett continued “Where does research and development come into this? Domestic governments are putting money into it and domestic resources are going up. Economists talk about "discounting" - would you rather have 50 Rand today or 100 Rand in 20 years time? Do we deal with things today or do we invest in things for the future? Of course we need both and we need to balance this".

He proposed "We need more than just treatment. A quarter of funds should be put into prevention.” A successful mosaic vaccine is more likely to arrive sooner if countries collaborate and share the load.

But vaccines don't just come in a syringe. Condoms, male circumcision and PrEP all decrease HIV transmission. PrEP is especially effective at preventing HIV but we're still not promoting it as well as we could be.

Glenda Gray (South African Medical Research Council) was asked what African-led science would look like in the future. Her response was simply that African governments don't fund enough science. "Until African countries see the value of funding medical research, we will always be behind. Our budget is puny compared to other organisations like the Bill and Melinda Gates Foundation" she said. "We need our government to support science. Science is slowly emerging in South Africa, but it's still not good enough. We need to see a renaissance of science in Africa. If you want a healthy country, you need to invest in Research and Development."

Mark Feinberg (International AIDS Vaccine Initiative) was asked to reflect on the pharmaceutical industry. He stated that people still think the pharmaceutical industry "only gets involved when there is a payback, but industry is evolving [to a place] where collaborative efforts can go ahead and answer big questions. Scientific challenges and the challenge of scientific partnerships is an area where there is incredible potential. Organisations need a pathway and direction to take them to a much greater scale". He stated that we all learnt a lot from the international efforts with Ebola and this has shown us a much different way of dealing with these big issues in a collaborative way.

Countries respond very differently to dealing with TB and HIV. Fragmented systems of care exist where health professionals are either concentrating on TB or HIV, but we need to be treating both. The general population doesn't equate TB with death like they used to do many years ago and there's currently a lack of engagement from the community. We don't provide aggressive case management and we lose patients to follow up. We have incredibly rigorous surveillance with our HIV patients, but we need to have the same approach with TB.

The panel was asked if scientific research and development funding would increase as we continue our search for an HIV vaccine. Glenda Gray replied "South Africa does fund HIV vaccine research, but the funding from the National Institutes of Health (NIH) is a thousand-fold more than what South Africa is funding. It's like South Africa isn't serious about its funding towards an HIV vaccine. We've been able to improve South Africa's life expectancy by 9 years due to aggressive antiviral therapy, but to fuel our economy we need to fund research & development." She continued “We need to harness an economy of knowledge, but we are short-sighted in our vision. We need science like we need clean water."

Dr Anton Pozniak (my new professional man-crush) stood up from the audience, took the microphone and addressed the panel. “There's currently a gross inequity between HIV and TB. Regarding vaccines, seven times the amount is spent on [research for] an HIV vaccine compared to a TB vaccine." We don't need to make it a competition, but it's a matter for the TB community to step up. "The TB community needs activists to show that a TB vaccination is important."

Anton continued "It's extraordinary that we don't give people more Isoniazid. There's a lot of evidence regarding TB and HIV (showing) that people do better when we put them on Isoniazid, but people aren't taking it." We need a continuous dialogue between organisations to decide where funding is most appropriately needed. "We have people talking about Zika, but we have people dying every day from TB. In Ethiopia the AIDS association is taking funding on behalf of TB." Money is eventually getting to Tuberculosis, but an answer may be to integrate health services.

“[We've just had the] TB Pre-conference and there are some signs of change, but it is nowhere near fast enough. There have been SIX trials for an HIV vaccine, but only ONE trial for a TB vaccine. We need to think about these issues together. We need to 'leap-frog" innovation and science by making an HIV/TB think-tank. Science is the driver of development. We need to see a lot less people dying from TB. We need people to know their HIV status and use antiretroviral (ARV) treatments. If they're using ARV, then they're less likely to die from TB infection."

The panel discussion came to a conclusion, but not before Dr Anton Wozniak dropped the mic saying that after all this discussion about TB and HIV “it's important to put it into perspective that non-communicable diseases kill far more people compared to infectious diseases” - but I don’t think we have a vaccine for that yet either.