In addition to the many resources mobilized in response to COVID19, it is essential not to overlook other pandemics that still have a great and lasting effect and on which equally important and lifesaving work has been concentrated. A recent seminar series called Life Sciences Across the Globe focused on global experts discussing how to advance life sciences. World-renowned HIV researchers were among those presenting.

The Institute of Infectious Disease and Molecular Medicine (IDM) at the University of Cape Town (UCT) held its monthly seminar on 4 August. The series is a collaboration between the Howard Hughes Medical Institute and Janelia Research Campus.

The IDM’s Education Committee chair, Associate Professor JoAnn Passmore, emphasized the institute’s focus on diseases relevant to Africa and its commitment to training the next generation of African scientists.

“The world currently has more than 40 million [people] living with HIV, many of whom live in sub-Saharan Africa. HIV researchers have been focusing on the endgame: a cure for HIV. 

Strategies towards a cure

Sharon Lewin is a physician and basic scientist who specializes in infectious diseases. Lewin is the inaugural director of The Peter Doherty Institute for Infection and Immunity, a joint venture between the University of Melbourne and Royal Melbourne Hospital in Australia. In addition to developing clinical trials to develop a cure for HIV, she conducts research to understand why HIV persists despite treatment.

The goal of reaching 95% of people living with HIV on treatment by 2025 is a challenging one, given that 1.8 million new infections occur annually in the world.

Due to antiretroviral therapy, the face of HIV has changed dramatically. With a daily dose of one tablet, antiretroviral therapy is now more straightforward. Additionally, treatment is relatively cheap, mostly accessible, nontoxic, and available to at least 70% of the world’s population.

“People will have to inject themselves every other month just to keep their virus under control with new advances in antiretroviral therapy. Since antiretroviral therapy isn’t perfect, we need a cure,” she said.

HIV testing is a core strategy in HIV prevention. A person who tests positive and begins treatment gradually becomes less infectious. We are treating it as we prevent it.

Destigmatizing testing is key – HIV testing and COVID19 testing are two very different things. We need to normalize testing since people don’t like to get tested for many reasons. In contrast, testing people frequently, with their consent, and starting treatment [early] is very effective. Those actions have led to reductions in HIV over time.”

Bringing it home

Thumbi Ndung’u is a professor of infectious diseases and the Max Planck group leader at Africa Health Research Institute. The Females Rising through Education, Support, and Health (FRESH) cohort is under his care. FRESH aims to empower young women through the programme and to encourage participation and feedback in a bidirectional manner.

Ndung’u noted that the highest HIV prevalence is in KwaZuluNatal. According to Dr. Emily Wong’s research published in Lancet Global Health this year, 36% of males and 60% of females aged 25 to 44 are HIV positive.

“As someone living in a resource-limited environment, the most exciting approaches revolve around early diagnosis and early immune therapy and these approaches are probably more likely to be implemented in these settings,” said Ndung’u. “There’s also evidence that this is achievable. So combination approaches will likely form the first line of HIV cure strategies.

“We have a history where we have seen that developing interventions by themselves is not enough. Instead, we need to make sure that interventions are tailored to the communities that will benefit from them.”

Hope and healing

Over the past 30 years, of the 78 million people who have been infected with HIV, 39 million have died of it.

The evolution of the virus and the eras of despair, hope, and most recently, the hope that a cure might be in sight.

“The cure for HIV will come. We’ve got to be optimistic. We’ve got to believe.”

There are a variety of barriers that can make it difficult to continue treatment, continue at scale, and continue well. Politics, discrimination, stigma, accessibility, and specific regulations are some of these barriers. This epidemic is far from over.

Working with community advisory boards and including those served in terms of education is crucial to ensuring that the community has a voice.

“The best science is relevant science. Relevance asks, ‘What is the priority?’ Science then asks the right question. If asked and listened to, the community frames the context. And together, the community and science can find the right answer.”

The Torch Caravan, an initiative of the Global Fund@20, spreads light and hope throughout Africa.  In addition to passing the torch, eight countries reflected on the Global Fund’s impact on reducing disease burdens and building sustainable systems for health care. 

The highest level of participation has been achieved by civil society organizations, parliamentarians, and people dealing with the disease themselves. The Global Fund changed the narrative because before it came if someone had HIV, they would waste away and die. But since then, people have a new perspective.”   Maurine Murenga, Lean on Me Foundation, Kenya

There is much excitement and gratitude expressed by various countries. The Central African Region will receive the torch in September from the East African Region.

Peter Sands, Executive Director, the Global Fund: “We celebrate the people, the partners, the advocates and the communities who have led to this remarkable success.”

While providing supply support for the COVID-19 response to support overstretched healthcare systems and community health networks, Global Fund works tirelessly to protect lifesaving AIDS, tuberculosis and malaria programs. We are stronger when we work together. 

Several health services have been negatively affected by COVID-19 outbreaks, partly due to overburdened systems. In low- and middle-income countries with high rates of HIV, tuberculosis, and malaria, disrupted services could result in premature deaths over the next five years.

During the largest epidemic in history, the WHO has warned against diverting funds from programs fighting HIV, TB, and malaria. Despite this, USD 1.7 billion is being diverted from health into security because of the Covid outbreak. This is equivalent to the amount needed to treat all three diseases over two years.

In light of rising COVID-19 mortality rates worldwide, it has become increasingly evident that vulnerable populations are disproportionately affected. Vulnerable people include those who live in densely populated areas, those with low socioeconomic status, migrants, and minorities. There are higher rates of comorbid chronic conditions in these groups, placing them at higher risk for infections and severe disease consequences.  

Services to prevent disease (voluntary medical male circumcision, pre-exposure prophylaxis, long-lasting insecticide-treated nets [LLINs], and seasonal malaria prevention) have been suspended or reduced; ongoing treatment (for HIV and tuberculosis) and new acute treatment (for malaria) have been cut by 25 to 50 per cent during peak demand periods, as well as treatment for those newly seeking care (HIV or tuberculosis testing and treatment). 

The Xpert MTB/Rif molecular diagnostic tool, intended to diagnose tuberculosis accurately, was potentially repurposed for COVID-19 diagnosis, further driving down diagnosis and treatment rates for tuberculosis. 

HIV experts and communities have often stepped up and provided support during the worst of the crisis. The worldwide response has drawn on decades of experience in combating AIDS. Globally, many countries responded quickly, addressing vulnerabilities, maintaining health services, and creating synergies between AIDS control and COVID-19. By doing so, HIV and COVID-19 threats are dealt with simultaneously.

Despite a decline of 23% in HIV-new infections since 2010, the COVID-19 pandemic may reverse this trend, and populations already behind may fall further behind. Recovery programs are therefore essential for areas with high HIV rates, as are programs for tuberculosis and malaria to reduce the health impact of the COVID-19 pandemic.

Priorities for reducing the effects of COVID-19 include maintaining services such as HIV and tuberculosis treatment (for new and existing patients), malaria prophylactic treatment, and LLIN distribution.

As a result of social distancing measures instituted by COVID-19, it is estimated that HIV transmission and tuberculosis transmission would be reduced by 10%.

Insufficient national and global investments in pandemic readiness are exposed by the recent HIV and COVID-19 pandemics and their responses. Health systems will need to be more resilient in the long run in order to handle shock events such as pandemics.

Together with HIV, TB and Malaria, COVID-19 should build synergies to make sure that they increase access to services, decrease the risk of infection and disease, and impact programme outcomes.

The latest report from UNAIDS that gains made in the fight against new HIV infections may be reversed ten years back is worrying. Every week this year, Kenya is recording 275 new HIV infections from adolescents and young women aged between 18 and 25 years. Although no research has been done, it is believed that girls younger than 18 are also getting infected.

Loss of incomes, schools closure, sickness and even deaths due to COVID 19 which continues to ravage the country since March 2020 have been pointed to as some of the reasons why there has been a spike in the numbers of girls who are contracting HIV. This is because adolescents and young women have turned to transactional sex to buy essentials like sanitary towels and even food, are engaged in cross generational sex due to early marriages to escape poverty, and some have been sexually violated.

“Unless all stakeholders come together and re-direct their efforts by doing everything necessary, we risk reversing the milestones made in fighting new HIV infections. If we are to attain our target of zero infections by 2030, we must ensure we are on the path to recording fewer cases of new infections,” said Rosemary Mburu, WACI Health Care CEO during a one day workshop dubbed ‘a conversation with young women and policy makers in Kenya in view of women initiated HIV prevention options’.

News that adolescents and young women can take charge of their own health and protect themselves from possible HIV infection is exciting. With a Silicon Ring laced with anti-retroviral drug Dapivirine, every sexually active woman has been afforded an opportunity to remain protected. The Ring which has been under research for 16 years received a positive opinion form European Medicines Agency (EMA) in July 2020 with the World Health Organisation (WHO) approving it for prequalification. It has already undergone phase I, II and III studies, and has been found to protect women from HIV infection at an over 50 percent rate for those who adhered to it as instructed. The ring is now into phase IV clinical trials, to ascertain its efficacy in mass population.

Once approved, adolescents and young women at their own privacy and convenience will have access to the first woman initiated HIV prevention option available for use. The Ring is designed to protect one for 28 days upon insertion to the cervix by releasing a daily dose of the Dapivirine drug to the cervix, making it effective for cisgender women only.

“The fact that I can protect myself from a possible HIV infection by using something which my sexual partner does not have to know I am using is empowering,” said one young woman who participated in the conference. Indeed, may other young women who attended the conference were grateful that for the first time, there is a product that has been developed with them in mind, and are looking forward to when the Ring will be made available in the country.
Joyce Ouma, a young HIV advocate urged all HIV negative adolescents and young women to embrace the Ring when it is eventually available, stating that whereas other options that exist are excellent, the Ring affords one the power to self- protect without having to negotiate for the same from a sexual partner. “Besides, since nobody plans to have sex, it is better to have something which will protect you for any in eventuality,” she added.
Indeed, although the Ring does not offer 100 percent protection from HIV, the consensus from the participants was that they were better of protected at some degree than remain exposed to the virus.

Scientists and Researchers are one trial closer to launching a woman’s first initiated HIV prevention option, the Dapivirine Ring. Years of research and three clinical trials are delivering the exciting reality of a product that a woman is in control of. Already, the Dapivirine Ring has received approval from World Health Organisation (WHO).
The ring which is developed by the International Partnership for Microbicides (IPM) is made of a flexible silicone matrix polymer contains the ARV Dapivirine, an NNRTI, which is slowly released over the course of a month. The ring delivers Dapivirine directly at the site of potential infection, with low systemic absorption. Women insert the flexible, long-acting ring themselves into the vagina and replace it every month.

Dr Nelly Mugo, while addressing participants in an event where young women and stakeholders met to discuss the innovation praised the Ring. A researcher with Kenya Medical Research Institute (KEMRI), Dr Mugo endorsed the product as an effective one, and was happy that women have yet another option in the basket of HIV prevention initiatives. “Africa remains hard hit by HIV, with young people accounting for half of all Africa’s infections. Women continue to be more vulnerable because of many factors such as their anatomy, social, cultural and even economic setbacks. That there is something which adolescents and young women can use without having to negotiate with anybody in order to protect themselves is a game changer in the world of HIV prevention research,” said Dr Mugo.
Maryann Mburu, WACI Health CEO, told the participants that the Dapivirine Ring when approved would go long way in helping prevent potential infections.

“At the moment, we risk reversing gains made in combating new HIV infections, if the numbers from UNAIDS is anything to by,” she said, adding that 275 girls are getting infected every week in Kenya. “These numbers are alarming and if there is anything we can do to stop the spread, then we must,” she added. Calling on all stakeholders to join hands and ensure that the Ring gets approved in Kenya, Mburu said that as much as the Ring does not deliver 100 percent protect from HIV infection, our adolescents and young women were better off with the Ring option than with nothing.

Same was echoed by Lydia Tuitai from Pharmacy and Poisons Board, who broke down the process of having a drug registered in Kenya. Ephasising on the need to ensure due process at all stages to ensure safety and efficacy, Lydia said once the Ring meets the board requirement, they would be excited to approve the Dapivirine Ring.

Maureen Inimah, a program officer at National AIDS and STD Control Programme (Kenya) (NASCOP) said that they were excited and open to more options that will help women protect themselves against HIV infections. NASCOP, which operates as a unit within the Ministry of Health and is mainly involved with technical co-ordination of HIV and AIDS programmes in Kenya promised to scale up youth friendly facilities so that when products such as the Dapivirine Ring finally comes in the country, Kenya’s adolescents and young women will find sensitized work force in the clinics. “In 2010, only seven percent of Kenya’s health facilities were youth friendly. This has in a way hindered effective service delivery to the same demography. Towards this, we are doing all we can to improve these numbers and to empower the service providers on how to interact with the young women seeking services from the clinics,” said Maureen.