CNS: Never Fall In Love With Technology...

….So said Dr Mitchell Warren, Executive Director of AVAC: Global Advocacy for HIV Prevention, in an exclusive interview given to CNS onsite at the AIDS Vaccine 2012. Underlining the importance of understanding the complexities of science and community, he emphasized that, “None of the HIV/AIDS prevention methods can be the answer to the problem by themselves. It is not the product but the person who uses it that prevents HIV. A condom will not work if not used. Even if we have the gel or a vaccine unless people think about their risk and go for testing nothing will work. So, one should resist the temptation to fall in love with technology - as all scientific interventions require behavioural changes—not only at the individual level but also at the health system levels.”

NO ONE SIZE FITS ALL

Dr Warren delved upon the need of multiple prevention options to end the HIV epidemic as none of the existing interventions are perfect and no one size fits all. According to him, “No one intervention is going to be for everybody-- whether it is the female condom which is a great blessing for some people; or Pre-Exposure Prophylaxis (PrEP) which is very challenging and we are still unclear as to how we will deliver it; or voluntary medical male circumcision (VMMC); or the microbicide gel and the ring (when we have one). In the case of vaccines, most of those in testing stage typically have only one sub type. But what we actually want is a global vaccine that is very cheap, simple to administer and works for all people all the time. We may be in a situation where we get a vaccine which is less than perfect - expensive, hard to deliver, works only some of the time, works only in some regions, prevents infections from vaginal sex but not anal sex, from sex but not from drug use. The best HIV response is that which puts together a number of imperfect solutions and mixes them together to provide different layers of protection to different people.”

HIV EPIDEMIC INCREASINGLY HAVING A FEMALE FACE

Dr Warren acknowledged that, “With more and more women falling prey to the disease, the HIV epidemic is increasingly having a female face and it is young girls in the age group of 12-20 years who most need better prevention and protection. The prevention package in general, and specifically, for women can empower them and give them more choices. The female condom, though not a secret weapon, is still a great female initiated method. A gel could even be better for some people, and so can rings which can be inserted once every month or 3 months, or better still a quarterly injectible—a product which is being studied is TMC278. But the ultimate tool will be a vaccine. A vaccine is going to be critical in turning the tide and getting an AIDS free generation.”

MORE CHOICES BETTER

He agreed that, “When people have more choices, they are more likely to find something that works for them. More is the number of choices for protection more will be the number of infections prevented. At the same time science, policy makers, advocates, communities need to be planning for success as well as failure. If the gel works we have to plan to roll it out and scale it up urgently to make it available to women. We also need to plan to deal with the setbacks if it does not work. So as we plan for success we must plan for other products, like the dapivirine ring, as well. Similarly in the field of vaccine we need to be building on RV144, accelerating the studies of P5, and trying to get better efficacy results than the current 31%. The vaccine may work better as it has been tweaked. But if follow up trials do not show that it works, it will be hugely disappointing. That is why we need to accelerate researching other areas as well.”

PRIORITIZE

In case of resource restraints, Dr Warren stressed the importance to prioritize our needs. He said that, “We need to be very strategic in our three pronged agenda to deliver, demonstrate, and develop. We need to deliver what works. We need to scale up testing, treating and circumcising to bend down the curve of the epidemic. We need to demonstrate the added benefit of tenofovir gel, and of oral PrEP. We know that they work in clinical trials but we do not know how they will work in the real world. We need to have demonstration projects that target those who can add the protection. But despite all this we still need to develop a vaccine and a cure. The cost of not developing a vaccine is far more than the cost of developing one. The more successful we are with the non vaccine preventions, the less good a vaccine can be.”

Dr Warren added: “Human rights are the bedrock on which the whole edifice of testing and treating is built. People need to make informed choices. They need to know their HIV status, and treated not forcibly but consensually. We need to get into communities and give them treatment for treatment’s sake even before we do treatment as prevention. Failure on our part to treat the infected people in time will mean that more people will potentially transmit the virus. People will have to understand that ending the epidemic is just not round the corner, and we have still a long way to go.”

Shobha Shukla - CNS

(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She received her editing training in Singapore, has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)