The possibilities for new and improved HIV prevention options were showcased at the recent HIV Research for Prevention (HIVR4P) conference, although the participants heard that many new tools are still several years from being ready for implementation.

The importance of pre-exposure prophylaxis (PrEP), including PrEP delivered by a vaginal ring and long-acting PrEP, including injectable PrEP, was featured in many presentations. Vaginal ring PrEP offers better female-controlled prevention options that can protect women without their partner’s knowledge, while injectable PrEP would mean that daily pill-taking and the risk of forgetting to take the pill would be history. Both vaginal ring PrEP and long-acting PrEP are still some way from being available, however, with the vaginal ring currently being reviewed for regulatory approval by the European Medicines Agency and trials for long-acting PrEP not due to deliver results until 2021 or later.

If antibodies and engineered molecules that mimic them can be shown to prevent HIV infection, the way to six-monthly injections for either prevention or treatment could be opened up, along with the possibility of a vaccine that made people develop their own similar antibodies. The participants heard that much progress had been made in discovering and developing such antibodies. The first proof of principle trials showing their effectiveness will report their results in 2020.

“Science has delivered us extraordinary advances in technologies for the diagnosis, treatment and monitoring of HIV infection. There is now real excitement that over the next years it will also lead to effective affordable prevention tools,” said Peter Godfrey-Faussett, Science Adviser, UNAIDS.

The participants heard that there are high levels of sexually transmitted infections (STIs) among the populations at higher risk of HIV and that, as we have known for decades, STIs lead to increased HIV acquisition. The rates of the major treatable bacterial STIs have been rising steadily and are at alarming levels among gay men and other men who have sex with men and young people in eastern and southern Africa, in part due to declining condom usage. The high rates of the major treatable STIs have become particularly evident with the advent of increased screening accompanying the roll-out of PrEP.

Many STIs have no symptoms and can only be diagnosed with modern diagnostic tests—these are simple, but still far too expensive for the countries that need them the most. Along with geography and age group, STIs are among the strongest indicator of risk of HIV. An integrated STI and HIV prevention approach could offer PrEP to people who are HIV-negative but have an STI and live in an area where HIV is prevalent.

New prevention technologies are likely to be relatively expensive and hence will need to be focused on populations at higher risk in order to be affordable and cost-effective. Mathematical modelling shows that these new HIV prevention technologies may have only a limited impact on new HIV infections in eastern and southern Africa. For example, modelling of the impact of the dapivirine ring—a vaginal ring with a slow release of an antiretroviral medicine that protects against HIV infection—shows that only 1.5–2.5% of HIV infections would be averted over the next 18 years in Kenya, Uganda, Zimbabwe and South Africa. With the cost of averting one HIV infection through the use of the dapivirine ring varying from US$ 10 000 to US$ 100 000, many of the participants argued for integrating and combining both HIV treatment and prevention, and the responses to HIV and other diseases, for maximum effect.

The biennial HIVR4P conference was held in Madrid, Spain, from 21 to 25 October.

Thailand is starting to roll out pre-exposure prophylaxis (PrEP) for HIV prevention among key higher-risk groups in high burden provinces, scaling up PrEP pilot projects within the national health system. The announcement was made at the satellite session “Breaking barriers and building bridges toward sustainability of the AIDS response in South-East Asia” during the International AIDS Conference in Amsterdam, Netherlands.

At the session, Dr Panumard Yarnwaidsakul, Deputy Director-General of the Department of Disease Control, Ministry of Public Health, said that the country is moving from trials and demonstration projects to policy and practice. PrEP now is a core part of the combination prevention package in the national HIV response in the country. Mr Yarnwaidsakul added that Thailand is also in process of including PrEP provision as part of the benefits package under the country’s universal health coverage.

As with many countries in Asia and the Pacific, Thailand's epidemic is focused among gay men and other men who have sex with men, transgender people and people who use drugs. The representatives of the Thai government acknowledged that PrEP is cost-effective and is an innovative approach for people at substantial risk of HIV infection.

Randomized trials have demonstrated that PrEP can decrease HIV incidence among at-risk populations, including men who have sex with men and sero-discordant couples. It has been shown that offering PrEP can encourage more people at higher risk to attend HIV clinics, undergo HIV testing and access either PrEP or treatment depending on the test result.

In Thailand, the discussion about offering PrEP at scale started in 2010.

The satellite session learned from "The Princess PrEP", a successful key population-led PrEP initiative under the support of Her Royal Highness Princess Soamsawali and PEPFAR/ USAID LINKAGES Thailand project.This effort served as local evidence to support the development of PrEP roll-out, where key population-led health services are a critical component.

As a next step, the Ministry of Public Health aims to train health care workers and key population peer providers to deliver PrEP.

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European Union political leaders met to discuss the successes, challenges and future priorities for addressing HIV in Europe at ministerial meeting in the margins of the 2018 AIDS conference.

The session started with a powerful appeal from the European civil society co-chair Esther Dixon-Williams (European AIDS Treatment Group) to ensure people living with HIV and key populations remain central to the discussions in keeping with the call from the inception of the AIDS response “nothing about us without us”.

A few European Union (EU) countries are on track to reach the 90-90-90 goals, however to reach the target of ending AIDS by 2030 and leaving no one behind, increased efforts to reach out to men who have sex with men, transgender people, migrants, sex workers, people who inject drugs and people in detention are needed.  

The rising epidemic among men who have sex with men in central and south eastern Europe was highlighted as well as the continuing emergency for people who use drugs in the eastern European states. HIV-related stigma and the criminalisation of people who use drugs, sex workers, MSM, transgender people are major obstacles to seeking, accessing or staying on treatment. Understanding this stigma and reducing it should be a key priority in the months and years ahead for the European Union institutions and its EU member states. Civil Society drew attention to the Ljubljana Declaration 2.0, a call for urgent action in response to rapidly expanding HIV epidemics among gay men, other men who have sex with men and trans people in newer EU member states and enlargement countries

Important announcements were made by Germany, France and the Netherlands highlighting that increasing demand and making pre-exposure prophylaxis (PREP) available and reimbursed nationally for all is a priority within the next months. It was highlighted that Europe needs to do more to ensure the right to health of migrants is respected.  Migrants must be protected from increased vulnerability to HIV to access needed health services regardless of residency or insurance status and that they are not returned to countries where there is no real access to treatment.

The ministerial meeting provided an opportunity to showcase the tremendous contribution European Union member states countries and the European Commission have made to the AIDS response globally and within their own borders. Participants highlighted that together the individual EU Member States and the EU itself via the European Commission contribute significantly to international funding for the AIDS response. The next Global Fund replenishment will be hosted in Paris, France in 2019. The role of the European Union is even more critical as international funding flatlines and the need is great for support particularly for countries in Eastern Europe and Central Asia.

The session was also an opportunity to hear about the innovations and excellent practices in some countries in the region. Speakers highlighting the importance of supportive legal environments and engagement of affected communities. Portugal highlighted its commitment to the agenda and the difference that introducing harm reduction approach has made as it has seen a drastic reduction in new HIV infections. The European Commission showed how an integrated approach to HIV, TB, viral hepatitis and STIs, as well as legal frameworks allowing for community engagement in health service delivery outside of medical settings is the way to reach more people and maximise investments at countries level.  This approach underpins the achievement of the Sustainable Development Goals on health and on justice. The city of Amsterdam showed it has virtually reached 90-90-90 with a city policy that supports the right to health, coordination between stakeholders and an inclusive and innovative environment for all citizens in the city. Speakers also highlighted the expanding epidemic in Eastern Europe and the need for increased collaboration with the region.

A focus on integrated health services, rights, reaching those at risk of being left behind and inclusiveness is emerging in a number of EU member states. Yet there is only twelve years to 2030 and efforts need to be sustained and expanded to ensure that Europe is on the Fast Track to ending AIDS – leaving no one behind

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The Executive Director of UNAIDS, Michel Sidibé, emphasized the importance of cities in ending the AIDS epidemic by 2030 during a speech to the Council of Paris on 4 July, highlighting that cities can use their HIV responses as a transformative force for society.

In his address, Mr Sidibé also spoke of the challenges faced in western and central Africa, where three out of four people living with HIV do not have access to HIV treatment. The African Union has endorsed an emergency catch-up for western and central Africa that sets a target of an additional 1.2 million people on treatment over the next 18 months. The emergency plan places a focus on cities and challenges mayors to take the lead. Mr Sidibé noted that support from Paris can assist western and central African countries to bridge the gaps and reach their goals.

Mr Sidibé finished his address with a call for unity across city borders and country boundaries. “Let us tackle inequalities together. We must not lose focus. Rather, let us continue to fully fund the response in Paris, but also support partners in Africa to tackle inequalities and fragilities.”

Following his address, the Mayor of Paris, Anne Hidalgo, invited Mr Sidibé to join the Let’s Make Paris the City of Love without AIDS! (#FaisonslAmour) campaign. #FaisonslAmour channels the spirit of Paris, uniting Parisians around the target of ending AIDS while raising awareness around the HIV treatment and prevention options available. #FaisonslAmour aims to inform people about the need to know their HIV status and seek treatment early, and to raise awareness about the availability of pre-exposure prophylaxis.

Six Parisians are profiled in the campaign, who reflect the reality of the epidemic within an inclusive city, proud of its diversity. One of the profiles highlights the efficacy of treatment as prevention. The campaign is the first in France to state that a person living with HIV adhering to an effective antiretroviral regime will not pass on the virus. Speaking about the radical campaign, Ms Hidalgo said, “Together, we must mobilize and be vigilant, but, above all, we must act to prevent new infections by delivering just and appropriate messages.”

The #FaisonslAmour campaign is a significant step towards ending AIDS in Paris and demonstrates that Paris is providing leadership in the response to HIV. The campaign is co-chaired by the City of Paris and the Vers Paris sans SIDA association, with the support of the MAC AIDS Fund, and produced by Agence Australie. The posters will be displayed across Paris from 28 June to 25 July.

Increased access to pre-exposure prophylaxis (PrEP) and HIV testing, together with the elimination of discrimination, are key to reducing new HIV infections in Portugal, representatives of civil society told UNAIDS Deputy Executive Director Luiz Loures in Lisbon, Portugal.

On 29 May, Mr Loures visited CheckpointLX, a community-based centre in Lisbon for men who have sex with men that offers rapid, confidential and free screening for HIV and other sexually transmitted infections, as well as counselling and referral to health care. During the visit, he discussed the challenges faced by civil society organizations in the response to HIV in the country.

The civil society representatives noted the progressive health policies that Portugal has regarding drug use, which are regarded as best practices in reducing new HIV infections among injecting drug users around the world. They also highlighted the importance of the current enabling legislation that is, for example, providing access to health services, including for HIV, to migrant populations regardless of their legal status, which puts Portugal at the forefront of the AIDS response in Europe.

The government’s political commitment to end AIDS by putting people at the centre of the response was further embodied by the Ministry of Health’s announcement on 29 May of the provision through the national health system of PrEP for key populations at higher risk of HIV infection, including gay men and other men who have sex with men and people who inject drugs, and for serodiscordant couples.

Nonetheless, challenges remain. Despite Portugal’s enabling legislation, the civil society representatives stressed the need to ease access to HIV prevention, diagnosis and treatment for migrant populations, given the raising HIV prevalence among migrants. The need to take a holistic approach in the provision of services, including screening for hepatitis, tuberculosis and sexually transmitted infections, was stressed. The representatives also noted that eliminating all forms of discrimination will be paramount to increasing access to services and to ending the AIDS epidemic as a public health threat by 2030.

UNAIDS is working with countries to achieve the commitment in the 2016 United Nations Political Declaration on Ending AIDS of ensuring access to combination prevention options, including pre-exposure prophylaxis, voluntary medical male circumcision, harm reduction and condoms, to at least 90% of people by 2020.

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