US Secretary of State Hillary Rodham Clinton. ©IAS/Ryan Rayburn - Commercialimage.net

The US Secretary of State, Hillary Clinton, made a number of important funding pledges in her address to the International AIDS Conference.

These included:

• $37 million for projects working with injecting drug users and gay men in countries with expanding HIV epidemics.

• $40 million for the roll-out of male circumcision in Africa.

• $80 for the prevention of mother-to-child transmission.

• $90 million for research into microbicides.

The Secretary of State used her address to reaffirm the Obama administration’s support for the reproductive rights of women.

"Every woman should be able to decide when and whether to have children. This should be whether she is HIV positive or not. There should be no controversy about this. Women need and deserve a voice in the decisions that affect their lives."

In partnership with UNICEF

Not surprisingly, funding for HIV programmes is a repeating topic at AIDS 2012. With many key players in the field declaring that AIDS can be ended, the question is “Who will pay for this?” A session at the conference looked specifically at this.

Experts from medical organisations, academia, UNAIDS and government stressed the need for increased funding, but also recognised the importance of making sure any response to ending the AIDS epidemic can be sustained in the long term, without interruption.

International funding continues to be important, but speakers also highlighted the increasing role national budgets should be – and in some cases already are – playing. 

One possible solution was presented at the session. A researcher from Liverpool University believes that a small increase in the taxes on alcohol and tobacco in the countries worst hit by HIV and tuberculosis (TB) would raise enough money to pay the treatment costs related to these illnesses.

As an example, Andrew Hill told the Washington conference that his idea of a ‘global health charge’ – a modest increase in the tax levied on alcohol and tobacco – if implemented in Nigeria, Uganda, Botswana, Thailand, Vietnam, India, Brazil, Russia, Ukraine and China – could potentially raise US$2.57 billion each year. That would be enough to provide universal HIV treatment in all these countries, with money left over for HIV prevention, TB, malaria, and other diseases.

"People are not just dying of HIV, but they are dying of tobacco in very high numbers, and they're dying of alcohol. A decrease in the consumption of alcohol and tobacco would have associated public health benefits," he said.

A new drug for the treatment of tuberculosis (TB) has performed very well in a clinical trial.

The drug, PA-824, was taken in combination with the antibiotic moxifloxacin and the anti-TB drug pyrazinamide.

In a randomised study lasting 14 days, the PA-824-containing regimen had better antibacterial activity than five other arms, one of which involved therapy with standard TB treatment.

The PA-824-containing regimen is expected to work against both drug-sensitive and drug-resistant TB. It is hoped that use of the drug could reduce the length of treatment for multidrug-resistant TB (MDR-TB) by up to a year.

Importantly, the combination is unlikely to have any significant interactions with HIV therapy.

“The regimen of PA-824 plus moxifloxacin plus pyrazinamide has really very dramatic improvement over a number of other combinations,” said researchers.

During two weeks of treatment, the combination killed 99% of TB bacteria.

A new treatment combination of maraviroc (Celsentri/Selzentry) plus ritonavir-boosted atazanavir (Reyataz) produced good results, it was reported to AIDS 2012.

The study compared this combination with tenofovir/emtricitabine (Truvada), and both arms also took atazanavir boosted with ritonavir. The new combination is unusual in that it doesn’t contain a drug from the NRTI class.

After 96 weeks, 67.8% of people taking maraviroc  and 82.0% of those on Truvada  had undetectable viral loads – the goal of HIV treatment. Using a less sensitive test, 78.0% and 83.6%, respectively, had a viral load below 400.

Rises in CD4 cell count were similar on both the treatment combinations.

More people taking maraviroc had serious side-effects than those on Truvada (22 vs 18%). These included jaundice because of raised bilirubin, a known side-effect of atazanavir.

But fewer people on maraviroc had indicators of reduced kidney function  or of bone problems (tenofovir is known to cause kidney and bone problems in some people).  

A new trial is now underway testing maraviroc with a different protease inhibitor, darunavir (Prezista).

Dr Josephine Birungi, who presented the recent findings from Uganda. ©IAS/Moreno Maggi

There’s a lot of excitement about the use of HIV treatment as prevention. Results of a large randomised trial (HPTN 052) presented to the International AIDS Society conference in Rome last year showed that effective treatment reduced the risk of transmission by 96% in monogamous heterosexual couples.

But a much smaller study presented to the International AIDS Conference in Washington has revealed the potential limitations of treatment as prevention in ‘real-world’ settings. Its results would suggest that treatment doesn’t have any real impact on the risk of transmission.

The study was conducted in Uganda and involved approximately 600 heterosexual couples in long-term relationships, where one partner was HIV positive and the other HIV negative. HIV transmission rates were compared between couples where the positive partner was taking treatment and couples where treatment wasn’t being used.

The couples were followed for approximately two years.

Annual HIV incidence was approximately 3% in couples where HIV treatment wasn’t being used, compared to 2% in those where the positive partner was on treatment.

Viral load was tested after transmission took place. All the participants not on HIV treatment had a viral load over 1000. Thirty-five per cent of the people on treatment who apparently transmitted HIV had a viral load above this level.

The researchers who conducted the study emphasised that they are not questioning the impact of HIV treatment on infectiousness. However, they think its effectiveness as a prevention tool can be undermined by social, biological and cultural factors.

For instance, they found that transmission was more likely to occur in polygamous relationships. Nor did the researchers have any information on the prevalence of other sexually transmitted infections, which can increase the risk of HIV transmission.

Celia Christie-Samuels and Bernard Pécoul, co-chairs of the Catching children before they fall satellite session.

New treatment options may soon be available for HIV-positive children and adolescents.

Treatment options for babies and children are currently more limited than those available to adults, and there is a need for new drugs to treat this group.

The Washington conference heard that new paediatric formulations of some drugs have been developed.

Research was also presented showing that combinations including integrase inhibitors or the NNRTI etravirine (Intelence) achieve good results and are safe in children.

A new paediatric formulation of tenofovir (Viread) was shown to be a safe treatment for the prevention of mother-to-child transmission of HIV. A single 600mg dose of tenofovir was given to pregnant women during labour.  Infants were treated with a daily 6mg/kg dose of tenofovir for seven days. Good concentrations of the drug were achieved and it caused no serious side-effects.

Results of a study looking at the safety and efficacy of therapy based on the ritonavir-boosted protease inhibitor fosamprenavir (Telzir/Lexiva) were also presented to the conference. After 48 weeks of treatment, up to 78% of children achieved an undetectable viral load. The safety profile of the drug was similar to that seen in adults.

Forty-eight week results from a study investigating the use of raltegravir (Isentress), in combination with other anti-HIV drugs, showed that it suppressed viral load to below 50 in 57% of patients and that CD4 cell count increased by over 150 cells/mm³. On the basis of these results, an application has been made in the US for a licence to use the drug in HIV-positive children and adolescents.

The experimental integrase inhibitor dolutegravir also did well in a small study involving children aged between 2 and 18 years of age. After four weeks of treatment, 70% of patients had a viral load below 40 copies/ml and the treatment also achieved good increases in CD4 cell percentage.

The effectiveness of etravirine was monitored in highly-treatment experienced children. After a year of therapy with a combination that included the drug, 56% had an undetectable viral load.

In partnership with UNICEF

The Sex Worker Freedom Festival in Kolkata  – an alternative conference hub for sex workers denied entry to the United States. Image courtesy of Luca Stevenson, Sex Worker Open University www.sexworkeropenuniversity.com and ICRSE www.sexworkeurope.org

A major theme for AIDS 2012 is turning the tide for key populations, and one of these groups is sex workers.

Sex work is illegal in many countries, creating its own problems for sex workers trying to protect themselves against HIV. Now there seems to be a global trend of criminalising condom possession, with police claiming it provides ‘evidence’ that sex work is taking place.

Research was presented at the Washington conference on the impact these new laws are having: condom use by sex workers has reduced significantly, increasing the risk of HIV transmission.

The session called for an end to this trend of new police powers, but – more importantly – for the decriminalisation of sex work for both the workers and their clients. This would have clear benefits for both public health and human rights.

Hillary Clinton mentioned sex workers specifically in her address to the conference, pledging money for prevention programmes for this at-risk group.

The US has been criticised this week for denying sex workers visas to enter the country and attend AIDS 2012. A Sex Worker Freedom Festival is taking place in Kolkata, India, as an alternative conference hub for sex workers denied entry to the United States. (You can follow events at the Kolkata conference through the HIVandhumanrights blog.)

Images by Greta Hughson/aidsmap.com

There was another day of activism in Washington DC yesterday, with five separate marches – each addressing a theme – taking place across the city.  Hear more from aidsmap’s Greta Hughson, who joined in, and about the mood from the conference so far.