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HIV Update

How Far AIDS Has Come, How Far it Must Go to Get to Zero

February 17th, 2016 at 9:10 am

candles

There is no story in global health as transformative, awe-inspiring, and yet as tragic as the AIDS pandemic. The disease was unknown only a generation ago — a medical curiosity among young gay men in New York and San Francisco in June 1981.

Within a few short years, AIDS could be found on every continent, enveloping the world to become one of the most devastating pandemics in human history. It has caused untold human suffering, social disintegration, and economic destruction.

In the early days of the pandemic, public health officials relied on prevention strategies devised for other sexually transmitted diseases. This includes testing, counselling, education, condoms and partner notification.

Newly diagnosed people had an average survival period of six to eight months. And their weakened immune systems made them vulnerable to rare cancers, pneumonias, chronic fatigue and horrific wasting until death ensued.

The early years of fear, pain and despair

The socio-political response was, at best, denial, ignorance, and silence. Ronald Reagan, US President at the time, did not utter the word “AIDS” in public until 1986. At worst, it was social marginalisation, discrimination, and punishment. People were blamed for their own suffering and criminalised for their behaviour. The fear, pain, and despair faced by people living with AIDS and their loved ones cannot be overstated.

But by 2010, UNAIDS announced a goal that was once unimaginable: getting to zero. Zero new infections, zero AIDS-related deaths and zero discrimination.

The 2012 International AIDS Conference was held in the US for the first time in 22 years because the US restricted entry of persons living with HIV between 1990 and 2011. At the conference, then Secretary of State Hillary Clinton called for an AIDS-free generation. To be sure, these high hopes provoked a skeptical response, with experts saying the goal was unrealistic and open-ended. What exactly is the definition of “zero” or “AIDS-free,” and which generation are we talking about?

But stepping back from perennial debates about aspiration tempered by realism, it is impossible not to marvel at the technological advances that enabled global health leaders to say the unthinkable: that we may one day see the end of the scourge of AIDS.

Powerful technological interventions


The technological advances that made all this possible include, first and foremost,antiretroviral treatments. A newly diagnosed 25-year-old today can expect to live another 50 years on treatment. But it also includes combination prevention, which extends well beyond traditional methods of testing, counselling, condoms and education. These do remain vital.

Research has shown remarkable reductions in HIV transmission from male circumcision, pre-exposure prophylaxis (PrEP), and antiretroviral therapy.

At the 2011 International AIDS Conference, scientists announced a jaw-dropping 95% plus reduction in sexual transmission among heterosexual couples adhering to antiretroviral treatment.

What if it were possible to reach every person at risk, or already infected, with these powerful interventions? What if the next discovery could empower women to protect themselves, such as with a vaginal microbicide, which is on the horizon? Given the political will, isn’t it imaginable that the international community could “get to zero”?

How did all these technological advances come about, and why did this particular disease forge a pathway toward unprecedented scientific discoveries? Very sadly, science has not been able to match these technological advances for most global health challenges. Not mental illness, cancer, or tuberculosis.

It has been said that these are all highly complex, multi-factorial diseases, while AIDS is not. But this is far from the truth.

Social mobilisation like never before

AIDS is one of the most complicated and stubbornly persistent diseases the world has ever known. Yet the sociopolitical dimension of AIDS has galvanised perhaps the greatest social mobilisation around a health crisis that the world has seen.

From the AIDS Coalition to Unleash Power (ACT UP) and Lambda Legal Defense in the US to the Treatment Action Campaign in South Africa, courageous individuals and organisations have literally transformed the politics of AIDS, turning neglect and derision into empowerment and social action.

This vast social mobilisation was targeted not only at fighting the social dimensions of this disease with poignant calls for dignity, nondiscrimination, and justice. It was perhaps principally about access to medicines.

AIDS campaigns had crisp clarity, appealing to a basic sense of social justice: the rich have access to life sustaining medicines while the poor do not. This message resonated in developed countries where the poor often were denied access to antiretroviral medication. But it also resonated in developing countries where most people could not afford a life-saving pill that the majority of those in the developed world could access.

The access-to-medicines campaigns brought AIDS advocates to pursue solutions beyond the health sector. Activists directly attacked the prevailing trade liberalisation paradigm, which protects intellectual property, and asserted the higher priority of the right to health.

In South Africa the TAC successfully challenged the government’s restrictions on access to perinatal treatment before the Constitutional Court. At the international level, the AIDS movement energised the World Health Organisation to take access to medicines seriously. This prompted campaigns such as the World Health Organisation’s 3 by 5 initiative. It forced the World Trade Organisation to change course, introducing Doha Declaration flexibilities to soften a harsh intellectual property regime.

A global effort

This social mobilisation also unleashed unprecedented resources in global health — new funding for biomedical research, vaccines, and treatment. Moreover, social mobilisation around AIDS literally transformed global health governance. It fundamentally altered the foreign assistance of the most powerful countries. For example PEPFAR in the United States, and UNITAID, formed by Brazil, Chile, France, Norway, and the United Kingdom.

For the first time, the major powers began to frame an infectious disease as a national security threat, addressed at the highest political levels at the G8. Social mobilisation drove the United Nations’ response, prompting the first high-level summit ever held on a health issue to be devoted to AIDS.

A novel public-private-partnership emerged, outside the UN/WHO structure, to generate and pool resources — the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Although the international community has rallied to fight AIDS, fierce debates have raged within the movement. Initially, advocates worried that traditional public health strategies such as testing and reporting would undermine privacy or foster discrimination. At the same time, policy makers debated which interventions — and in what combination — were most effective. And then there was the divisive issue of cost-effectiveness. Could governments afford expensive interventions such as lifetime treatment with antiretrovirals?

If not, how could the benefits be fairly allocated among the large population of persons at risk or living with HIV? And should the same level of resources devoted to AIDS be made equally available for other pressing health conditions, such as child/maternal health, injuries, or non-communicable diseases?

These battles ensued within both domestic health sectors and foreign health assistance budget debates. They remain topics of lively debate.

*This is the first of three articles drawn from the book Global Health Law, released by Professor Lawrence Gostin.

The Conversation

Lawrence O. Gostin, Prof. Global Health & Dir. O’Neill Institute, Georgetown University

This article was originally published on The Conversation. Read the original article.

Test Every Canadian for HIV/AIDS Says BC AIDS Expert

November 25th, 2015 at 11:16 am

drmontaner

The best way to eliminate HIV and AIDS in Canada is to test everyone for the virus, regardless of whether they are at risk or not, according to one of the world’s leading experts on the disease.

Dr. Julio Montaner, the director of British Columbia’s Centre for Excellence in HIV and AIDS, says that in B.C. alone, 2,000 of the 15,000 people with HIV/AIDS don’t even know they’re infected and so are more likely to spread the virus.

“What we have come to recognize is that there are pockets of people who are HIV infected who are not aware … not only that they’re not infected, but not aware of their risk of HIV infection.”

Universal HIV-testing is the best way to eliminate the disease, according to one of the world’s leading experts. (CBC )

It’s estimated one in six people have an advanced form of HIV by the time they’re diagnosed, and that more than half of new infections are transmitted by people who don’t know they have HIV.

“The only way that we can get at them is if we ask all of the people in B.C. to confirm the fact that they’re not infected,” Montaner said.

“Finding them is critical,” said the doctor, who wants universal testing across Canada.

“In finding them, we will stop the epidemic … By bringing them out, we’re able to help them help themselves accessing treatment that is life-saving, but in addition, that stops HIV transmission.”

Vancouver leading the way

Since 2011, Metro Vancouver hospitals have been offering free voluntary HIV testing to everyone who comes through their doors. Andhospitals on Vancouver Island will soon be doing the same.

Last year, the province announced all adult B.C. residents will be offered a free voluntary HIV/AIDS test every five years under an expanded program aimed at preventing transmission of the virus in the province.

There is evidence the province is winning the battle against the virus. B.C.’s HIV infection rate has fallen by 60 per cent since 1996, while rates in other provinces have remained unchanged.

But Montaner said testing could be broader, and more consistent.

“It’s not being done to the extent that we would like it to be done,” he said. “We want this to become the norm in B.C. and the norm in this country.

“We’re asking the rest of the country to embrace this strategy. We need to do it here to show the world that it can be done, and should be done,” said Montaner.

He said not only would universal testing save lives, it would also save money, by reducing the amount spent to treat people infected with the virus.

“Why are we saving? Because we are preventing disease progression, premature death, and more important from a financial perspective, the spread of the disease.”

Earlier this year Montaner, was inducted into the Canadian Medical Hall of Fame and made an Officer of the Order of Canada for leading the global fight against HIV/AIDS.

Last September, the United Nations endorsed Dr. Montaner’s TasP plan to eradicate the AIDS pandemic by 2030.

HIV Prevention Drug Appears to Work in First Real-World Test

September 3rd, 2015 at 10:02 am

hivprep

A drug designed to prevent people who are at risk of HIV from being infected is showing promise: a new real-world study found that those who took the drug stayed HIV-free. The finding adds to growing evidence the drug, PrEP, serves as an effective method of curbing the spread of the HIV virus.

For the study, the first to look at PrEP outside of a clinical setting, researchers evaluated more than 650 people who began the drug during a 32-month period. Nearly all of the participants were men who have sex with men. Users were more likely than non-users to report that they had multiple sex partners. During the study, participants developed a number of different sexually transmitted diseases but remained free of HIV.

The Food and Drug Administration approved PrEP for use in 2012 and it has since been recommended to groups that engage in sexual practices that place them at increased risk of HIV. The drug can reduce risk of HIV infection by 92% if taken properly, according to the Centers for Disease Control and Prevention (CDC).

HIV infection rates in the U.S. have persisted in recent years despite campaigns to raise awareness and encourage condom use.

Justin Worland  @justinworldand

New Candidate is One Step Closer to an HIV Vaccine

June 22nd, 2015 at 11:31 am

hiv

Despite more than 30 years of intense research, a cure or vaccine for HIV still continues to elude us. But scientists are not quitting, and slowly but surely they seem to be making promising progress in this field. For example, two new mouse studies have just come out that demonstrate that a novel vaccine candidate is able to prompt the beginnings of an immune reaction needed to prevent infection. While the results are not the “breakthrough” everyone is looking for, they are certainly a stride in the right direction.

Vaccines can be made in a variety of different ways, for example by inactivating whole pathogens or isolating particular components of them, both with the ultimate goal of stimulating a defense response from the immune system, readying it for any future assaults. But the problem with pesky HIV is that it mutates remarkably rapidly, changing its components so that they become unrecognizable by the immune system. This means that should a vaccine be successful in inducing the production of protective antibodies, they usually have such a narrow window of activity that they are effectively useless.

But there are some antibodies that are different, called broadly neutralizing antibodies (bNAbs), and scientists have high hopes that these may hold the key to producing a successful HIV vaccine. As the name suggests, rather than being specific to just one target, these antibodies are able to recognize and inhibit a range of HIV variants, or strains, and thus are much more therapeutically useful. Although a subset of HIV-positive individuals produce these antibodies, scientists have so far failed to induce their production via vaccination.

Many researchers believe the key to achieving this is by presenting the body with multiple targets, or antigens, that differ slightly, training the immune system to recognize and hone in on the more conserved elements of HIV that are found in different strains. One particular molecule that scientists are interested in is an antigen called eOD-GT8, which was engineered by researchers, headed by William Schief, at The Scripps Research Institute.

Rather than attempting to directly elicit bNAbs, this antigen is designed to stimulate the production of precursor antibodies that will eventually mature into bNAbs following prolonged exposure to the virus, The Scientist explains. So by starting off with these immature antibodies, scientists hypothesize it may be possible to encourage them to develop into bNAbs over time by gradually exposing the immune system to slightly different HIV antigens, forcing the antibodies to mutate in order to recognize more conserved regions of the virus.

When testing this molecule out in mice genetically engineered to produce antibodies similar to those found in humans, the researchers found that it was indeed able to elicit these first-line antibodies. Additionally, they found it also created a pool of antibody-producing “memory” B cells that the researchers believe could be boosted through exposure to different antigens, sort of like receiving booster shots. These findings have been reported in Science.

In another paper, published in Cellscientists used the same molecule but a different mouse model, and once again the vaccine was able to prompt an immune response that was headed in the right direction. Unfortunately, however, the antibodies were unable to neutralize HIV. But the researchers still believe it has merit, and could be effective if combined with other molecules, which is what they will investigate next.

June 19, 2015 | Justine Alford

Single Blood Drop Now a Multi-Infection Indicator

June 9th, 2015 at 1:46 pm

blooddrop

New technology developed by Howard Hughes Medical Institute (HHMI) researchers makes it possible to test for current and past infections with any known human virus by analyzing a single drop of a person’s blood. The method, called VirScan, is an efficient alternative to existing diagnostics that test for specific viruses one at a time.

With VirScan, scientists can run a single test to determine which viruses have infected an individual, rather than limiting their analysis to particular viruses. That unbiased approach could uncover unexpected factors affecting individual patients’ health, and also expands opportunities to analyze and compare viral infections in large populations. The comprehensive analysis can be performed for about $25 per blood sample.

Stephen Elledge, an HHMI investigator at Brigham and Women’s Hospital, led the development of VirScan. “We’ve developed a screening methodology to basically look back in time in people’s [blood] sera and see what viruses they have experienced,” he says. “Instead of testing for one individual virus at a time, which is labor intensive, we can assay all of these at once. It’s one-stop shopping.”

Elledge and his colleagues have already used VirScan to screen the blood of 569 people in the United States, South Africa, Thailand, and Peru. The scientists described the new technology and reported their findings in the June 5, 2015, issue of the journal Science.

VirScan works by screening the blood for antibodies against any of the 206 species of viruses known to infect humans. The immune system ramps up production of pathogen-specific antibodies when it encounters a virus for the first time, and it can continue to produce those antibodies for years or decades after it clears an infection. That means VirScan not only identifies viral infections that the immune system is actively fighting, but also provides a history of an individual’s past infections.

To develop the new test, Elledge and his colleagues synthesized more than 93,000 short pieces of DNA encoding different segments of viral proteins. They introduced those pieces of DNA into bacteria-infecting viruses called bacteriophage. Each bacteriophage manufactured one of the protein segments — known as a peptide — and displayed the peptide on its surface. As a group, the bacteriophage displayed all of the protein sequences found in the more than 1,000 known strains of human viruses.

Antibodies in the blood find their viral targets by recognizing unique features known as epitopes that are embedded in proteins on the virus surface. To perform the VirScan analysis, all of the peptide-displaying bacteriophage are allowed to mingle with a blood sample. Antiviral antibodies in the blood find and bind to their target epitopes within the displayed peptides. The scientists then retrieve the antibodies and wash away everything except for the few bacteriophage that cling to them. By sequencing the DNA of those bacteriophage, they can identify which viral protein pieces were grabbed onto by antibodies in the blood sample. That tells the scientists which viruses a person’s immune system has previously encountered, either through infection or through vaccination. Elledge estimates it would take about 2-3 days to process 100 samples, assuming sequencing is working optimally. He is optimistic the speed of the assay will increase with further development.

To test the method, the team used it to analyze blood samples from patients known to be infected with particular viruses, including HIV and hepatitis C. “It turns out that it works really well,” Elledge says. “We were in the sensitivity range of 95 to 100 percent for those, and the specificity was good — we didn’t falsely identify people who were negative. That gave us confidence that we could detect other viruses, and when we did see them we would know they were real.”

Elledge and his colleagues used VirScan to analyze the antibodies in 569 people from four countries, examining about 100 million potential antibody/epitope interactions. They found that on average, each person had antibodies to ten different species of viruses. As expected, antibodies against certain viruses were common among adults but not in children, suggesting that children had not yet been exposed to those viruses. Individuals residing South Africa, Peru, and Thailand, tended to have antibodies against more viruses than people in the United States. The researchers also found that people infected with HIV had antibodies against many more viruses than did people without HIV.

Elledge says the team was surprised to find that antibody responses against specific viruses were surprisingly similar between individuals, with different people’s antibodies recognizing identical amino acids in the viral peptides. “In this paper alone we identified more antibody/peptide interactions to viral proteins than had been identified in the previous history of all viral exploration,” he says. The surprising reproducibility of those interactions allowed the team to refine their analysis and improve the sensitivity of VirScan, and Elledge says the method will continue to improve as his team analyzes more samples. Their findings on viral epitopes may also have important implications for vaccine design.

Elledge says the approach his team has developed is not limited to antiviral antibodies. His own lab is also using it to look for antibodies that attack a body’s own tissue in certain autoimmune diseases that are associated with cancer. A similar approach could also be used to screen for antibodies against other types of pathogens.

HHMI Howard Hughes Medical Institute