Partners must prioritize access in fight against HIV/AIDS, experts say

SAN FRANCISCO — In July, researchers, advocates, policymakers, and others will gather in San Francisco and Oakland, California, for the International AIDS Conference, billed as the largest conference on any global health or development issue.

The last time that San Francisco held the conference was in 1990, when the city was considered the epicenter of the growing public health crisis.

While the city still has one of the largest HIV-positive populations in the U.S., infection rates have plummeted, though new infections are on the rise in Oakland, particularly among racial and ethnic minorities.

Over the past 30 years, advances ranging from medical technology to policy implementation have reduced new infections and suppressed the virus for those already living with HIV. There is a lot of excitement about technological innovations already on the market and those that will be available in the near future, including preexposure prophylaxis, or PrEP, which could soon be available as implants instead of daily pills. But progress in the global fight against HIV has been uneven, with the San Francisco Bay Area serving as an example of the global inequities in the disease burden.

In the lead up to the AIDS 2020 conference, the conversation on existing and emerging HIV technology is shifting toward how to ensure that these products and services are scalable, affordable, and sustainable.

Partnering to go faster

Thanks to scientific advances, there are now more prevention and treatment options than ever before to tackle the HIV pandemic.

“Just because we have those approaches and tools available doesn’t mean they’re accessible to those who need them the most,” said Sara M. Allinder, executive director and senior fellow at the CSIS Global Health Policy Center, during a recent event hosted by CSIS on improving access to HIV technology.

The reasons for this inaccessibility range from inadequate financing to regulatory and guideline obstacles to inefficient delivery systems.

Drug companies can play an important role in providing access to medicines in low- and middle-income countries. For example, in low-income countries, Viiv Healthcare, which is focused on research and development of new medicines for HIV, issues voluntary licenses to generic manufacturers. However, as the company marked its 10-year anniversary last year, its chief executive officer said she was proud but not satisfied.

“We didn’t go fast enough,” said Deborah Waterhouse, CEO of Viiv, at the CSIS event.

Partnerships have been the key to success in overcoming the challenging regulatory approval process in countries with the greatest need. Last month, Viiv filed submissions to the U.S. Food and Drug Administration and the European Medicines Agency seeking approval to make dolutegravir, an antiretroviral medication used to treat HIV/AIDS, in a dispersible tablet that works for children. The commitment was made almost exactly a year after the Vatican hosted a convening on pediatric HIV with partners in a position to bring innovations to the markets that need them most.

Going beyond an analog response

Technology has driven some of the most important biomedical breakthroughs for HIV prevention and treatment. But the response to the HIV pandemic remains an analog response, with service delivery methods from the 20th century, according to the founders of Tech4HIV. The organization aims to engage tech companies in the fight against HIV in order to leverage nonbiomedical technologies in a more coordinated and streamlined way.

“The pandemic is not only not slowing down, but actually growing,” said Marguerite Hanley, director of Tech4HIV.

While emerging tech may play a role in the HIV effort, public health organizations need to start by taking advantage of off-the-shelf technologies already in existence, from relationship management software to cloud-sharing, she said.

“There are a lot of one-off examples of tech being used to help a local clinic or a particular software being involved to help one organization,” she said. “But there’s really no coordinated tech response.”

She said she sees AIDS 2020 as a unique opportunity to engage the tech sector, particularly groups based in the San Francisco Bay Area, to focus more on HIV prevention and treatment.

Moving from tools to systems

Like many efforts in global health, the fight against HIV/AIDS is too focused on the tools rather than what to do after those tools are available, said Mitchell Warren, executive director of AVAC, a nonprofit organization aimed at accelerating the development and delivery of HIV prevention options.

“We need to focus on the systems to take these innovations forward,” he said.

Despite the efficacy of oral PrEP, uptake around the world has been slow for a range of reasons. With the introduction of injectable PrEP, there is an opportunity to move from thinking product-by-product to system-by-system, Warren said.

For example, AVAC is leading a collaboration between Viiv, the Gates Foundation, and multilaterals including PEPFAR — the U.S. President’s Emergency Plan for AIDS Relief — to create the infrastructure through which any and all next-generation products can be delivered.

Innovation is rooted in the question “What if we could X?” said Charles Lyons, president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation.

“As you’re what if-ing, you also have to ask: Would this thing be plausibly scalable, is it plausibly affordable, is it plausibly sustainable?” he said at the CSIS event.

If these innovations are not scalable, affordable, and sustainable, there will be no access, which renders innovation meaningless, Lyons said.

At the CSIS event, Warren, Lyons, and Deborah Birx, coordinator of the U.S. government’s activities to combat HIV/AIDS and U.S. special representative for PEPFAR, all emphasized the importance of engaging members of the community to ensure that innovations being developed actually meet their needs.

“We’ve learned that paper on a shelf doesn’t work,” Birx said. “The question is: Is the dialogue strong enough to get the insights quick enough to get that translated to the people we’re serving fast enough?”

Update, January 9, 2020: This story has been updated to clarify AVAC’s role in the partnership to create the infrastructure through which any and all next-generation products can be delivered.