IS Global: Innovative ideas to encourage people to access HIV & AIDS services

As part of the Imagine2030 campaign we want to show that innovation is not just something for the future. Biomedical advances being made right now will shape how we fight diseases of poverty in the future, and are delivering changes every day. It will be these advances, and the organisations behind them, that will bring us closer to our goal: an end of diseases of poverty by 2030.

For our celebration of World AIDS Day, and the role innovation has to play in fighting the disease, we profile an ongoing project by our colleagues at IS Global, the Barcelona Institute for Global Health, ISGlobal, which is an innovative alliance between academic, government, and philanthropic institutions to address the challenges in global health. Innovation is not just new products or medicines. Sometimes it is also finding new ways of doing things, improving access and using research to improve health care delivery.

Their “TESFAM” project is looking at how to keep people living with HIV in contact with health care in Mozambique. TESFAM is a collaborative project between ISGlobal and the CISM (Centro de Investigação em Saúde da Manhiça), a leading African HIV research centre, in alliance with Fundação Ariel Glaser contra o SIDA Pediátrico.

Mozambique is a country with a particularly high HIV prevalence in adults. Estimated at 10.6%, it is said to be the eighth highest in the world. In 2014, according to UNAIDS, an estimated 1.5 million people were living with HIV in the country and the mother-to-child transmission of HIV was around 12%. In Manhiça District, an area in Maputo Province in southern Mozambique, it is estimated that 40% of all adults and close to 29% of pregnant women are infected with HIV. Many of these individuals receive lifesaving antiretroviral therapy (ART), which has been available in Mozambique since 2004, due in large part to international support.

Health systems struggling with impact of HIV & AIDS

However, the magnitude of the HIV epidemic and the fact that ever more effective guidelines recommend earlier initiation of ART mean that immediate sustainability is unlikely without a huge effort to strengthen health systems countrywide. Indeed, very few health systems in the world could cope with the logistics and costs of the clinical management of 40% of the population needing lifelong care and treatment. Consequently, international collaboration and integrated efforts are essential if we are to reach the target set by the Global Health Sector Strategies for HIV, which stipulate that, by 2020, 90% of all people living with HIV will know their status, 90% of people diagnosed will be on antiretroviral therapy, and 90% of people receiving antiretroviral therapy will be virally suppressed, with the ultimate goal of eradicating AIDS by 2030.linkages

In Mozambique, ART coverage for those who need it is currently estimated at approximately 50% in adults and 39% in children, according to UNAIDS country report. These figures illustrate the sheer number of people dependent on the health system for HIV prevention and care. Despite the rapid expansion in coverage seen in recent years, over a quarter of a million adults who are eligible for ART are not receiving treatment. Stigma, overburdened health systems and poverty present daily challenges to retention in care and treatment.

TESFAM – getting people care they need

The objective of the Tesfam study, which focuses on the Manhiça district, is to give more people access to HIV testing, link them to care, and retain them in care and treatment. The study compared clinic-based and home-based HIV testing and counselling approaches, comparing rates of linkage to care and cost-effectiveness. Ultimately, the hope is that the findings of Tesfam will optimize HIV counselling and testing strategies, leading to the engagement of as many people as possible in the care cascade. hiv-cascade


Over the course of the study, approximately 16,000 adults were offered HIV testing. Of those eligible for the study, almost 15% already knew their HIV-positive serostatus. The 1,122 adults identified as new HIV diagnoses were enrolled for follow up. A key step in the cascade from testing to treatment is the CD4 test to determine eligibility for ART. In the Tesfam study, at 3 months post diagnosis, only 43.7% of those enrolled had undergone CD4 testing  (see Figure 2).

Despite increased rates of HIV testing, loss to follow up at each step in the HIV care cascade is very common in both resource-constrained settings and in more resource-rich countries. The reasons why patients drop out of the HIV care cascade are very complex and are influenced by multiple factors relating to the healthcare system and the individual, including socioeconomic profile. Standard of care in many sub-Saharan African settings does not include routine patient tracing, and the fate of individuals lost to follow-up is largely unknown. Since the HIV-infected population is especially vulnerable to illness and early death, it is important that these patients are traced and re-engaged into care. The design of the Tesfam study included home visits and counselling for the 850 individuals who abandoned treatment at different phases of the cascade. While some had migrated or died, the home visit was very effective at re-engaging a large proportion of the 468 patients who received this additional visit. Moreover, these patients were interviewed to ascertain why they had dropped out of the study.

tesfamRaising awareness of HIV treatment – community engagement

One of the main contributions of the Tesfam project in Manhiça was that it raised awareness in the community of HIV and HIV treatment through organised community events and presentations at public markets to discuss the obstacles and solutions relating to accessing HIV/AIDS care and treatment. These sessions are dynamic and enriching discussions led by an experienced counsellor. Community members actively participate by presenting their concerns and offering suggestions on ways the barriers to adherence to care for HIV-positive patients could be overcome. These events bring the community together to discuss the best approaches to HIV/AIDS care and treatment and health-seeking behaviour and to emphasise the importance of HIV testing, prevention and transmission mechanisms. The discussions brought to light various reasons why people do not go to the hospital for testing or treatment, such as a lack of time and the fact that they do not feel comfortable with the hospital staff.

Finally, community participation can reduce stigma and give people an opportunity to share their views on HIV/AIDS programmes and contribute to their improvement.  In this respect, the Tesfam project clearly identified a need for a better understanding of the barriers and facilitators of retention in care. Local leaders were also shown to have considerable influence on the behaviour of members of their communities.

In the future, more efforts aimed at retaining and re-engaging patients in care will be crucial. A few weeks could mean the difference between life and death. In addition, there is a great need to train health care workers to create a non-judgmental enabling environment. There is no one-size-fits-all approach, and in order to achieve the 90-90-90 target we must adapt our strategies to different settings and cultures so that all HIV-positive individuals are diagnosed, linked and retained in care. This challenge can only be met by intervening at various stages of the HIV care cascade.

Learn more about IS Global here.

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IAVI: researching an AIDS vaccine in East Africa

As part of the Imagine2030 campaign we want to show that innovation is not just something for the future. Medical advances being made right now will shape how we fight diseases of poverty in the future, and are delivering changes every day. It will be these advances, and the organisations behind them, that will bring us closer to our goal: an end of diseases of poverty by 2030.

Focusing on World AIDS Day, and the fight against HIV & AIDS, we sat down to talk with Dr. Anatoli Kamali, PhD, the Regional Director – Africa for the International AIDS Vaccine Initiative, based in Nairobi, Kenya. Dr. Kamali talks about the work of IAVI, and the potential benefits an AIDS vaccine could bring.

DSW: Can you explain a little what IAVI Africa does, and how it is advancing the search for a HIV vaccine?

Dr. Kamali: The International AIDS Vaccine Initiative (IAVI) is a not-for-profit organization with the mission to ensure the development of safe, effective and accessible AIDS vaccines. IAVI’s Africa work is to examine and understand the extent of HIV epidemic in Africa, and to contribute to the development of an AIDS vaccine that can ultimately help to end the epidemic. Our work is conducting epidemiological studies to better understand how the virus is transmitted and how the disease progresses, and engaging communities at the epicenter of the epidemic to generate data that informs vaccine design; evaluating promising AIDS candidates through clinical trials among populations who most need it; capacity building initiatives that enable the conduct of HIV vaccine research in Africa, such as laboratory infrastructure and training the next generation of African scientists; and extensive work on advocacy, policy and communication to promote HIV vaccine research and development, with a special focus on donors, policymakers and political leaders.

The work in Africa is conducted in collaboration with a network of leading scientific institutions in East and Southern Africa (centers of excellence in Uganda, Rwanda and Zambia, Kenya and South Africa). To date we have a network of over 10 clinical facilities with fully equipped pharmacies and accredited laboratories with ability to conduct state of the art research. The facilities are run by highly trained African scientists. Together the clinical centers have capacity of recruiting 5000 volunteers per year in clinical trials. A total of 23 early (phase 1 and 2) AIDS vaccine trials, 25 non-vaccine efficacy trials (phase 2b/3, including for microbicides and treatment), and over 20 epidemiological and mucosal immunology studies have been conducted in collaboration with the research centers in Africa.

The IAVI Africa work is coordinated in the Nairobi Regional office with a hub in Johannesburg.

What kind of an impact would a HIV vaccine have on the fight against HIV & AIDS, in East Africa and beyond?

UNAIDS estimates indicate that by 2015, 36.7 million people were living with HIV/AIDS, of whom 25.5 million live in sub Saharan Africa and 19 million are from eastern and Southern Africa. There were approximately 2.1 million new HIV infections in 2015 and 46% of these were from east and Southern Africa. Since 2010 the number of new infections has remained static despite the current behavioral (ABC strategy) and biomedical interventions (such as PrEP, treatment as prevention, male medical circumcision), and HIV testing and counselling.  Thus the current preventive efforts are unlikely to stop the epidemic. We also know that vaccination is the most effective public health strategy for controlling epidemic infectious disease. Therefore, a safe and efficacious AIDS vaccine could be the most cost effective tool to combat the HIV/AIDS epidemic. Modelling studies have indicated that a 70% efficacious and well-adopted vaccine could prevent the majority of annual new HIV infections within 25 years after introduction.

IAVI is an international, not-for-profit, Product Development Partnership working across sectors and borders to advance the research and development of effective, safe and accessible AIDS vaccines for global use. Partnering with academia, industry, government, philanthropy, civil society and communities, we catalyze innovation and help translate findings into new products that will help end HIV/AIDS. Our investments in research, capacity and collaborations advance our own projects and the promising candidates from other researchers.

What is the one thing that you would want European politicians and donor governments to help the kind of research that you are doing?

We would ask European politicians and donor governments, as well as civil society and researchers, to keep the development of an AIDS vaccine a priority in health and development agendas, and to help advance the research with supportive policies and sustained funding. The partnership between Europe and Africa can help us achieve this important mission.    

What, in your opinion, is the key obstacle standing in the way of global health research from fulfilling its potential?

Global Health research has already achieved the development of important new drugs, diagnostics and vaccines to combat infectious diseases and epidemics, saving millions of lives in our region and globally. Major advances have also been made in AIDS vaccine research – to bring this to the finish line we need more incentives for international collaborations across regions and sectors, and sufficient resources across the entire product development chain.

What is in the development pipeline from IAVI in the coming years?

Over the coming years, IAVI will design and test novel AIDS vaccine candidates based on promising results in early studies with new immunogens and delivery systems. We will also develop innovative preclinical and clinical models that facilitate the rapid prioritization of candidates, and conduct new clinical trials of the promising candidates. There are currently in IAVI’s portfolio 5 vaccine candidates in clinical trials and another 6 in early development / preclinical studies; we also support over 20 additional development efforts for AIDS vaccines and other HIV prevention and vaccine technologies.

What is your one hope for how the world will look in 2030?

My hope is that by 2030 considerable progress will have been made in the discovery of an AIDS vaccine and that ultimately a vaccine will be available to all those who need it globally. The world will hopefully be better prepared to manage global emerging and re-emerging epidemics, and that technology, infrastructure and resources will be available in the current low income countries to reverse the 10/90 gap, with substantially more resources devoted to health research in developing countries, where over 90% of all preventable deaths worldwide occur.

Learn more about IAVI here.

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Anatoli Kamali, PhD

He is currently the Regional Director – Africa for the International AIDS Vaccine Initiative, based in Nairobi, Kenya. He trained at Makerere University in Medicine and Surgery and also holds Master of Science at the London School of Hygiene and Tropical Medicine, UK, and PhD in Public Health from the City University, UK. Kamali is also an Honorary Professor, Department of Infectious Disease Epidemiology at the London School of Hygiene and Tropical Medicine. Previously he was the Deputy Director and Head of HIV Epidemiology and Prevention Programme, MRC/UVRI Uganda Research Unit on AIDS, and Head of Department of Epidemiology, Uganda Virus Research Institute, Entebbe.  

He has been involved in HIV/AIDS research since 1989, and he has led several prevention studies including early HIV vaccine trials, Ebola vaccine trials, phase III microbicide trials; prophylactic trials among HIV infected individuals, HIV epidemiological studies in general populations and high risk cohorts (female sex workers and fishing communities). He participates in several international scientific collaborations with institutions in the UK, USA and Africa. He was a member of the UK Microbicides Development Programme (MDP) that conducted a large efficacy and safety phase III microbicide trial for vaginally acquired HIV infection.

He has served on several scientific boards for international organizations such as the WHO, UNAIDS, International Partnership for Microbicides, and Data and Safety Monitoring Board for the National Institute of Allergy and Infectious Diseases Division of AIDS (NIAID) Vaccine and Prevention. He has published over 100 scientific peer reviewed articles and book chapters.


IPM: Developing new HIV prevention options for women

As part of the Imagine2030 campaign we want to show that innovation is not just something for the future. Biomedical advances being made right now will shape how we fight diseases of poverty in the future, and are delivering changes every day. It will be these advances, and the organisations behind them, that will bring us closer to our goal: an end of diseases of poverty by 2030.

For our celebration of World AIDS Day, and the fight against HIV & AIDS, we profile an organisation that is working to produce innovative ways to help women protect themselves, and their sexual and reproductive health.

IPM – pioneering HIV prevention options for women

Fourteen years ago, the International Partnership for Microbicides (IPM) entered the HIV prevention field with a promise and a clear vision to create products that women in developing countries could use themselves to prevent HIV, and protect their sexual and reproductive health.

Since IPM was founded as a nonprofit organization in 2002, it has leveraged public, philanthropic and private sector resources to accelerate the development of safe and effective life-saving technologies for women. The organisation builds on partnerships — with governments, foun­dations, researchers, pharmaceutical companies, policy-makers, advocates and communities — to bring scientific ingenuity, political will and financial resources to bear on all phases of product development.

The dapivirine ring

IPM led the development and testing of the monthly dapivirine ring, the first long-acting HIV prevention method shown to safe­ly help offer protection. The novel vaginal ring delivers the antiretroviral (ARV) drug dapivirine continuously over the course of one month, offering women a practical and dis­creet way to protect themselves against HIV. By marshalling scientific know-how and resources through partnerships with public, private, research and civil society stakeholders, IPM brought the ring from concept to Phase III efficacy trials just seven years after acquiring the license for dapivirine. In 2016, two parallel Phase III trials confirmed the safety and efficacy of IPM’s monthly dapivirine ring.


Strengthening medical research capacity in Africa

IPM has collaborated with in-country partners and research staff to build and strengthen capacity at more than 15 re­search centers across sub-Saharan Africa. They have trained more than 600 research center clinical staff, including community engagement teams on microbicide trial implementation. These staff are well-equipped to conduct high-quality HIV prevention and related clinical trials that contribute to the health of their communities.

Because HIV and unintended pregnancy are major caus­es of serious health complications and death for women worldwide, IPM is developing a multipurpose technology: a 90-day dapivirine-contraceptive ring designed to offer both HIV prevention and contraception. A Phase I trial is expect­ed to begin in 2017.

Developing the first combination ARV ring

IPM developed the first combination ARV vaginal ring to reach clinical trials, the dapivirine-maraviroc ring, and is exploring formulations using potent new ARVs. Combin­ing ARVs with different mechanisms of action may provide greater protection against HIV than a single drug alone and reduce the chance of acquiring drug-resistant HIV.

What’s next?

For IPM? The first long-acting, self-initiated HIV prevention product for women potentially approved for public use. The dapivirine ring is being made available to women who participated in both Phase III trials through two “open-label” studies now under way across Africa. IPM is also pursuing regulatory approval to license the ring, with the first regulatory submissions planned for mid-2017. The earliest potential product approvals could be received in late 2018 in some countries.

Learn more about IPM here.
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