7 AUGUST 2020 VOLUME 22 ISSUE 31

A recent announcement about a vaginal ring to prevent HIV has AIDS activists and women’s sexual and reproductive health advocates excited. But where would this ring be effective in South Africa’s HIV prevention programme?

Five years into tracking global pre-exposure prophylaxis (PrEP) data, the HIV advocacy organization AVAC has launched a new interactive site that allows users to visualize worldwide country-level information about PrEP use.

It begins with a mild fever and malaise, followed by a painful cough and shortness of breath. The infection prospers in crowds, spreading to people in close reach. Containing an outbreak requires contact tracing, as well as isolation and treatment of the sick for weeks or months.

The 23rd International AIDS Conference (AIDS 2020) was held virtually for the very first time and featured discussion about the current direction and future prospects for HIV prevention, diagnosis, treatment, and even cure. During the official press conference on July 7, Ricardo Diaz, M.D., Ph.D., reviewed promising results of what might be the first adult with HIV to achieve long-term HIV remission without a bone-marrow transplant.

The World Health Organisation has announced additional efforts to eliminate hepatitis by 2030. The overall strategy calls for the prevention of new infections through universal implementation of the hepatitis B birth-dose vaccine. It also calls for full vaccine coverage, and access to affordable diagnostics to identify and care for infected individuals.

At the time of writing, more than 17 million people have contracted COVID-19 globally and more than half a million have died.1 However, the health impact of COVID-19 is likely to be far more substantial and long-lasting in countries with high incidences of tuberculosis and HIV-2 than in those with low incidences. Tuberculosis and HIV each have more than double the mortality rate of COVID-19, as shown in the Western Cape, South Africa.

Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South.

Among this cohort of HIV-positive and high-risk HIV-negative MSM, lubricant use and douching was common and independently associated with an STI, suggesting the utility of prevention messaging around barrier methods/condoms for sexual encounters involving douching/lubricant use.

We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.

Here, we evaluate TDF and FTC in combination with the broadly neutralizing antibody VRC01-N using a highly reproducible humanized mouse model. The agents were vaginally dosed individually and in combination, and the efficacy of HIV-1 prevention was analyzed using the established, rigorous median-effect model. Surprisingly, the triple combination showed a high degree of synergism, unprecedented for in vivo HIV-1 PrEP, leading to a possible fivefold dose reduction for some of the agents. Vaginal administration of the TDF-FTC-VRC01-N combination holds significant promise for HIV-1 PrEP.

These data indicate the profound effect that the South African response to the COVID-19 pandemic might have on HIV prevention efforts in this setting. Study visits were scheduled at the same time as antenatal or postnatal visits; missed visits have implications for maternal and infant health. Pregnant and post-partum women who are on PrEP cited fear of COVID-19 and contact with the health facility as common barriers. Community-based PrEP delivery and telephone interviews are needed to address barriers to attending facility-based PrEP prescription and study visits.

Exposure to physical partner violence and poor partner discussions about condoms are key deterrents to condom usage. Holistic interventions are required in order to address the risky behaviours, and consequently reduce sexually transmitted infections and/or unintended pregnancies.

This work has implications for future knowledge translation (KT) that deploys a community-based participatory research (CBPR) framework, including an expanded understanding of reciprocity that can include benefits such as training and professional development, as well as introducing a novel approach to KT that is driven by community and integrates multiple perspectives. We conclude with reflections on implementing CBPR practices for KT in different settings.

Lessons learned included the following: (1) ETE-based programming should be tailored to each jurisdiction’s unique political and social climate, HIV epidemiology, fiscal resources, and network of HIV service providers; (2) key stakeholders should be involved in developing ETE metrics and setting targets; (3) performance-based measurement and timely communication to key stakeholders in real time are essential; and (4) examining trends in HIV prevention and care metrics is important for developing realistic ETE timelines.

The discovery of numerous potent and broad neutralizing antibodies (bNAbs) against Human Immunodeficiency Virus type 1 (HIV-1) envelope glycoprotein has invigorated the potential of using them as an effective preventative and therapeutic agent. The majority of the anti-HIV-1 antibodies, currently under clinical investigation, are formulated singly for intra-venous (IV) infusion. However, due to the high degree of genetic variability in the case of HIV-1, a single broad neutralizing antibody will likely not be sufficient to protect against the broad range of viral isolates.

The imbalance of power in intimate relationships affects the ability of women to use microbicides as directed. To improve adherence to HIV prevention methods within trials and for successful rollout of proven HIV prevention methods in populations, it is important that the complicated dynamics of sex and relationships be taken into greater consideration and that women receive targeted support to navigate product use and communication within the context of these gender dynamics.