Friday, 27 July 2012 00:00
Whoopi! - Day 6 of the International AIDS Conference
"Hey, there's Whoopi Goldberg," I blurted into a cell phone during a call with someone halfway across the country. Half from fatigue after six, 12-hour conference days and half from the surprise that I didn't know that Whoopi was even going to be here. Whoopi has long used her celebrity to raise awareness and support for African women and kids affected by HIV and TB and was fierce in her advocacy on these issues today.
It's the classic International AIDS Conference experience. Not just seeing but talking with the famous researchers, politicians and advocates, mixing of cultures throughout the world and reconnecting with friends and colleagues from around the globe. All totaled 23,767 attendees from 183 different countries reviewed the latest AIDS developments through more than 5,000 formal speeches, meetings, abstracts, and posters and countless informal, on-the-spot discussions throughout the 2.3 million square feet on the conference center.
All of this activity is surrounded by panels of the AIDS Memorial Quilt hanging on walls throughout the conference venue as a solemn reminder of the millions of people who have died from AIDS. For me the quilt will always bring to mind my friend Mike Johnson who lost his valiant fight against AIDS in 2010.
Summaries of the Conference are already populating the Internet. For me, at the conclusion of my fourth International AIDS Conference and on the cusp of my 20 year anniversary working in AIDS, inspiration is met with pragmatic reality of the challenges that lie head.
It is difficult not to be inspired by the strength of the international AIDS community as evidenced throughout the Conference. Delegates working in rural third world countries to deliver HIV medications and the hope for a brighter future, African grandmothers hand making jewelry to fund prevention and treatment programs, and professionals who have dedicated their whole lives to beat AIDS all inspire. Where else would you find a group of people calling for zero new HIV infections when we are now facing more than 2.8 million new infections annually?
The reality, however, is that the pragmatic challenges are immense. The Gardner Cascade shows us that even in the U.S., the wealthiest country in the world, treatment is only succeeding with 28% of people with HIV. New HIV infections are steady or rising. HIV patients are facing severe problems related to accelerated aging especially chronic inflammation and non-AIDS cancers. Success in overcoming the social injustice that fuels the AIDS epidemic is slow, if happening at all. How many times can conference attendees clap in appreciation for the Obama Administration's lifting of the travel ban on people with HIV, while many basic rights and full equality is still denied for people with and at risk for HIV here and across the globe?
The work ahead to finally defeat AIDS is substantial. Most frustrating and troubling is the rhetoric of an 'AIDS-free generation' and its expectation of a cure. We are far from this goal, maybe even generations away. I am greatly concerned that the hopeful message may diminish safe practices to stop the transmission of HIV, lead patients to not stay in care thinking a cure is close at hand and that, at a time when more resources are needed, this message could lead to reduced private and public support. These developments would assure that the goal of an AIDS free generation would never be met.
It is amazing that we can even discuss and begin research to find a cure. This is something we struggled to imagine just a few years ago. But the loudest refrain from Washington, DC remains the moral obligation for universal HV prevention, care and treatment while we patiently await scientific advancement.
That's the most urgent call. It must be heard. Across the globe and in America. In Wisconsin we must hear this call and retain our leadership in the national fight against. If we do we can look towards, someday, a world without AIDS.
Condomize! - Day 4 of the International AIDS Conference
Resounding chants of "Condomize!" greet delegates of the International AIDS Conference each morning. An enormous display spanning the main entrance with countless condoms of every type and color. For me it is a chilling reminder that in the U.S. we have made little or no progress in reducing the number of new HIV infections over the last 15 years.
Nationwide, 50,000 new people are diagnosed with HIV a year, putting mounting pressure on the health care system to care for an ever increasing number of HIV patients. Moreover, every new HIV diagnosis takes an unacceptable toll on the people newly infected, their families and our state and country.
The diversity of conference delegates and presentations clearly demonstrates that HIV knows no barriers affecting men and women, young and old, gay and straight, wealthy and poor, all regardless of race or ethnicity. Yet, the epidemic continues to be a troubling and leading example of health disparities. In Wisconsin, the majority of new cases are among gay men and people of color and are occurring at rates far higher than among whites in our state.
To confront these troubling trends we must embrace combination prevention, a concept first introduced at the 2006 International AIDS Conference. This strategy should be further built upon with the new announcements surrounding this year's conference.
Combination prevention will work by taking traditional behavioral interventions like risk reduction counseling, condom distribution, needle exchange and HIV testing and integrating them with new biomedical interventions such as pre- and post-exposure prophylaxis (taking HIV medications either before or just after exposure) while also aggressively treating all HIV patients. By treating all HIV patients we can dramatically reduce the chance of them transmitting HIV to their loved ones.
Done effectively, combination prevention holds great promise. Today, the hope is that by customizing HIV prevention based on each person's needs collectively the interventions will do even better. We must take all of these tools and enhance current prevention efforts to reach more people, always prioritizing people at highest risk.
After all, HIV prevention is all about saving lives among our family, friends and communities. The added benefit: it costs a fraction compared to the more than $600,000 in lifetime health-related costs of treating an HIV patient.
As I attend sessions, review posters and talk with my national colleagues, I am troubled by the turning of attention away from some at risk populations, especially women and people with alcohol and drug addiction issues. It's a divisiveness in the fight against AIDS that is rare and one that will not serve us well in the quest to defeat AIDS.
In Wisconsin, we can have none of this. Instead we will continue to help lead the country with aggressive, targeted, evidence-based and effective HIV prevention programs, building on our past successes until we defeat AIDS.
A Moral Obligation - Day 3 of the International AIDS Conference
The International AIDS Conference is widely regarded as the finest scientific research conference in the world. Buttressed by the refrain of achieving an AIDS-free generation, the AIDS research agenda has refocused its attention on the “HIV holy grail” - a cure.
Tony Fauci, MD, one of the world's preeminent HIV researchers and a leader at the U.S. National Institutes of Health (NIH) struck a cautionary note on the AIDS-free generation rhetoric. His comments indicate that the science is finally available to provide us with the foundation to begin to consider the possibility of developing a cure.
A cure would likely come in one of two forms. The first is eradication or the complete purging of HIV from a patient. The second is a functional cure which would achieve long term suppression of HIV without the need for ongoing treatment.
A new international research collaborative entitled “Towards an HIV Cure” was announced in the days leading up to this year's conference. Building on recent scientific advances, the collaborative creates the first-ever global roadmap outlining the research that needs to be accomplished to produce a cure. This is a promising step forward, but it is tempered by the reality that it took three years to develop the strategy, research is either developing hypotheses or determining proof of concept and that the hard work of clinical trials is still to come. Among the collaborative’s priorities will be research on treatment intensification, activation of latent cells, gene therapy and elite controllers who are HIV patients who do not need treatment to keep the disease at bay.
Many years of research lie ahead coupled with the immense issues of safety, cost and ability to deliver a cure to people across the globe. But, prolonged investigation, complexities of the research and serious implementation barriers cannot be a deterrent to starting on this path. In fact, Dr. Nelly Mugo, a Kenyan physician was clear, "it’s not a choice but a moral obligation."
The head of NIH, Dr. Francis Collins, provided attendees the best picture of where we are in finding a cure, "when asked if I view the glass half full or half empty in our quest for a cure, I say we finally have a glass."
While we await a cure that remains well off into the future, the AIDS-free generation refrain expanded today to include the decades-long call for universal access to HIV prevention, care and treatment. This is what holds promise or a long, healthy life for people with HIV today. This is what must remain a top priority for all of us in Wisconsin.
However, the commitment to finding a cure for HIV remains a testament to the spirit, vision and tenacity of the international AIDS movement - the researchers, doctors, patients, government bodies, donors, advocates and others – who will persevere together in the many challenging years ahead until we do finally find a cure.
The "Ifs Test" - Day 2 of the International AIDS Conference
Phill Wilson, Executive Director of the Black AIDS Institute, called upon the words of Charles Dickens from 'The Tale of Two Cities' proclaiming that in the fight against AIDS "it's the best of times and it's the worst of times."
U.S. Senator Lindsay Graham(R-SC) summed it up saying "we have good news, but we have the bad news too."
This good news/bad news message welcomed the delegates to the International AIDS Conference Monday morning.
In fact, much of the news in the fight against AIDS is good. A record 8 million people with HIV are on treatment in developing countries; mother-to-child transmission of HIV in America has all but been eradicated; and advances in medical treatment have made it possible for an HIV patient to live almost as long as an un-infected individual - if they are in care, if they get on treatment and if they strictly adhere to medication regimens.
It's this series of “ifs” that become the litmus test defining the worst of times in AIDS in the United States and in Wisconsin.
The Gardner Cascade modeled by a Colorado researcher identifies the challenge. In the U.S. approximately 1.1 million people are living with HIV, but only 80 percent of them know that they are HIV-positive. For these 880,000 patients, the Gardner Cascade shows them falling away from successful health care because they are not getting enrolled in care, not being retained in care, or not being prescribed HIV medications. At the end of the cascade, just 28%, or a little more than 300,000 Americans pass this “ifs test” and therefore have the opportunity for the near-normal life expectancy. The other 800,000 people with HIV in America don't have that chance.
Many of the studies presented at the conference identify interventions to help patients overcome negative social determinants of health and achieve treatment success. These interventions include securing stable housing, ensuring food security, providing case management, linking patients to healthcare and fighting discrimination. The AIDS Resource Center of Wisconsin (ARCW) will continue to provide and enhance all of these services along with medical care to help patients achieve HIV treatment success.
The outcomes related to overcoming social determinants are exceptionally beneficial for HIV patients. By translating best practices learned at previous International AIDS Conferences into care at ARCW, 75% of our patients pass the 'ifs test' and have the chance for a long, healthy life. This success will allow us to focus on working toward other goals of the International AIDS Conference including diagnosing more people with HIV, expanding our clinics to serve more patients and providing additional care for the remaining 25% of our patients who need more help.
In her remarks at the conference, U.S. Secretary of State Hillary Rodham Clinton summarized the good news/bad news dichotomy as "AIDS is still incurable, but it's not a death sentence."
In Wisconsin, we have more good news than bad, but we still have much work to do.
A Big Tide to Turn - Day 1 of the International AIDS Conference
Just hours before the Opening Ceremonies of the XIX International AIDS Conference with the moniker 'Turning the Tide Together' began, just how large a tide we need to turn became evident - $13 billion in new funding by 2015.
In 2010 the United States issued its first-ever National HIV/AIDS Strategy. It called for achieving a country where new HIV infections are rare. And, when new infections do occur, access to the full continuum of care is readily available. With that great vision, benchmarks of a 25 percent reduction in annual infections and enrollment of 85 percent of people with HIV in care by 2015 were set.
The price tag for these relatively limited successes will close the gap on HIV testing, increase HIV prevention for individuals at greatest risk and implement the new treatment guidelines released today calling for everyone with HIV to be on treatment rather than only after their immune system begins to deteriorate. This price tag is even before implementation of the newly-approved pre-exposure prophylaxis treatment of HIV negative individuals at highest risk that is among the most promising HIV prevention strategies in more than two decades.
And, this amount is for just here in the states, it is not inclusive of the tremendous global demands of AIDS.
In Wisconsin we took a step back from achieving the national goal of reducing new HIV infections, instead reporting a 19 percent increase in cases in 2011. We know that 1 in 5 Wisconsinites living with HIV have not yet been diagnosed and hundreds, if not thousands, of HIV patients are not in regular care or on medication treatment regimens consistent with today's new guidelines.
Diane Havlir was one of the first physicians in San Francisco to treat HIV in the early 1980s. She continues to maintain her HIV practice, but also found time this year to serve as the AIDS conference co-chair. In her opening remarks Sunday night she said that it would be an "extraordinary failure" if current financial constraints held us back from closing these gaps and prevailing in the fight against AIDS.
Across America, and in Wisconsin where we can measure the need in millions rather than billions, it is a tremendous risk to not secure the necessary private and public funding to achieve the goals of the national strategy and an even more important goal being whispered throughout the convention hall - the idea that today's young kids have the opportunity to become an AIDS-free generation.