tag:theconversation.com,2011:/uk/topics/aids-2016-29356/articlesAIDS 2016 – The Conversation2023-09-24T12:02:25Ztag:theconversation.com,2011:article/2130852023-09-24T12:02:25Z2023-09-24T12:02:25ZYoung people with sexual or gender diversity are at higher risk of stopping their HIV treatment because of stigma and harsh laws<p>Ending the AIDS pandemic – particularly in eastern and southern Africa – cannot be achieved unless more resources are channelled to meet the needs of key vulnerable populations.</p>
<p>This is one of the themes that emerged during an <a href="https://www.samrc.ac.za/event/11th-sa-aids-conference-2023-20-23-june-2023-durban">AIDS conference in June</a> in South Africa. Prejudice against particular groups – such as men who have sex with men (MSM) and transgender communities – interferes with treatment regimes and people’s adherence to treatment. These groups are also at higher risk from HIV due to increased levels of stigma, discrimination, violence and criminalisation. </p>
<p>Our research is part of a three-year <a href="https://www.heard.org.za/wp-content/uploads/2023/06/SADC-Symposium-Report_final.pdf">project</a> on HIV-related stigma linked to young people with sexual or gender diversity. The research, conducted in Malawi, Zimbabwe and Zambia, involved 156 participants.</p>
<p>The research identified three main findings:</p>
<ul>
<li><p>Criminal laws and strongly negative socio-cultural and religious beliefs produced deeply rooted intolerance around sexual or gender diversity. </p></li>
<li><p>Participants spoke about repeated experiences of verbal harassment, being gossiped about and physical violence.</p></li>
<li><p>Other population groups with HIV said their lives had become more tolerable as social awareness and acceptance of HIV had increased over time. However HIV-related stigma regained its potency when linked to sexual or gender diversity, with adverse effects for adherence to antiretroviral treatment. </p></li>
</ul>
<p>Our research provided novel evidence on the deeply rooted fears and anxieties around multiple forms of stigma among young MSM and transgender women in southern Africa. </p>
<h2>Criminalising sex</h2>
<p>Across 13 countries in east and southern Africa, laws and policies criminalise same-sex sexual relations and facilitate the process of stigmatising gay and transgender individuals.</p>
<p>Recently, Uganda passed the Anti-Homosexuality Act of 2023, which punishes same-sex conduct with life imprisonment. Several acts considered as “aggravated homosexuality” are liable to the death penalty. </p>
<p>Our study also noted that young people had developed various strategies to manage their lives. For example choosing when to disclose or identify as a person living with HIV or as a member of the sexual minority community in others, but rarely being both at once. </p>
<p>The constant worry and stress of living with HIV, and the fear of being stigmatised, could have a significant impact on health and wellbeing. </p>
<p>The burden of concealing their identities resulted in a range of mental, emotional and physical vulnerabilities. Signs of depression as well as frequent alcohol use were evident.</p>
<p>Overall 42% of participants had contemplated suicide at least once. According to one participant, an 18-year-old:</p>
<blockquote>
<p>I feel like I am nothing, I am useless. In the community, looking at HIV, I am a gay, people they isolate me. So, I don’t feel comfortable, even failing to go to work and finding some money, whatever. And, sometimes, I decide if I can die today, I can rest. So, a lot of things come into my mind when I am disturbed … Sometimes my parents try to comfort me but, internally, I am really disturbed.</p>
</blockquote>
<p>As well as signs of depression, frequent alcohol use was evident. </p>
<p>There were few services available to assist in coping with these multiple stigmas, with those that came closest being provided by “sexual minority friendly” organisations or led by sexual minority peers themselves.</p>
<h2>Fear of being found out</h2>
<p>Being seen taking antiretroviral therapy or having it found in one’s possession signalled that one was living with HIV. Some individuals preferred to miss doses, occasionally or over more prolonged periods, rather than endure actual or feared stigma linked to being “found out” as someone living with HIV.</p>
<p>A 24-year-old told us:</p>
<blockquote>
<p>What made me to delay taking medication is when my partner wants me to visit his home because he stays in Zomba, and I haven’t disclosed my HIV status to my partner yet, and I can’t take the ARVs with me there. As a result, I go there without the ARVs.</p>
</blockquote>
<p>A 19-year-old said:</p>
<blockquote>
<p>It affects me sometimes because, if people reject you, you feel like stopping to take the medication. ‘Maybe am just wasting my time, let me just die.’ It affects me a lot.</p>
</blockquote>
<p>Other findings we made were that:</p>
<ul>
<li><p>Many participants had had their status disclosed by LGBTIQ+ peers without their consent. HIV-related stigma is still highly prevalent within the LGBTIQ+ community and has many negative impacts. </p></li>
<li><p>Participants continued to experience or fear stigma related to their sexual orientation at health facilities, which also affected their access to healthcare and retention in care.</p></li>
<li><p>Tailored HIV services for key populations, including young MSM and transgender women, were not reaching everyone; rural areas were the least included.</p></li>
<li><p>Through their experiences, gay young men and transgender women were familiar with the harmful consequences of stigma and yet they were often ostracised from planning and decision-making roles. </p></li>
</ul>
<h2>The way forward</h2>
<p>Key populations in our study faced inequalities in three main areas: access to HIV services; justice and human rights; and investments in programmes geared towards them.</p>
<p>There were few services available to assist in coping with these multiple stigmas. Those that came closest were provided by “sexual minority friendly” organisations or led by sexual minority peers themselves.</p>
<p>There need to be more community-based organisations that are run by members of these key populations. In Cameroon, for example, the <a href="https://www.usaid.gov/cameroon/health/hiv-aids">CHAMP</a> programme supports grassroots advocacy to mitigate stigma and violence and trains peers to offer counselling, </p>
<p>We can only achieve progress if we treat everyone as equal partners in fighting this pandemic.</p><img src="https://counter.theconversation.com/content/213085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaymarlin Govender receives funding from the National Research Foundation and Sida</span></em></p><p class="fine-print"><em><span>Patrick Nyamaruze receives funding from HIV/AIDS Special Fund Round III initiative of the Southern African Development Community. </span></em></p>Stigmatised people living with HIV often suffer from fear, depression and abuse. It’s sometimes easier to stop a treatment regime than risk being ostracised or assaulted by the community.Kaymarlin Govender, Research Director at The Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-NatalPatrick Nyamaruze, Post-doctoral research fellow, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623602016-07-21T17:34:05Z2016-07-21T17:34:05ZIt’s not enough to test for HIV and treat it – social factors matter too<figure><img src="https://images.theconversation.com/files/131403/original/image-20160721-32610-4vnigg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Testing and treatment is important in tackling HIV. But stigma and access need to be addressed too.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Giving HIV-positive people access to antiretrovirals as soon as they become infected is an important step in controlling the infection. The challenge lies in making sure people who know they are infected actually take the drugs.</p>
<p>Taking antiretrovirals results in viral suppression by lowering the amount of virus in the bodily fluid of those infected with HIV. This makes them less infectious to other people. It is key to reducing HIV infection rates.</p>
<p>The World Health Organisation’s <a href="http://www.who.int/hiv/pub/guidelines/en/">new recommendation</a> is that a person who tests HIV positive should start treatment immediately. But in South Africa, at the moment, only patients with a CD4 count of 500 receive antiretrovirals. This policy is due to change in September 2016, when all those diagnosed with HIV will be eligible for treatment. As a result it is hoped that many more people will move onto treatment, towards the estimated <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">six million people</a> in the country living with HIV.</p>
<p>We undertook a <a href="http://www.avac.org/trial/anrs-12249-tasp">clinical trial</a> in KwaZulu-Natal province to find out whether the rate of new infections in a certain geographical area where everyone was tested and treated with antiretrovirals would be lower than in those areas where only people with CD4 counts of 500 were treated.</p>
<p>The trial was one of four treatment-as-prevention studies around the world. The KwaZulu-Natal study is the first to report its findings. The others are in Botswana, Kenya, Uganda and Zambia.</p>
<p>It was hypothesised that the KwaZulu-Natal study would demonstrate a 34% drop in new infections.</p>
<p>But our study found that there was no difference in the rate of new infections between people who have access to antiretrovirals from the get-go, and those who only have access at a certain stage of immunological decline. </p>
<p>Instead, we found that only 50% of the people who were tested and found to be positive visited a clinic within a year of being diagnosed HIV positive. And this tells us that even when people have access to treatment, the challenge lies in making sure they collect the medicine as soon as they are aware of their status. </p>
<p>While the biological approach is important, it is insufficient on its own. Our study highlighted many social and infrastructural barriers to getting people onto treatment. A series of social and behavioural factors needs to be considered in the context of preventing HIV. </p>
<p>The findings are important because they come months before South Africa begins implementing the new treatment policy. </p>
<h2>How we did it</h2>
<p>The trial took place in an area around the Africa Centre for Population Health. The centre is based in the Mtubatuba, a town in northern KwaZulu-Natal. The area around the centre has one of the highest prevalence of HIV in the world: about 30%.</p>
<p>We identified 22 geographical clusters of 1,000 people per cluster. Everyone in that population of the cluster was recruited and tested for HIV in their homes. </p>
<p>The clusters then fell into one of two groups. Depending on the cluster, people were either offered treatment according to the South African National Department of Health’s current national guidelines. This is based on their immune status. Or they received treatment for HIV regardless of immune status. </p>
<p>The care and mobile clinics were located near people’s homes. </p>
<p>But there were two significant factors at play. First, even after people were tested in their homes, found to be infected and provided with local clinics to access treatment, we found it difficult to get them to attend the clinics. Only 50% of those who tested positive got to clinics within a year of being diagnosed HIV positive. As a result they didn’t benefit from early treatment and reduction of infection. </p>
<p>Second, a large number – even up to about 50% – described that their most recent sexual partner was outside the study area. </p>
<h2>Reduction in viral loads</h2>
<p>The trial participants who were tested and who got into care and were treated showed significant reduction in their viral loads. This means that they could be considered non-infectious.</p>
<p>The big challenge we encountered was that the number of people who got into care was lower than we wanted. This may be the explanation for the fact that the rate of new HIV infections was not affected in ways we had anticipated.</p>
<p>A number of factors contributed to this. One of our findings is that it was more difficult to test men for HIV and, second, it was more difficult for those men to get into care. When they got into care, they did just as well as women. </p>
<p>There remains a significant stigma around HIV in this population. Not wanting to be seen in a clinic may have been a contributing factor.</p>
<h2>What’s missing</h2>
<p>With the national guidelines in South Africa changing, the trial highlights how to best treat everyone to maximise the effect. It shows that unless this policy is associated with increased effort to provide care and treatment and encourage people to come for treatment, then the benefit of treating everyone won’t materialise.</p>
<p>What this means is that we need to look at whether treatment can be given in people’s homes – or if there are other things that will encourage people to come to clinics, such as mobile phone technology that reminds them to do so. Even incentives to come to clinics may be an option. </p>
<p>Those clinics also need to be more friendly and efficient. They must be run in a way that ensures that waiting periods are minimal so that people aren’t required to take time off from work. And the stigma issue needs to be addressed to ensure that people aren’t uncomfortable and worried about coming to the clinic. </p>
<h2>Positive lessons</h2>
<p>There were also positive things that came out of the trial. These included:</p>
<ul>
<li><p>research teams having no challenges accessing the homes and households of all 22,000 people in the 22 clusters. This means the approach to gathering information at this level is feasible; </p></li>
<li><p>people accepting our approach; and </p></li>
<li><p>participants being happy that clinics were near their homes so they did not have to spend a large amount of money on transport to get to clinics. Transport costs were previously identified as a barrier in access to care.</p></li>
</ul>
<p>The research has provided valuable insights into what needs to be done to reduce the HIV infection rate in South Africa, which remains the highest in the world. This, as the country prepares for one of the biggest changes in policy since antiretrovirals were first introduced.</p><img src="https://counter.theconversation.com/content/62360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The treatment as prevention trial (ANRS 12249) was funded by the French ANRS and the Bill and Melinda Gates Foundation through 3ie. </span></em></p>Taking antiretrovirals is key to reducing HIV infection rates, but the challenge lies in making sure people who know they are infected actually take the drugs.Deenan Pillay, Director of the Africa Centre for Population Health and Professor of Virology, University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/626122016-07-20T13:12:35Z2016-07-20T13:12:35ZWhy migration patterns are so important to designing responses to HIV<figure><img src="https://images.theconversation.com/files/131236/original/image-20160720-31114-7jj509.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Activists protest the criminalisation of sex work outside the 21st International AIDS Conference in Durban, South Africa.</span> <span class="attribution"><span class="source">International AIDS Society/Abhi Indrarajan</span></span></figcaption></figure><p>Significant strides have been made in the global response to HIV. But there is an urgent need to rethink the ways that prevention and treatment programmes are developed and implemented. </p>
<p>There is a body of knowledge that highlights the important role of <a href="http://www.ncbi.nlm.nih.gov/pubmed/20958895">migration and mobility</a> in mediating the HIV epidemic in sub-Saharan Africa. Despite this, <a href="http://www.samj.org.za/index.php/samj/article/view/8569">current responses</a> fail to adequately engage the movement of people.</p>
<p>The policy and programme responses to HIV that are developed must be relevant for the different contexts of the continent. Population movement in the region is mostly associated with the search for <a href="http://www.samj.org.za/index.php/samj/article/view/8569">improved livelihood opportunities</a>. It involves a lot of internal movement of people who move within their country of birth. </p>
<p>South Africa receives the largest number of migrants from the region. Between 3% and 4% of the population is estimated to be <a href="http://www.statssa.gov.za/census/census_2011/census_products/Census_2011_Census_in_brief.pdf">cross-border migrants</a>. </p>
<p>The relationship between people’s mobility and local HIV epidemics must be taken into account. </p>
<p>But mobility should not merely be considered a risk factor. It should also be looked at as a structural determinant in how HIV responses are designed and implemented. This is because it has implications for the roll-out of pre-exposure prophylaxis and facilitates adherence to antiretroviral therapy. </p>
<h2>Traditional patterns have changed</h2>
<p>Population mobility has, historically, been a key driver in the early spread of the HIV epidemic on the continent. </p>
<p>But <a href="http://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(15)00057-0/abstract">recent evidence</a> suggests that <a href="http://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-14-350">national migration levels</a> are no longer linked to national HIV prevalence or incidence in epidemics. </p>
<p>HIV risk profiles are instead associated with the individual movements of key populations. </p>
<p>Some migrants, for instance, reside in <a href="http://www.queensu.ca/samp/sampresources/samppublications/policyseries/policy24.htm">spaces of vulnerability</a> such as transport corridors, urban informal settlements or mining hostels. These are areas associated with an <a href="http://www.queensu.ca/samp/sampresources/samppublications/policyseries/policy24.htm">increased risk of acquiring HIV</a>. </p>
<p>Certain mobile groups, including <a href="http://www.globalhealthsciences.ucsf.edu/sites/default/files/content/gsi/kpn3-da-female-sex-workers-fact-sheet.pdf">long-distance truck drivers and migrant sex workers</a> are considered <a href="http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf">key populations</a> at higher risk of acquiring HIV than the general population.</p>
<p>In a forthcoming chapter of the “<a href="http://www.e-elgar.com/shop/handbook-of-migration-and-health">Handbook of Migration and Health</a>”, Associate Professor Jo Vearey of the <a href="http://www.migration.org.za/">African Centre for Migration and Society</a> argues that an improved and nuanced understanding of population mobility would help the fight against HIV. According to Vearey: </p>
<blockquote>
<p>strengthening the understanding of the role of migration will assist in the development of migration-aware responses that are needed to support a more successful response to HIV in sub-Saharan Africa.</p>
</blockquote>
<p>Vearey argues that there is a need to ensure that people living with HIV can access continued treatment regardless of their mobility trajectory.</p>
<h2>The responses on the continent are limited</h2>
<p>Regional and national responses often fail to engage with migration even in contexts where mobility is prevalent. </p>
<p>In South Africa, for example, the responses to the <a href="http://www.mm3admin.co.za/documents/docmanager/f447b607-3c8f-4eb7-8da4-11bca747079f/00104917.pdf">National Health Insurance green paper</a> highlight the lack of consideration of migration and mobility to health responses at a national level. </p>
<p>Another example in the country is the <a href="http://www.gov.za/sites/www.gov.za/files/national%20strategic%20plan%20on%20hiv%20stis%20and%20tb_0.pdf">National Strategic Plan</a> for HIV.</p>
<p>Regionally, at the Southern African Development Community level, responses are limited. The 2009 Framework for <a href="http://www.arasa.info/files/6613/7574/3254/SADC_Policy_Framework_FINAL.pdf">Population Mobility and Communicable Diseases</a> remains in draft form. The framework aims to harmonise responses to migration and HIV/TB/malaria within the region. The draft sits, despite the framework’s <a href="http://www.opml.co.uk/projects/financial-assessment-sadc-policy-framework-population-mobility-and-communicable-diseases">proposed financing mechanism</a> being finalised.</p>
<p>In most countries, and in the southern African region particularly, undocumented migrants face complex obstacles in <a href="http://www.unaids.org/sites/default/files/media_asset/04_Migrants.pdf">accessing health-care services</a>. These include HIV testing and antiretroviral therapy. </p>
<p>On the continent this is further compounded by the absence of regional job-seeker permits. The lack of effective systems to ensure treatment continuity such as the use of standardised <a href="http://www.samj.org.za/index.php/samj/article/view/8569">patient-held records</a> or cross-border referrals also play a role </p>
<h2>A migration-aware response</h2>
<p>The 2016 <a href="http://www.aids2016.org/">International AIDS Conference</a>, themed “<a href="http://www.aids2016.org/About/Overview/Theme-Objectives">Access Equity Rights Now</a>”, urgently calls for extending HIV prevention, treatment and care services to those who still lack access. It also calls for HIV research and evidence-based interventions to be strengthened. </p>
<p>This should be coupled with the <a href="http://www.iol.co.za/capetimes/pre-exposure-arvs-for-sex-workers-2029352">roll-out</a> of pre-exposure prophylaxis to high-risk key populations such as <a href="http://www.iol.co.za/capetimes/pre-exposure-arvs-for-sex-workers-2029352">sex workers</a> – many of whom are migrants. </p>
<p>It certainly appears to be the best time for South Africa – and the sub-Saharan African region as a whole – to re-focus on poorly understood structural realities of HIV such as population mobility, and invest in migration-aware policy and programming.</p>
<p>Vearey argues that these programmes should support public health systems in the region to facilitate and respond to the movement of people. This movement can be within countries and across borders but should include anyone receiving antiretroviral therapy.</p>
<p>She also recommends that migration-aware HIV responses improve measures of migration and HIV prevalence. This would avoid unfounded automatic links between national and individual levels. </p>
<p>Programmes should look at disease-induced migration – where people move to seek treatment – such as HIV treatment-induced mobility.</p>
<p><em>“The Handbook of Migration and Health” will be published in December 2016 and made available via <a href="http://www.e-elgar.com/shop/handbook-of-migration-and-health">Edward Elgar Publishing</a>.</em></p><img src="https://counter.theconversation.com/content/62612/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ntokozo Yingwana does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mobility is not only a risk factor for HIV – it is also a structural determinant in how HIV responses are designed and implemented.Ntokozo Yingwana, Researcher and PhD Candidate at the African Centre for Migration & Society, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/625702016-07-20T13:12:33Z2016-07-20T13:12:33ZA cure for HIV: what science knows, and what it doesn’t<figure><img src="https://images.theconversation.com/files/130898/original/image-20160718-2115-1yqeb9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This human T cell (blue) is under attack by HIV (yellow), the virus that causes AIDS. T cells play a critical role in the body's immune response.</span> <span class="attribution"><span class="source">Seth Pincus, Elizabeth Fischer and Austin Athman, National Institute of Allergy and Infectious Diseases, National Institutes of Health</span></span></figcaption></figure><p>Antiretroviral therapy has revolutionised the lives of people living with HIV. In many countries, the <a href="https://www.sciencebasedmedicine.org/hiv-treatment-extends-life-expectancy/">life expectancy</a> for someone living with the virus is now almost the same as someone who isn’t infected. </p>
<p>But antiretroviral therapy is not a cure. When it is stopped, the virus rebounds within a few weeks in almost all infected individuals – even after many years of suppressive therapy. </p>
<p>So HIV research continues to search for a cure. The focus is on understanding where and how HIV persists on antiretroviral therapy. These insights are then used to develop therapies that will ultimately enable us to cure HIV infection – or allow people living with HIV to safely stop antiretroviral therapy and keep the virus under control.</p>
<h2>Theoretical possibility</h2>
<p>There has been a substantial increase over the past decade in our understanding of where and how HIV persists when someone is on antiretroviral therapy. It is now clear that integration of the HIV genome into long-lived resting cells is a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381961/">major barrier</a> to a cure. This state is called HIV latency. </p>
<p>The virus can also persist on antiretroviral therapy in other forms. In both monkey models of HIV and in HIV-infected individuals on antiretroviral therapy, the virus has been found in T follicular helper cells, which are found in a specialised compartment in the lymphoid tissue. These cells are found in a part of the lymph node where penetration of immune fighting cells, or cytotoxic T cells, is limited. </p>
<p>In some tissues, antiretrovirals may not penetrate well. This could also contribute to persistence. Finally, there is also <a href="http://tagbasicscienceproject.typepad.com/tags_basic_science_vaccin/2016/02/new-paper-rekindles-debate-on-hiv-replication-during-art.html">some evidence</a> that, in at least some individuals and some sites, the virus may still be replicating at very low levels.</p>
<p>To date there has been just one case of a <a href="http://www.iflscience.com/health-and-medicine/scientists-closer-understanding-how-berlin-patient-was-cured-hiv/">cure for HIV</a>. This was in the context of haematopoietic stem cell transplantation for leukaemia with HIV-resistant donor cells. This is clearly not a feasible curative strategy for HIV. But what we have learnt is that the complete eradication of HIV is theoretically possible. Similar approaches have been tried, but no others have yet been successful. All six individuals receiving a similar transplant died of infection or cancer relapse within 12 months of transplantation.</p>
<p>Other case <a href="http://www.ncbi.nlm.nih.gov/pubmed/26731468">reports</a> have confirmed that haematopoietic stem cell transplantation, even from a regular stem cell donor, can drastically reduce the frequency of infected cells. But when antiretroviral therapy was subsequently discontinued, the virus still rebounded – though it took months and not weeks.</p>
<p>These cases demonstrate that although reducing the frequency of latently infected cells might delay time to viral rebound, there’s a need for continued effective immune surveillance against HIV to keep whatever remains in check.</p>
<h2>Gene therapy</h2>
<p>Using <a href="http://www.aidsmap.com/Gene-therapy-snips-HIV-out-of-infected-cells-and-makes-uninfected-cells-resistant/page/3046950/">gene therapy</a> to either make a cell resistant to HIV or to literally remove it from the cell is now being actively investigated. The initial target of gene therapy was CCR5. This same gene is missing in some rare individuals who are naturally resistant to HIV.</p>
<p>There have been safe clinical trials of gene therapy that eliminate the CCR5 gene and make other cells resistant to HIV. But a lot of work still needs to be done to increase the numbers of gene-modified cells.</p>
<p>Other <a href="https://www.quora.com/Can-molecular-scissors-be-used-to-mutate-the-CCR5-gene-and-cure-HIV">work</a>, still at the stage of test-tube experiments, uses gene scissors to target the virus itself. This approach might be trickier than targeting CCR5. This is because the virus can rapidly mutate and change its genetic code so that the gene scissors no longer work.</p>
<h2>Other options</h2>
<p>By starting antiretroviral therapy very early – within days to weeks of infection – it is possible to substantially reduce the number of latently infected cells. This also helps preserve immune function. Although not an option for the majority of HIV-infected individuals who are diagnosed too late, early diagnosis and treatment could be an effective strategy to maintain immune control for some patients. </p>
<p>Several years ago, <a href="http://www.aidsmap.com/French-researchers-report-14-patients-in-remission-after-controlling-HIV-for-over-4-years-off-treatment/page/2602347/">French investigators</a> described that post-treatment control was possible in up to 15% of individuals treated within months of infection. These data remain a little controversial, as in other cohorts post-treatment control is far less common. We still don’t fully understand what factors are important for post-treatment control, but it seems that the nature of the immune system is critically important.</p>
<p>Interestingly, post-treatment control may differ in different ethnic groups. A <a href="http://www.aidsmap.com/Post-treatment-control-of-HIV-appears-rare-biomarkers-may-help-predict-viral-rebound/page/3008234/">recent report</a> from Africa suggests that post-treatment control could occur at far higher frequencies in African populations than in Caucasians.</p>
<p>And the <a href="http://www.nature.com/nri/journal/v16/n4/full/nri.2016.19.html?WT.feed_name=subjects_antigen-processing-and-presentation">early treatment of infants</a> may potentially shift the virus from hiding in long-lived to short-lived T cells. Understanding the differences in where the virus persists in children and in adults could provide important insights into novel strategies to find a cure for HIV. </p>
<h2>‘Shock and kill’</h2>
<p>Activating the expression of HIV proteins in latently infected cells by drugs called latency-reversing agents could drive the elimination of virus-expressing cells through immune- or virus-mediated cell death. This approach is usually referred to as “shock and kill”.</p>
<p>A substantial body of research has helped identify <a href="http://tagbasicscienceproject.typepad.com/tags_basic_science_vaccin/latency-reversing-agents-1/">latency-reversing agents</a> that have now been tested in experimental clinical trials. These studies demonstrated that although HIV expression can be induced in patients on suppressive antiretroviral therapy, this did not reduce the frequency of infected cells. In other words, shock but no kill.</p>
<p>Ongoing studies are looking at ways to augment the killing of these cells by <a href="https://www.ucl.ac.uk/news/news-articles/0415/130415-human-immune-system-control-HIV">boosting the immune system</a>, for example through vaccines or medications that trigger suicide of the infected cells.</p>
<h2>Prevention and boosting immune responses</h2>
<p>Cure research is likely to benefit from the very significant investment in vaccines that have been developed to protect people from getting infected. Some of these could work in a cure too. These vaccines are now being investigated in the setting of clinical trials in infected individuals on antiretrovirals.</p>
<p>There have been spectacular recent advances in the <a href="http://www.cancer.gov/research/areas/treatment/immunotherapy-using-immune-system">treatment of some cancers</a> using drugs that boost the immune response. These are called immune checkpoint blockers. </p>
<p>These drugs reinvigorate exhausted T cells so they can move into action – against cancer cells and in the same way, against HIV-infected cells. These drugs are now in the clinical trial stage in HIV-infected patients being treated for different cancers.</p>
<p>Another way to boost the immune system is to trigger a very primitive immune response designed to respond to infections. These drugs are called <a href="http://www.nature.com/cti/journal/v5/n5/full/cti201622a.html">toll-like receptor (TLR) agonists</a>. In monkeys, TLR-7 agonists stimulate latently infected cells and an effective immune response. This leads to a modest reduction in infected cells. Clinical trials are now under way in HIV-infected individuals on antiretrovirals.</p>
<h2>Other interventions are needed</h2>
<p>A successful strategy is likely to need two components: reducing the amount of virus that persists on antiretroviral treatment and improving long-term immune surveillance to target any residual virus. Far more work must be done on an HIV cure in low-income settings to better understand the effects of different HIV strains, the effects of co-infection and the impact of host genetics.</p>
<p>Lessons from other fields, particularly oncology, transplantation and fundamental immunology are all relevant to inform the next advances needed in cure research. Finally, we have to ensure that any intervention leading to a cure is cost effective and widely available.</p>
<p>The implementation of combination antiretroviral therapy in the mid-1990s is still regarded as one of the most remarkable achievements in modern medicine. Life-long antiretroviral therapy remains the single best option for any person infected with HIV. Finding a cure for HIV remains a major scientific challenge, but many believe it to be within the realm of possibility and it will hopefully play an important role in seeing an end to HIV.</p>
<p><em>This is an edited version of an article that appeared in <a href="http://www.spotlightnsp.co.za/">Spotlight</a>, a quarterly South African health publication.</em></p><img src="https://counter.theconversation.com/content/62570/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharon Lewin receives funding from the NHMRC, the National Institutes for Health, Wellcome Trust, American Foundation of AIDS research, the University of Malaya, the Danish Medical Council, the Australian Centre for HIV and Hepatitis and investigator-initiated company funded studies from Merck, Gilead and ViiV. She is a member of the International AIDS Society.</span></em></p><p class="fine-print"><em><span>Thomas Aagaard Rasmussen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>HIV research continues to search for a cure. The focus is on developing therapies to cure HIV infection or allow people with HIV to safely stop antiretroviral therapy and keep the virus under control.Sharon Lewin, Consultant Physician, Department of Infectious Diseases, Alfred Hospital & Director, The Peter Doherty Institute for Infection and ImmunityThomas Aagaard Rasmussen, Clinical Research Fellow, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/624792016-07-18T12:29:13Z2016-07-18T12:29:13ZHow three new studies unravel South Africa’s patterns of HIV transmission<figure><img src="https://images.theconversation.com/files/130885/original/image-20160718-2110-ob5v2v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The more scientists understand about what drives HIV transmission, the more they can start to fight the virus.</span> <span class="attribution"><span class="source">Rupak De Chowdhuri/Reuters</span></span></figcaption></figure><p><em>Young women bear a disproportionate burden of HIV in sub-Saharan Africa – and South Africa has a particular challenge. In some parts of the country more than 36% of people are HIV positive.</em> </p>
<p><em>Three studies conducted by the Centre for the AIDS Programme of Research in South Africa (Caprisa) in rural and urban sub-districts of the KwaZulu-Natal province provide new insights into the engine that drives HIV transmission in the country. They also reveal a new way to tackle the problem of HIV. Caprisa’s director Professor Salim Abdool-Karim explains the latest findings.</em> </p>
<p><strong>What did you discover about the patterns of HIV transmission?</strong></p>
<p>Our first study focused on interrogating the age-disparate sexual relationships between older men and younger women. This would help us better understand who was infecting young girls within the community. </p>
<p>The study used gene sequencing on HIV positive people within the community to get a clearer picture of how many people had the same or similar versions of the virus. It was found that in about a third of the sample, they could link people to a cluster where there was the same or similar virus to others in that community.</p>
<p>This data showed that adolescent girls and young women were contracting HIV from their partners, who were on average eight years older. These older men were simultaneously in sexual relationships with women – of similar ages to the men – who have HIV prevalence rates exceeding 60%. While the fact that young women are engaged in sexual relationships with older men is not new information, this study provides insight into how HIV is transmitted within this community.</p>
<p>This is where the “cycle of transmission” became apparent. Older women, who are HIV positive, are in relationships with men the same age as themselves. However these men, who are mostly unaware of their HIV status, are then also sleeping with younger women. The younger women will then contract HIV and when they grow up they will become the source of infection for men in the same age group as them. This perpetuates the cycle.</p>
<p><strong>What additional factors account for the high infection rates in adolescent girls?</strong></p>
<p>In addition to this “cycle of transmission”, our other two studies revealed biological factors that put young women at high risk of HIV infection. We did this by analysing vaginal bacteria. The second study looked at the genetic codes of vaginal bacteria of 119 South African women. </p>
<p>It was found that women who had an abundance of a naturally present bacterium (Prevotella bivia) had a 13-fold increased risk of acquiring HIV. Overgrowth of the bacteria resulted in a protein called lipopolysaccaride being released which increased genital inflammation 20-fold. This genital inflammation increases vulnerability to HIV infection and places young women with excess Prevotella bivia at greater risk of becoming HIV positive.</p>
<p>The third study also looked at genital bacteria in women. Here we wanted to gain a better understanding of the efficacy of tenofovir gel being used as a pre-exposure prophylaxis (PrEP). </p>
<p>It showed that tenofovir gel was effective in three out of five women who had a dominant presence of a bacteria called lactobacillus. Lactobacillus bacteria is naturally present in the vagina and helps maintain an acidic pH. This is beneficial as it maintains a “healthy” vaginal environment.</p>
<p>Women with low levels of this bacteria had increased levels of Gardnerella vaginalis – a bad bacteria naturally which is naturally present in the vagina. This poses a problem to the efficacy of tenofovir, since Gardnerella absorbs the tenofovir drug. This reduces the amount of tenofovir present and inhibits the efficacy of PrEP.</p>
<p>The results of these studies and the new information they provide enable us to re-examine HIV prevention interventions to break the cycle of transmission. The presence of Prevotella and Gardnerella can both easily be tested for. There is a readily available antibiotic treatment should women require it. </p>
<p>These new targeted interventions can have a significant impact on reducing the spread HIV and reducing the risk young women face of becoming HIV positive in South Africa.</p>
<p><strong>How do you break this transmission?</strong></p>
<p>Our studies show that there are a complex set of social and behavioural factors that have an impact on HIV transmission. Treatment is key but you need additional measures. Circumcision in young men will reduce their risk of contracting HIV but there may still be some transmission. Young girls also need to be protected with pre-exposure prophylaxis. </p>
<p>In total, test and treat initiatives with circumcision and PrEPs are a combination that can break the patterns of HIV transmission. But the critical issue is that we cannot adopt an ostrich approach to older men sleeping with younger women. We need a new set of community norms. </p>
<p>These studies can also be applied to Eastern Africa and the rest of southern Africa, where 70% of the HIV population lives, to see if there are similar results. This would inform policies to tackle the problem of HIV transmission.</p><img src="https://counter.theconversation.com/content/62479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>These studies were funded by PEPFAR, Centers for Disease Control and Prevention, the M·A·C AIDS Fund, USAID and the Canadian Institutes for Health research. </span></em></p>Three new studies conducted in South Africa provide insights into the engine that drives HIV transmission in the country.Salim Abdool Karim, Director , Centre for the AIDS Program of Research in South Africa (CAPRISA)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/623812016-07-17T17:20:35Z2016-07-17T17:20:35ZWhy the International AIDS Conference still matters<figure><img src="https://images.theconversation.com/files/130715/original/image-20160715-2133-1qwfmz8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Trinn Suwannapha/World Bank</span></span></figcaption></figure><p><em>More than 18,000 scientists, clinicians, experts, civil society representatives and leaders are descending on Durban, South Africa, for the <a href="http://www.aids2016.org">International AIDS Conference</a> from July 18. Some have suggested that these sorts of conferences are little more than “<a href="http://www.aljazeera.com/blogs/africa/2013/07/81701.html">talk shops</a>” that do little to further the fight against HIV/AIDS. Professor Mzi Nduna of the University of the Witwatersrand’s Department of Psychology tells Candice Bailey, The Conversation Africa’s health and medicine editor, why she disagrees with these critics.</em></p>
<p><strong>Some say the AIDS conference is just a talk shop. Is that unfair criticism?</strong></p>
<p>It is easy for people without a deep understanding of the epidemic and how far we have come in addressing the challenges faced by communities, governments and the scientific community to think and say that the AIDS conference is just a talk shop. </p>
<p>Still, perhaps we need to relook at the regularity and repetition of these conferences. The same people tend to attend national, regional and international conferences on this issue. This selective attendance is created by access, or lack thereof, to funding. Scientists who do “good” science have their abstracts accepted and receive funding to attend. </p>
<p>This model excludes many people who work in the field of HIV/AIDS and could participate meaningfully in the conference. It also results in presenters talking only to each other in front of small audiences.</p>
<p>It’s important to change the faces of attendees and to open up opportunities for participation. Academic and scientific institutions must re-examine how they fund conference attendance. Funding should be made accessible to civil society bodies so their members can participate in bigger numbers.</p>
<p>All of that said, there is undisputable value in these meetings. They provide an opportunity for scientists to share their most recent findings. They’re also a platform for advocates and activists to engage with science in a way that’s not usually possible. Most of these findings may not otherwise be disseminated beyond exclusive, expensive research journals.</p>
<p>These conferences are also a chance for civil society to meet and engage with governments and donor partners. These meetings are very important: decisions that change lives flow from them. There are chances for networking and information sharing, particularly about what works. It mustn’t become an “acronym festival” – there’s no need to always start new programmes with interesting acronyms when existing programmes can be strengthened and expanded. </p>
<p><strong>What do you think the major changes have been since the <a href="https://theconversation.com/16-years-on-the-worlds-biggest-aids-conference-returns-to-africa-62399">last Durban meeting</a> (in 2000) in the attitudes to and management of the disease?</strong></p>
<p>South Africa has moved from a <a href="https://muse.jhu.edu/article/172446/summary">denialist phase</a> in which its leaders questioned the origins of HIV and denied its link to the disease clinically labelled AIDS. Now we know and collectively accept that the HI virus is a precursor for AIDS; that it affects men, women, straight and gay people, those who are poor and also the rich. The discourse has moved beyond creating categories of people “at risk”. These categories have not been useful in the past; they have misled and deceived. </p>
<p>But it’s undeniable that some people are <a href="https://jiasociety.biomedcentral.com/articles/10.1186/1758-2652-13-44">more vulnerable</a> because of their social context . For example, Africans everywhere in the world form a larger number of people infected with HIV. Young black African women in particular form a larger part of the number of people living with HIV globally and in sub-Saharan Africa – with South Africa at the front of the pack.</p>
<p>Given this knowledge, it becomes clear that the answer to HIV prevention and treatment for AIDS is a call beyond the bio-medical approach. Responding to the HIV/AIDS epidemic is a developmental challenge and should be treated as such. All sectors of society are needed to implement their work in ways that take into cognisance their role in either increasing or reducing vulnerability. Sector collaboration has resulted in strides in reduction of new neonatal infections globally. Women need to worry less about decisions to have a child when living with HIV. This is a situation that has <a href="http://www.ncbi.nlm.nih.gov/pubmed/19301114">dominated narratives</a> of women living with HIV before the effective implementation of prevention of vertical transmission of HIV. This has since changed. </p>
<p><strong>What are the important decisions that should come out of this conference?</strong></p>
<p>One of the pre-conference meetings I attended was the <a href="http://womennow2016.org/">Women Now!</a> conference, also in Durban. It was a vibrant space where African women from all over the world gathered to share information about their HIV prevention and treatment programmes. Women agreed in this meeting that “our stories are our data”, a statement made in response to the marginalisation of the black women’s narrative in the HIV/AIDS scientific world. </p>
<p>This statement resonated with us all. As the most infected and affected sector of the population, women need to re-appropriate the narrative of the HIV/AIDS epidemic and to be at the centre of responses aimed at addressing their prevention and treatment needs. I am hoping that this will be carried through and beyond this 21st International AIDS Conference.</p>
<p>Decriminalisation of sex work is another issue that’s really important. The opening of the conference coincides with the observation of Mandela Day. What better way to remember Nelson Mandela, the former president of South Africa and an icon for human rights than to address decriminalisation?</p>
<p>Decriminalising sex work will go a long way in the fight against human right abuses. As delegates arrived, it is alleged that some sex workers were denied accreditation because of their “criminal records”. If we continue at this conference to discuss sex and risk while excluding sex workers, we’d be talking out of context. I am hoping that this is resolved immediately so that as we deliberate, we leave no-one behind. </p>
<p>One other important conversation at this year’s conference is dissemination of information about <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00056-2.pdf">pre-exposure prophylaxis</a> (PrEPs). We need governments to make decisions on the roll-out of PrEps for prevention. In some countries PrEps is made available to sex workers and men who have sex with men. It is important to extend this tool to other young women as well to reduce the risk in the general population.</p><img src="https://counter.theconversation.com/content/62381/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mzi Nduna receives funding from the DST NRF Centre of Excellence-Human development. She is also a research partner with AIDS Foundation of South Africa and AIDS Accountability International.</span></em></p>The International AIDS Conference is more than just a talk shop. The platform it offers for engagement between governments, scientists and civil society is of undisputable value.Mzi Nduna, Associate Professor in Psychology, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.