The fight against HIV and AIDS stands at a crossroads.
Worldwide, new infections have fallen by one-third since 2001, and AIDS-related deaths have decreased by 30 percent since their peak in 2005, largely due to the availability of antiretrovirals for treatment. Our arsenal of prevention and treatment tools is stronger than ever, with strategies ranging from male circumcision, pre-exposure prophylaxis and treatment-as-prevention to female condoms and voluntary counseling and testing.
Yet, on World AIDS Day, we must acknowledge the profound challenges we still face. The epidemic continues to disproportionately overwhelm certain populations, and some regions of the world are seeing the problem worsen. Our work is far from over. Business as usual will not get us anywhere near the goal of zero new cases — we need game-changing solutions.
There is no question that a highly effective vaccine would be the holy grail of HIV prevention that other tools will complement. Many organizations are working to make one a reality as soon as possible, but it’s safe to say that a HIV vaccine could be 10 years away, and no vaccine will be 100 percent effective or appropriate for everyone.
To bring an AIDS-free generation within reach, we need additional options and continued investments in other innovative prevention technologies, especially those that prioritize women. They bear the greatest burden of HIV and AIDS globally despite the rollout of existing, effective interventions. AIDS is the leading cause of death among women of reproductive age globally. In parts of sub-Saharan Africa, young women are three times more likely to become infected than men, and approximately 40 percent of young women are already infected with HIV in some regions of South Africa.
New female-initiated health technologies have the power to reverse this unacceptable inequity by giving women — who have been left behind by global progress — products they can use to protect themselves. Vaginal microbicides are one such innovation in development. These products contain the same types of ARV drugs that are already being used successfully to treat HIV-positive individuals and to prevent mother-to-child transmission. Discreet and self-initiated, microbicides could put HIV prevention directly in the hands of women.
Right now, the HIV prevention community is eagerly awaiting the results of two late-stage microbicide trials evaluating products that could revolutionize the way women protect themselves against HIV. Tenofovir vaginal gel, developed by Gilead Sciences and used around the time of sex, previously demonstrated the ability to reduce HIV transmission to women by 39 percent. It is now in a confirmatory trial, with results expected in 2014. The monthly vaginal dapivirine ring, developed by the International Partnership for Microbicides, could offer women a long-acting prevention option that may encourage consistent use. It is now in two parallel third-phase trials, with results expected in 2015. Rectal microbicide gels for both men and women are in earlier stages of development as well.
But any product, no matter how technically effective it may be at preventing HIV, will not work unless women find it easy to incorporate into their everyday lives. Therefore, we need new and complementary tools that fit women’s needs to ensure they will be widely used and ultimately increase the real-world effectiveness of the broader HIV prevention toolkit.
We must also recognize that women’s HIV prevention needs do not exist in isolation of their sexual and reproductive health, and that we need to take a holistic approach to have maximum impact against the disease. In response, IPM, CONRAD, Population Council and others are also developing multipurpose prevention technologies, or MPTs, and other tools designed for women that could deliver simultaneous protection against unintended pregnancy, HIV, and in some cases, other sexually transmitted infections. Because women’s perceived risk of HIV is low compared to their perceived risk for pregnancy, combined technologies may also be widely used. Together, microbicides and MPTs will be critical to closing the HIV and AIDS gap for women everywhere.
In addition, a robust pipeline of new drugs and optimized formulations for both women and men will be required to build upon current successes and stay one step ahead of the virus. HIV is extraordinarily adaptable, so the emergence of drug resistance is a serious concern. This is compounded by the fact that HIV treatment is lifelong, which increases the potential for resistance to develop to products over time.
Because it takes more than a decade for most prevention products to go through clinical trials and reach regulatory approval, we cannot wait until we need a new product to begin developing it. When it comes to HIV, the luxury of time is not an option, so research and development on additional prevention drugs must happen now.
That is why organizations, including nonprofit product developers like IPM, are working on a variety of microbicides, MPTs and other products that use new and different types of ARVs — alone and in combination — that may be more likely to prevent HIV over time.
AIDS is an incredibly complex, opportunistic disease, and we need equally creative and bold solutions to beat it. The global community must continue to invest in breakthrough and complementary global health technologies like vaccines, microbicides, MPTs and pre-exposure prophylaxis that hold immense promise. Innovation will broaden the prevention options available to everyone, and help offset the risk of the virus’ resistance — two factors that will make or break our ability to change the course of the epidemic.
This work should be motivated by the simple recognition that global health research and development for HIV prevention is not secondary to the global development agenda, but integral to it. It is an investment in a healthy, productive future for women, families and communities everywhere.
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Zeda Rosenberg is CEO of IPM, a nonprofit working to develop new HIV prevention and sexual and reproductive health products for women. Previously, she served as scientific director for the HIV Prevention Trials Network at Family Health International, and senior scientist at the U.S. National Institute of Allergy and Infectious Diseases at NIH. She received her master's in epidemiology and a doctorate in microbiology from Harvard University.
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