Community Advisory Group report by Simone Marcotullio
The Italian Minister of Heath Professor Ferrucio Fazio was an unexpected guest this morning. He welcomed the delegates giving us a short lesson on the history of HIV, while saying nothing about the cancellation of the Italian AIDS research programme, the implementation of policies regarding active prevention, or any message concerning Italy’s plan to refund the Global Fund. Italian activists protested loudly against him and the Italian government at the end of his speech. Veni, vidi, non vici.
Nora Volkow is the Director of the National Institute on Drug Abuse at the National Institute of Health in the United States. She focused her lecture on ending HIV transmission in drug users and the impact to the HIV epidemic. She advocated for Drug Abuse Treatment as an effective HIV/AIDS prevention strategy for IDUs. She outlined the fact that many countries do not implement methadone and buprenorphine programmes and gave also a quick insight on heroin, opioid dependence vaccines development. She also focused on the importance of HAART in reducing HIV transmission in IDU population citing British Columbia data on the decline of community viral load as a marker strongly associated with the declining of HIV incidence. In her opinion, it should be recognised that the very proactive “test and treat” strategy for this population is necessary. Alessandra Cerioli from the Italian LILA was not very happy with the presentation. She says doctors cannot decide when people have to stop to be drug consumers. The implementation of comprehensive harm reduction programmes would be essential for preventing the HIV epidemic in this community. This would allow people to decide freely about their lives, and prevent HIV at the same time.
The conclusion of Philippa Musoke’s presentation well sums up the key message of this talk: ”It is a human right for every woman to survive pregnancy and child birth and their child to reach their 5th birthday!”. 500,000 women die annually, one woman is dying every minute, 99% from low and middle income countries. Moreover, 8 million children die annually before reaching 5 years of age, which means that one child is dying every 3 seconds. Most of these deaths are preventable and related to infectious diseases and malnutrition: this is unacceptable! The interventions needed to prevent the majority of maternal and child deaths are well known and yet most countries will not achieve the Millenium Development Goals unless drastic measures are taken. Governments, civil societies and international donors need to commit to scale up these well known high impact and low cost interventions that can prevent most of these deaths. The prevention of mother-to-child transmission is just one example.
Eric Verdin gave a comprehensive overview on cure and eradication research. HAART cannot eradicate HIV infection and people on HAART show significant higher prevalence of morbidities, which may be linked with residual HIV replication and immune activation. The reasons for finding a cure are multiple. Elite controllers and CCR5delta32/delta32 stem cells transplantation are two examples of - respectively - non sterilising (functional) and sterilising cure. Latency, persistent infection and sanctuaries are the causes of persistent HIV RNA production in patients. Concerning the roadmap to a cure, intensification, therapeutic vaccination, elimination of latency infected cells and gene therapies are considered as possible strategies.
Track C report by Danielle Haley
Nora Volkow presented on the convergence of HIV seroprevalence among injecting drug users (IDUs) and non-injecting drug use. Non injecting drug use appears to be an important contributing factor to HIV risk, independent of risk related to needle and syringe sharing.
Drugs of abuse (both legal and illegal) activate dopamine pathways that are crucial to motivating sexual behaviors. Studies in both animals and humans have demonstrated that the consumption of drugs increases impulsivity and decreases loci of control, and hence can lead to significant enhancement of sexual arousal while simultaneously inhibiting the brain’s ability to inhibit limbic responses that regulate sexual arousal (and associated control). These alterations in the brain’s response are present both in instances of acute and long-term substance use, and can cause lasting changes to the brain. Given this data, it is important to treat substance use itself, as well as substance use behaviors such as needle and syringe sharing.
Among IDUs, drug abuse treatment is an effective HIV/AIDS prevention strategy. Opiate substitution therapies as well as vaccines are viable approaches to addressing drug addiction. However, larger social and political challenges inhibit large scale access and uptake. Once HIV-infected, IDUs are less likely to receive antiretroviral therapy (ART), and if treated, receive ART later in disease progression- despite the fact that studies do not support poorer adherence in substance users when ART is accompanied with substance abuse treatment. Successful approaches to HIV prevention will most likely require tailored seek, test, treat and retain approaches that address disparities, as well as substance use and sexual risk.