35 years into the AIDS epidemic, it's an opportune but precarious time

When AVAC was founded on World AIDS Day in 1995 as the AIDS Vaccine Advocacy Coalition, it had a single focus: an AIDS vaccine.

“But we began to recognize it was about advocacy and engagement across the research to roll out continuum,” Mitchell Warren, executive director of AVAC, told Devex. “We expanded our focus from the science of product development to include the science and art of product and intervention delivery.”

The changes in AVAC reflect broader shifts in the fight on HIV/AIDS, from the expansion of the prevention research landscape beyond vaccines, to the recognition that interventions in and of themselves do not end epidemics. This World AIDS Day, Devex spoke with Warren during what he said is a precarious time for the epidemic. After working for several decades on HIV/AIDS, he said there is an opportunity to bend the curve by delivering at scale the existing tools for treatment and prevention while also developing additional tools for the future.

I know that the Bill & Melinda Gates Foundation, one of your major funders, invests heavily in advocacy across its program areas, and that you also focus on advocacy in your work on HIV/AIDS. World AIDS Day is about raising awareness but effective advocacy goes far beyond raising awareness. Can you talk about your approach?

The earliest advocacy in the prevention space was twofold: The world needs an AIDS vaccine and the world needs more money to get that vaccine. It’s almost yes, yes, and so what am I going to do now?  

It’s not enough to say, “OK, we need an AIDS vaccine.” And that is just as true today as it was 20 years ago. We have got to do more than say it. We need to address it.

To me the advocacy that is successful and so urgently needed is an evidence-based advocacy that always recognizes ‘What has to come next? AVAC’s advocacy is really constantly driven by the question: “What is the next most important thing that has to happen on this very complex journey, what are the barriers that stand in the way, and what do we do to overcome them?”

Advocacy has been at the cornerstone of the AIDS response for 35 years and if you look at the greatest gains they come when science and advocacy were deeply fused.

I was interested to read that you have been a champion of efforts to expand female initiated prevention methods like the female condom. Last week, UNAIDS put out a report, and one of the takeaways was that the world has failed young women ages 18 to 24 when it comes to HIV/AIDS. What more would you like to see when it comes to women in particular?

The report demonstrated that 18.2 million people are on antiretroviral therapy, which is terrific. But there is one area where we are are not making gains at all and that is young women, particularly in Africa.

If people tell me one more time the HIV epidemic has a woman’s face on it, I’m going to scream, because that is what we said 20 years ago.

The DREAMS initiative, a partnership between PEPFAR and others, is all about determined, resilient, empowered, AIDS-free, mentored, and safe young women. DREAMS is an example of an understanding that it is about biomedical, behavioral, and structural issues, and that you have to figure out innovative ways to do all of that in combination.

It is still early days but I do think that at the heart of that work and the work we are doing at AVAC it is about understanding what young women in different contexts are facing. We have to understand that adolescent girls and young women are not some homogenous group.

We just did landscape mapping as part of our work with the Gates Foundation of all these efforts to “understand” young women in Africa. There are now 54 projects in East and Southern Africa alone. I think we are gaining some important insights but some of them are what we have known for a long time. We have got to stop relearning and start acting on that information.

We recently wrapped up a campaign at Devex called #MakingMarketsWork where one of the key themes was the need to focus on structural issues that have nothing to do with technology. Can you talk about how that translates to your work on HIV/AIDS?

One of my first interactions with the Gates Foundation was right after it started which is now 16 years ago. I was working on the female condom. And I actually went to the Gates Foundation with it to support programs to introduce it. It was not a perfect product but it was the product we had. And sadly they did not fund that.

What is being funded today is work with Oral PrEP and the heart of our work with the Gates Foundation and USAID is not just about PrEP. The heart of this work is how do we build prevention platforms that we can introduce anything to, whether that is PrEP today whether it is the the Dapivirine Ring tomorrow, whether it is a combination contraceptive HIV prevention ring in five years, whether it’s an AIDS vaccine in a decade.

We have have not yet built comprehensive sexual and reproductive health programs that include HIV prevention that is not not separated but included. My argument is that it’s never about the technology, but rather it’s about the programs and the processes we create together with the communities that would be able to absorb the new technology. My analogy is antiretroviral treatment itself. Every time there is a new drug, we know where and how to introduce it. That doesn’t mean our health systems are perfect. But the systems do exist such as they are and you can introduce the next innovation in therapy. We don’t have that for prevention. If we were so lucky to have one of the next big ideas, if we don’t build the platforms today, we will have to wait years and we will have failed. And that is what makes this time so opportune but also so precarious.

This week, in South Africa, a group of public and private partners, including the Gates Foundation, launched the first new HIV vaccine efficacy study in seven years. There is a lot of excitement around that, of course, but the global health community is a long way off on many of its targets on HIV/AIDS. What thoughts or calls to action do you have as we reflect on all that has been accomplished and all the work that remains 35 years into the AIDS epidemic?

There is all this talk of ending this epidemic. The end of the epidemic is overstated but not overrated. We clearly need to get on with the job of ending this epidemic.

I personally have always been a huge fan of bold and audacious targets but we also need to be realistic in what we can accomplish. We need to be self-critical and honest.

One of the key expectations or hidden assumptions in those targets was to have incredibly robust funding. There were a lot of assumptions about domestic financing, low- and lower-middle-income countries beginning to direct more of their resources towards AIDS response, and while we have seen that in South Africa, we are not seeing that across the board.

Two incredibly important data points came out at the AIDS conference in Durban that should really cause us to take a step back and look at what we are doing and how we are doing. New infections amongst adults are not going down, but funding is going down, so we’ve got to course correct. The whole premise of epidemic control in 2030 was, beginning five years ago, we needed to see a downward trajectory of new infections, and we haven’t even begun to get that line to go down.

There still remains a lot of this treatment versus prevention conversation amongst funders and implementers and everybody knows we can’t, with treatment alone, end this epidemic and we can’t with prevention alone end this epidemic. There are some promising signs that people are starting to get this. We’ve got to be crafting what I describe as a comprehensive, integrated, sustained response to the epidemic.

We are not yet there with funding flows or programs but it is beginning to emerge that people are looking at the new normal and seeing they need to do their work work differently.  

We’re at this really precarious moment, and it’s been precarious for 35 years. It used to be because we were failing miserably in treating and preventing. Now, it is because we have seen these huge advances but we are nowhere near the end. The progress we have made, which is truly incredible, is not yet at all sustained or guaranteed.

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