Almost 20 000 people are expected to descend on Durban as the International Aids Conference returns to the port city 16 years after it first came to South African shores. Then, the gathering was defined by a lack of antiretroviral (ARV) treatment in South Africa. This week, the meeting is likely to be a moment of reflection in an era of HIV treatment as the world charts the future of the HIV response.
1. The "c-word" For most of the epidemic's three decades, talk of a cure has been largely confined to charlatans, but major scientific breakthroughs in the past 10 years have paved the way for talk of a cure in decades to come.
"Not long ago, few considered the possibility that a cure for HIV infection could some day be possible," Nobel Laureate Françoise Barré-Sinoussi told Bhekisisa. She co-chairs the International Aids Society's Towards an HIV Cure Initiative, which launched a new strategy charting the future of HIV cure research this week.
"Berlin Patient" Timothy Ray Brown received a bone marrow transplant from a donor with a rare genetic mutation. This mutation prevents HIV from establishing itself in the body. In a February 2009 report in the New England Journal of Medicine, researchers posited this genetic mutation has halted replication of HIV in Brown's blood.
Although this type of treatment would be too costly to replicate on a large scale, it has paved the way for other cure research, including talk of HIV remission in some aggressively treated patients.
Not far behind HIV cure research is work on vaccines, which some scientists say will be needed to control HIV epidemics. Researchers are hoping to attain or surpass the relative Holy Grail in current vaccine work — replicating the world's only moderately effective HIV vaccine trial in Thailand. The Thai vaccine was about 30% effective in preventing HIV infection, according to a 2009 study in the New England Journal of Medicine. An adapted vaccine is being tested in South Africa.
2. Young women Each week, about 2 000 young women contract HIV in South Africa, according to the country's latest HIV household survey by the Human Sciences Research Council.
In February, the Aspire trial conducted among about 2 630 women in Malawi, South Africa, Uganda and Zimbabwe reported that a vaginal ring, which releases antiretroviral (ARV) drugs, reduced a woman's risk of contracting HIV by 27%, according to research published in the New England Journal of Medicine earlier this year.
New findings from Aspire are expected to be released at the conference and may shed light on this device means for young women.
In 2012, the World Health Organisation recommended all pregnant women diagnosed with HIV start on lifelong ARV treatment not only to prevent mother-to-child HIV transmission but also to simplify the medicine regime. Five years later, Durban delegates are likely to discuss how the treatment shift is working for mothers and babies.
In South Africa, the mother-to-child HIV transmission rate has dropped from almost 30% in 2004 to about 1.5% in 2015, according to National Health Sciences Laboratory data.
3. The one-pill-a-day that can keep HIV at bay South Africa is one of just seven countries that provide HIV p re-exposure prophylaxis (PrEP) in the public sector in the form of an ARV pill taken daily. Research has showed that the pill, Truvada, can reduce a person's chances of contracting HIV by more than 90%. Currently available for sex workers at 11 sites, PrEP is likely to be rolled out to high-risk populations such as young women and men who have sex with men.
There will also be big news from one of the first studies in Africa to look at what happens when PrEP is given not only to sex workers but also to adolescents.
4. Those left behind We may have entered the HIV treatment era, but former Human Science Research Council chief executive and Aids conference local co-chair Olive Shisana warns progress remains precarious. Globally, almost half of all people living with HIV are not on treatment, according to UNAids.
As donors and countries increasingly shift their focus to treating the most vulnerable — including those marginalised by their professions, such as sex workers, or by their identities, such as members of the lesbian, gay, bisexual, transgender and intersex communities — rights and access among these groups are expected to be hot topics at the conference.
Also not to be forgotten are entire regions such as West and Central Africa, with traditionally low HIV infection rates, that lag behind in ARV coverage. International humanitarian organisation Doctors Without Borders has pointed out that, in the face of ambitious global treatment targets calling for 90% of people living with HIV to be on treatment by 2020, more than 70% of HIV-positive people in West and Central Africa remain without ARVs.
5. The price tag By 2033, the cost of South Africa's HIV response will more than double, soaring to about R40-billion a year, according to the government's 2016 HIV and tuberculosis investment case. The country may be home to the world's biggest HIV treatment programme, but it's not the only one thinking hard about how to fund it.
"It's very a heartening trend — and you'll hear a lot about this in Durban — more than half of all HIV dollars in low- and middle-income countries are national dollars," International Aids Society president Chris Beyrer told Bhekisisa. "That is not to say that we are not concerned about [the level of] global donors and investments."
In 2014, international donors distributed $8.64-billion in HIV funding — a level almost unchanged from the previous year, according to 2015 UNAids research.
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