Julie Davids is the Executive Director of CHAMP (Community HIV/AIDS Mobilization Project).
Twenty years ago, AIDS was burning through the country and decimating whole communities while Reagan fiddled away. ACT UP New York burst onto the scene with a rallying cry of "drugs into bodies," shutting down Wall Street over the price of AZT, the only treatment and the most expensive drug ever marketed.
The group grew into a powerful and innovative social force—with hundreds of independent chapters worldwide—and racked up hard-won victories from the accelerated approval of the drugs that turned around the epidemic in the U.S., to changing the very definition of AIDS, to include the conditions seen in women and injection drug users so they could access research and benefits, to the establishment of underground and legalized needle exchanges, to the vigilant defense of the civil and human rights of people living with HIV.
There are now few chapters—many tragically and literally died off as members lost their personal battles to AIDS, and others waned in the Clinton era—but the struggle continues: ACT UP Philadelphia has just won expanded access to condoms in city jails, and a new chapter in Austin Texas is going strong.
On March 29, ACT UP NY and its allies will commemorate this two-decade legacy with a march to Wall Street—but this time, the demand is for health care for all and single payer health insurance, as well as drug price controls.
Meanwhile, this week at the Conference on Retroviruses and Opportunistic Infections (CROI), health care policy was not a big part of the agenda, given that this long-standing scientific confab focuses on research … but it looms large for anyone following the science on HIV prevention, and for the dozens of web-cast sessions at the conference that dealt with prevention technology, policies, and epidemiology.
As the powers-that-be put more chips in the "biomedical intervention" basket, we have to ask: where are the systems of care that are ready to bring prevention options everywhere they are needed, as soon as we can get them out of the research pipeline?
The dictionary tells me that biomedical means "relating to the activities and applications of science to clinical medicine." A report released by the Forum for Collaborative Research just before this week's conference tells me there are a spectrum of such activities being looked at for HIV prevention—including the use of anti-HIV drugs by those at risk of HIV (with a daily dose like the use of birth control pills) or those recently exposed, microbicides that could be or new approaches to "barrier" methods like the female condom or even diaphragms, and microbicides.
But the report urges the need for coordination of research, an end to the competitiveness between researchers that impairs collaboration, and an investment in "sustainable" research, by "building ownership in host communities by genuinely involving local researchers and establishing standards for trial participant protections and community engagement."
And biomed prevention sure has been big in the news lately, with large studies in South Africa, Kenya and Uganda showing that circumcision of adult men reduced risk of HIV by as much as 60%. That's vaccine-level efficacy, and next week the powers-that-be, like WHO, UNAIDS and PEPFAR (the US global AIDS program), will meet in Geneva with the goal of coordinating work on this striking finding, with many ethical, practical and cultural issues to consider.
And then there was the disappointing news that a microbicide trial was halted after one of its three sites had more cases of transmission in the treatment arm than the placebo arm. It is still unclear if it was the microbicide itself or something about the particular site, and the press conference by trial sponsors at CROI did not shed much light.
But these aren't the only biomedical trial result we can expect in the coming few years. The AIDS Vaccine Advocacy Coalition (AVAC) has made this handy chart showing that we can expect results from multiple biomed trials in the next two years—and are we ready.
Hey, it's not even just about upcoming results; it's about what we know right now … HPV has been shown to increase susceptibility to HIV… Hello! Vaccine! Hello!
So … if we're looking at prevention efforts that require health care system, like, say, making circumcision available as a safe and sterile practice, or treating the STDs that increase the risk of someone getting or passing on HIV, we are not ready if we don't have health care systems—and we don't have them if we don't have health care workers. Hundreds of groups worldwide have joined in the call for US government investment in the people who make care a reality, and they are asking you to call your senator with the request that they co-sponsor the Africa Health Capacity Investment Act.
The Forum's report recommends that we get ready to get going on male circumcision and other prevention interventions "through a coordinated operations research effort, improved marketing, behavioral research, use of AIDS treatment scale up as an opportunity to deliver prevention, and lower prices and adequate purchase capacity for prevention commodities."
Add that all up and what does it spell? Health care.
The next wave of desperately needed HIV prevention options will require not just better coordination of research but investing NOW in systems of care. Otherwise, we risk having scientific breakthroughs that have no real effect in stemming the epidemic.