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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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.

"So, what are you doing about TB?"

There’s a particular gentleman at the AIDS 2016 Conference who causes a kerfuffle wherever he goes and I’ve witnessed his performance a number of times over the past few days.

At the end of every session he asks the lecturer “So, what are you doing about TB?”

It’s an AIDS Conference so most speakers are caught off guard when they don’t get a question about AIDS, but on Tuesday a speaker retorted “Well Anton, I didn’t know you were in the room, otherwise I wouldn’t have asked if there were any questions”.

I’m sure you’ll be pleased to hear that Dr Anton Pozniak finally got his own platform to speak in the plenary session.

He informed his captive audience that it’s all very good to treat HIV, but every year in Africa, Tuberculosis causes more deaths. He reminded us that our current TB vaccination is 95 years old and we need a new one.

Tuberculosis is diagnosed too late, with half the diagnoses made at post-mortem. HIV testing is improving, but we also need to be using a rapid test for TB. Whether it’s spitting in a pot or peeing in a jar, we already have the technology to test for Tuberculosis - but we need it to be quick, portable and affordable. 

We know Tuberculosis causes significant morbidity and mortality for people living with HIV (PLHIV). We also know that using Anti-Retroviral Therapy (ART) by itself is not sufficient to treat Tuberculosis. ALL patients co-infected with HIV & Tuberculosis need to be treated by a combination of ART and anti-TB medications.

We cannot shorten the duration of Tuberculosis treatment to any less than 6 months using our current anti-TB medications. New drugs are being trialled and some appear promising, but we’re even trialling old drugs to see if they might possibly work for Tuberculosis too.

Nelson Mandela once said “We can’t fight AIDS unless we do much more to fight TB”, but Anton isn’t keen to stop there. He not only wants to fight HIV and Tuberculosis, but he’s keen to eradicate viral hepatitis too.

Anton's dream is for everyone with viral hepatitis to be treated, but this dream comes with a price.

Hepatitis B treatment costs ~$15,000 in the USA, but the estimated true cost is $36. Hepatitis C treatment in the USA costs ~$84,000, but the estimated true cost is $62. Affordable medication can truly change the lives of millions of people around the world, but that's not yet happening.

Anton urged everyone to communicate and combine efforts to provide integrated health services for people in need. Testing and treatment should not only be for HIV, but also for Tuberculosis, Hepatitis B & Hepatitis C. 

We’re aiming to end HIV by 2030, but let’s aim to eliminate Hepatitis C and Tuberculosis too.

Anton closed his speech by saying that we need new 90:90:90 goals. We should aim for the cost of HIV treatment to be $90 per year, Hepatitis B treatment should be $90, and Hepatitis C cures should be $90 too.

NB - There was no kerfuffle at the end of his presentation as Dr Anton Pozniak wisely did not ask the audience if they had any questions.