Advocacy

While IAVI’s mission is to ensure the development of a safe, effective HIV vaccine, the development process itself offers more immediate-term benefits for to those groups like discordant couples who are most in need. IAVI and partners have helped discordant couples to lower their rates of transmission through education, healthcare and prevention efforts that ultimately result in their ability to live fuller, healthier lives, and reduce the spread of HIV/AIDS to others. At the same time, discordant couples have helped researchers gain unique insights into the early stages of HIV transmission and infection that is critical for the development of an HIV vaccine.

In 2003, an estimated 70 percent to 90 percent of HIV infections in southern Africa occurred in married or cohabitating couples who did not realize that one partner was HIV infected and the other was not1 – making transmission in these discordant couples a major contributor to the spread of HIV/AIDS in sub-Saharan Africa2

discordant 1 300pxIAVIHistorically, HIV prevention beginning in the late ‘80s often focused on risk in casual relationships outside of marriage or stable partnerships, as these relationships were often seen as a safe haven. HIV testing and prevention efforts within couples who had been married or living together for a long time already, held little importance despite their high risk of HIV transmission. Moreover, information on strategies to sustain relationships and make sexual and reproductive choices while maintaining health and avoiding HIV transmission were also quite limited.  But the work of the Rwanda Zambia HIV Research Group (RZHRG) set out to change this, and in 2008, a Lancet study concluded an intervention that could reduce transmission for discordant urban cohabiting couples in Zambia and Rwanda from 20% to 7% every year could avert 35.7% to 60.3% of heterosexually transmitted HIV infections that would otherwise occur3

Today, the difficult day-to-day reality for discordant couples continues to realize bright spots of change, in part as a result of RZHRG and HIV vaccine research studies efforts sponsored by IAVI throughout the past twelve years. RZHRG’s work with discordant couples has contributed to a wide range of health and transmission reducing strategies tailored to their needs and fertility intentions including Couples HIV Testing and Counseling (CHTC), disclosure of HIV test results, condom promotion, antiretroviral therapy (ART) for the HIV-infected partner, contraceptive use or safe conception strategies and the use of ART as pre-exposure prophylaxis (PrEP) by the HIV-uninfected partner4.

From 2003-2012, IAVI supported Project San Francisco’s (PSF) work with discordant couples in Kigali, Rwanda, where 3.1% of all married or cohabitating couples were known to be discordant5 This effort, built on work initiated by PSF’s Susan Allen and Etienne Karita in 1986, is recognized as the earliest, longest-standing and largest heterosexual HIV-discordant couples’ group in the world. IAVI supported PSF efforts to translate results of scientific research into policy directed at the needs of discordant couples in local communities. Through close links with government officials and policymakers, PSF advocacy, research and evidence led the Rwandan government to officially recognize the importance of discordant couple interventions to tackle its HIV epidemic.

With IAVI’s support, PSF also contributed to Rwanda’s nationwide spread of couples testing and helped shape national Couples Voluntary Counseling and Testing (CVCT) policy. Well-implemented CVCT is proven to reduce the transmission of HIV by more than two-thirds among those couples who do not share the same HIV status6  Voluntary HIV Counseling and Testing (VCT) programs typically place a focus on testing individuals. By failing to test couples together, traditional testing often misses a critical opportunity for HIV prevention in one of Africa’s largest risk groups – long-term, cohabiting couples7  CVCT includes testing couples and sharing the results with the partners together. Counselors work with the couples to develop a plan to protect each other, depending on whether the couple is concordant (those who share the same results) or discordant (those having different test results). Counseling and testing together builds respect, confidence and commitment within relationships. When people know their HIV status and their options in coping with this situation, they are in a better position to make informed decisions about prevention, sexual behavior and family planning.

PSF, with support from IAVI, has been a leader in promoting CVCT in Africa. In fact, Rwanda’s pioneer implementation of CVCT on a national scale is based on data and advocacy from PSF. Initially, PSF services included on-site couple's voluntary counseling and testing facilities, medical clinic, laboratory and pharmacy – work now owned and sustained by Rwandan government-run clinics that have been trained by PSF staff.

discordant 2 300pxIAVIThese clinics have in turn acted as entry points into numerous IAVI/PSF observational studies to better understand the HIV/AIDS epidemic and clinical trials to investigate the efficacy and safety of vaccine candidates over the past decade. With IAVI support, PSF has worked to engage influential community leaders – such as clergy, clinic staff, traditional healers, birth attendants and policy leaders – to advocate for CVCT and to help increase demand for services on the basis that it has proven to be relatively cheap and effective. PSF now conducts training with other IAVI-affiliated sites as well as with other African health workers and researchers in more than 20 other countries, including countries outside of Africa. The number of requests for training continues to grow, mirroring a corresponding interest in effective and inexpensive prevention methods.

The PSF-led and IAVI-supported discordant couple study has also proved invaluable in adding to critical knowledge about HIV immuno-pathogenesis, the process leading to AIDS following HIV infection that informs vaccine development. These couples offer a rare opportunity to better understand the complex interaction between HIV and the immune system immediately after infection, how the immune system appears to control the initial burst of virus, how HIV changes and escapes from immune defenses, and what virus characteristics allow it to establish persistent infection. In 2010, an IAVI supported study with the Zambia Emory HIV Research Project (ZEHRP) focused on HIV transmission within discordant couples in Lusaka, Zambia. The study, specifically aimed at HIV-1 discordant cohabiting heterosexual couples with subsequent intra-couple (epidemiologically linked) HIV-1 transmission, led to important findings about transmission. The study showed preventative or therapeutic approaches that even marginally reduce viral replication capacity may lower the overall transmission rates and offer long-term benefits even upon transmission8 Most recently, an IAVI-supported discordant couple study and offered insight into ART to further prevention efforts9 The findings support the WHO’s recommendation to put both partners in all discordant couples on ART, regardless of CD4+ T-cell count, to both lower their viral load and the likelihood of transmission.

More than 30 years into the epidemic, it is clear that a vaccine, in combination with proven prevention and treatment tools, is essential to achieving and sustaining the end of AIDS. While a vaccine still remains to be developed, groups like discordant couples who are most in need have already benefited from the research efforts, and they have been helping to ensure that these efforts will succeed in the end.


1 Allen, S., J. Meinzen-Derr, M. Kautzman, I. Zulu, S. Trask, U. Fideli, R. Musonda, F. Kasolo, F. Gao & A. Haworth. 2003. ‘Sexual Behavior of HIV Discordant Couples after HIV Counseling and Testing.’ AIDS 17 (5): 733–740.

2 El-Sadr, W.M., B.J. Coburn, & S.M. Blower. 2011. ‘Modeling the Impact on the HIV Epidemic of Treating scordant Couples with Antiretrovirals to Prevent Transmission.’ AIDS 25(18):2295–9.

3 Lancet. 2008 Jun 28;371(9631):2183-91. doi: 10.1016/S0140-6736(08)60953-8. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data. Dunkle KL1, Stephenson R, et al.

4 Kathryn Curran, MHS, Jared M. Baeten, MD PhD, Thomas J. Coates, PhD, Ann Kurth, CNM PhD, Nelly R. Mugo, MBChB MMed MPH, and Connie Celum, MD MPH,

5 El-Sadr et al. 2011

6 Ingabire et al. 2013

7 El-Sadr, 2011.

8 Carlson JM, Schaefer M, Monaco DC, et al. Selection bias at the heterosexual HIV-1 transmission bottleneck. Science (New York, NY). 2014;345(6193):1254031. doi:10.1126/science.1254031

9 Karita E, Price M. et al. [The IAVI Africa HIV Prevention Partnership] High Transmitter CD4+ T-Cell Count Shortly after the Time of Transmission in a Study of African Serodiscordant Couples August 20, 2015 DOI: 10.1371/journal.pone.0134438

HIV vaccine research efforts in underserved fishing communities on the shores and islands of Lake Victoria have led the International Aids Vaccine Initiative (IAVI) to inform and mobilize numerous implementing partners to address a wide range of social and health problems.

coastal fishing community in africaIAVIThe search for a safe and effective HIV vaccine identifies and engages those most in need to understand their disease burden, collect scientific data to inform suitable vaccine design and prepare them for participation in future HIV vaccine safety/efficacy clinical trials. This research has also revealed the unmet healthcare and daily living needs of millions of men, women and children who are living and working in fishing communities around Lake Victoria. While research discoveries ultimately raise awareness for the region and can inform healthcare policies and strategies, the conduct of research can also directly improve the quality of both healthcare as well as day-to-day life for those communities that are hosting HIV vaccine research. IAVI routinely engages and mobilizes policy makers, civil society and a range of implementing partners to link these participating communities to essential healthcare and HIV services while improving infrastructure by building latrines, harvesting rainwater, and investing in small-scale agricultural projects.

The fishing communities on the shore and islands of Lake Victoria, site of the first AIDS cases in Uganda in 1982, are some of the most isolated and marginalized in East Africa. These fishing villages are widely scattered across numerous island and shore locations in Uganda, Kenya and Tanzania.  It is difficult to estimate the size of this population since many of them are migratory and live in small, undocumented and informal settlements in remote locations on the world’s second-largest lake. Today, fishing communities remain one of the highest-risk groups for HIV infection. Yet, findings from IAVI’s work on Lake Victoria reveal that for many members of fishing communities, poverty related stresses in addition to other social and economic issues tend to overshadow the real possibility of contracting HIV. Drowning, diarrheal diseases, respiratory infections, parasitic infections and maternal/child mortality are some of the daily stresses that fishing communities are concerned about before they consider HIV as a threat.

Since 1982, the fishing community population has continued to grow while the HIV epidemic remains unchecked. Little has been done to successfully target fishing communities in the region’s otherwise comprehensive response to the HIV epidemic as evidenced by IAVI-supported studies in Uganda. AIDS vaccine research led IAVI and its partners to work closely with organizations to both engage with and understand underserved fishing communities as part of the early efforts in Uganda to collect credible data on the HIV epidemic. IAVI-supported research discovered these fishing communities are vulnerable to HIV as well as a multitude of other diseases and public health concerns. In 2010, IAVI supported the Uganda Virus Research Institute (UVRI) in the first observational study to demonstrate Lake Victoria’s fishing communities have HIV prevalence rates over 4 times higher (26.7%) than the general population and, even more alarming, a new HIV infection rate found to be 8-10 times higher than in the general population1.

fishing community members in africaIAVIMultiple social, economic and cultural factors shape lifestyles in fishing communities including their vulnerability to HIV transmission. Hopelessness, a risk-taking culture, alcoholism, drug abuse, transactional sex and a lack of access to prevention and treatment further contribute to high rates of new HIV infection and AIDS burden. Research teams have also recorded large numbers of women, adolescents and vulnerable children living in extreme poverty with limited access to health care, HIV treatment and care, food security, transportation, clean water and sanitation. HIV also takes a toll on the communities and families. The data suggested that women in fishing communities are at a particularly high risk, as they are often in a subordinate economic and social position and must turn to transactional sex for survival. The power dynamics in these exchanges favor men and can make it more difficult for women to negotiate safe sex2

Much of the research in Uganda, conducted by IAVI partners the Medical Research Council /UVRI and the UVRI-IAVI HIV Vaccine Program, has proved to be instrumental in identifying and addressing the HIV epidemic and the larger public health needs of this at-risk population. In the districts where IAVI-supported research is being conducted, innovative strategies have contributed to the improved delivery of services to remote island-based communities through partnering with a range of implementing partners to deliver family planning services, HIV counseling and testing (HCT), voluntary medical male circumcision (VMCC), prevention of mother to child transmission (PMTCT) and the provision of basic health services. By building on this pre-existing network, IAVI also established more robust referral systems and mechanisms for connecting people living with HIV to the care they need. Based on study recommendations and subsequent emerging discussions, IAVI has also supported the Uganda AIDS Commission and the Ministry of Health to develop strategies for accelerating the provision of healthcare services and combination HIV prevention to fishing communities.    

IAVI and partners continue to work with healthcare and HIV service providers, local authorities, international NGOs and grassroots organizations to improve access to healthcare and HIV services to these struggling fishing communities where few had existed before. Through these efforts, IAVI partners have built trust with these communities – an ingredient that is crucial to effective and sustained community engagement. IAVI’s work with civil society organizations, such as the Ugandan Fisheries and Fish Conservation Association (UFFCA) has ensured that the Ministry of Health, the Uganda AIDS Commission and district health officials are more aware of the gaps in health service delivery to fishing communities.

boats 4 medIAVIIAVI, in partnership with the USAID-funded Uganda Health Marketing Group (UHMG), has helped service providers to better understand the magnitude of gaps in health services and to better reach those most at-risk communities with a range of health services including family planning, HIV prevention, malaria prevention and clean water solutions. IAVI has also worked to improve access to health services at the grassroots level by supporting the training of village health teams (VHT) who serve as the community’s initial point of contact for health across three districts and 12 villages. This strategy, adopted by Uganda in 2001, addresses a shortage of doctors and peer leaders from fishing communities. Training provides VHTs with the knowledge and skills to provide both HIV risk reduction counseling and basic first aid, as well as the ability to establish reliable referrals to the next level of health services as needed. Additionally, the engagement of VHTs and peer leaders has built a wider awareness and understanding of HIV and HIV prevention research. IAVI has also established counseling services that address high rates of both alcohol and substance abuse – both proven to contribute to HIV’s spread amongst members of fishing communities.

IAVI cultivates close links with government officials and policymakers in Uganda to further impact these underserved fishing communities. IAVI is a member of the National Prevention Committee in Uganda that is responsible for ensuring the integrated and coordinated development of Uganda’s HIV prevention strategic framework. The IAVI-supported national Fisherfolk Summit in December 2013 brought key stakeholders to discuss strategies to accelerate the prevision of HIV combination prevention to fishing communities. This groundbreaking summit ultimately led to the development of a roadmap to guide service providers in better targeting HIV/AIDS services to fishing communities. The roadmap highlights a need for integrated outreach services, community involvement in intervention design, improved access to health centers at key hubs, expanded healthcare beyond HIV/AIDS services and sustained dialogue with policymakers. 

little girl in african fishing communityIAVIIAVI’s multi-front approach has also supported campaigns to raise visibility more broadly to facilitate direct engagement with fishing communities and foster discussion about stigma and perception with people from outside the community. A Knowledge Management and Communication Capacity initiative (KMCC) supported a television series aired in December 2013 to increase the public understanding of fishing communities and their challenges related to health and HIV.  The series, aired on Minibuzz, a daily current events television program in Uganda, engaged men and women from fishing communities to openly discuss behaviors and attitudes towards HIV and also provided information related to treatment and prevention. Regionally, IAVI has supported the development of the Lake Victoria Consortium for Health Research (LVCHR) that also includes research groups in Tanzania and Kenya. The LVCHR aims to better understand the HIV epidemic on Lake Victoria and to create a research platform that could be utilized for HIV prevention, research as well as research into other communicable and non-communicable diseases.

More than 30 years into the pandemic, it is clear that a vaccine is essential to both achieve and sustain the end of AIDS. Clinical research efforts to develop a safe, effective, preventive HIV vaccine are already benefiting those most in need by producing dividends that extend far beyond the vaccine search.


1 Kiwanuka et al. 2013. “High HIV-1 Prevalence, Risk Behaviours, and Willingness to Participate in HIV Vaccine Trials in Fishing Communities on Lake Victoria, Uganda.” Journal of the International AIDS Society. 16 (March 2013): 18621. http://www.jiasociety.org/index.php/jias/article/view/18621.
 
2 MacPherson EE1 et al. 2012. “Transactional sex and HIV: understanding the gendered structural drivers of HIV in fishing communities.” J Int AIDS Soc. 2012 Jun 14;15 Suppl 1:1-9. doi: 10.7448/IAS.15.3.17364. http://www.ncbi.nlm.nih.gov/pubmed/22713352

Men who have sex with men (MSM) in Kenya are a highly stigmatized population and constitute a disproportionate percentage of both existing and new HIV infections. They face discrimination including denial of services by doctors, physical violence and hate speech, alienation by family, expulsion and/or suspension from public schools and losing the right to raise their own children1. Vaccine research by IAVI and partners is helping to raise awareness and slowly change these realities.

In 2003, the International AIDS Vaccine Initiative (IAVI) and the KEMRI Wellcome Trust Research Program, funded in part by USAID, began a collaboration to identify people or groups of people at higher risk of acquiring HIV. Research with those individuals would allow researchers to estimate the annual incidence of new HIV infection, provide prevention counseling, characterize the evolution of HIV infection over time, and prepare clinical research sites for future vaccine efficacy trials. In 2005 researchers began working with MSM and Female Sex Workers (FSW) in coastal Kenya. Over the past ten years this effort has steadily evolved into a more holistic response to the HIV/AIDS epidemic among these groups. Through a wide range of advocacy, policy and community engagement activities, services for Kenya’s vulnerable MSM population have begun to improve. Research efforts are indeed contributing to efforts that build social and political support and acceptance.

msm 1FREDERIC COURBET/IAVI Nationwide, roughly 6 percent of adults in Kenya are infected with HIV2 though much of those infections are clustered in specific regions and groups of people, including MSM. Although awareness of HIV and AIDS is comparatively high in Kenya, MSM in general, and those living with HIV in particular, face high levels of social stigma and rampant discrimination.  This reality has compounded the challenges in reaching this vulnerable group and made them less likely to seek out health services including antiretroviral therapy (ART), sexually transmitted infections (STI) treatment, health education and psychosocial support. Their acute health care needs are often further exacerbated by substance abuse, high rates of violent assault and barriers to health care access. This story has been all too familiar among Kenyan MSM whose sexual behavior is still considered illegal and whose HIV rate is more than three times the national average. In 2010, HIV prevalence among MSM was an estimated 18.2 percent3

In 2015, this difficult day-to-day reality for Kenyan MSM is slowly realizing some bright spots of change, in part as a result of those HIV vaccine research studies that began in 2005. HIV vaccine research is an investment that realizes benefits beyond the promise and potential benefits of a preventive HIV vaccine. As HIV vaccine science in Africa is contributing to an array of research-driven discoveries, efforts by IAVI and partners are also incrementally empowering MSM to write a new narrative that extends their voices from the halls of healthcare facilities to the halls of Kenyan government.

Beginning in 2005, IAVI clinical research center (CRC) partner the KEMRI-Wellcome Trust Research Programme at the Center for Geographic Medicine – Coast (CGMR-C) received approval to develop the first MSM HIV clinical trials in Africa. For the first time, previously invisible MSMs emerged from the shadows to shed light on both behavior and epidemiology among this high-risk group. To date, CGMR-C has tested more than 1,500 MSM, and enrolled 950 in studies that look at HIV incidence and disease progression. Both studies have contributed significantly to knowledge about transmission and immuno-pathogenesis that is now frequently referenced around the world. At a national level, this research has helped inform public health policy and practice towards most-affected populations. For those involved in this research, it has also meant increased access to counseling and testing, prevention options, STI treatment and basic healthcare and referral.

IAVI-sponsored research data has been used by both IAVI and CGMR-C to highlight the needs of MSMs in Kenya within the Ministry of Health’s National AIDS & STI Control Programme (NASCOP). This work has helped influence the inclusion of MSM issues in Kenyan national strategies, guidelines and policies including NASCOP’s Most at Risk Populations Surveillance Report (2012), the HIV Prevention Roadmap (2014 - 2030), Kenya National AIDS Strategic Framework and a global best-practice guidance document, Respect, Protect, Fulfill, (RPF) outlining the challenges and opportunities for conducting HIV research with MSMs (developed in collaboration with amfAR, Johns Hopkins University and the United Nations Development Programme (UNDP)). RPF has also been adopted by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) to inform their community engagement for the on-going Ebola vaccine clinical trials in Africa.

The strong commitment of IAVI and partners to influence government policy toward those most affected by HIV/AIDS is also evident through their work with community grassroots organizations. IAVI partners with the Gay and Lesbian Coalition of Kenya (GALCK), Kenya’s national Lesbian, Gay, Bisexual or Queer umbrella organization, to work on issues of rights, health and social welfare. The list of IAVI- and CGMR-C supported MSM empowering activities continues to grow. IAVI helped support Kenya’s first ever national consultative forum on MSM/ Lesbian, gay, bisexual, transgender and intersex (LGBTI) research partnership meeting and develop the G-10, a LGBTI Kenyan national research advisory committee that has helped define the LGBTI research priorities for Kenya in collaboration with leading researchers. IAVI supported the first ever national MSM/LGBTI research partnership forum and a 2012 MSM symposium that led to the formation of the GMT HIV Prevention Network Kenya (GHPN-Ke). IAVI-sponsored work with MSM has been used to provide training on the use of evidence-based research for advocacy to local organizations and NGOs.

msm 2KEMRI STAFF, UTAFITI PWANI MEMBERS, AND REPRESENTATIVES FROM G10,
GALCK, NOPE AND IAVI AT KEMRI CGMRC-MTWAPA CLINIC
The KEMRI-Wellcome community engagement program, including community advisory boards (CABs), has worked to engage religious leaders, local authority representatives, law enforcement experts, people living with HIV, medical professionals and MSMs. Researchers have brought these stakeholders together to both inform them and ensure that research safeguards the rights of participants while reflecting the interests of the community. In so doing, they have helped sensitize community leaders about issues faced by MSM on the coast, helping to build a base of support to recognize the need for improved access to services and care. This community support has fueled significant change in peoples’ thinking and is critical to allow research to continue. 

IAVI and CGMR-C continue to partner to refine community engagement mechanisms to ensure support and involvement of the MSM community in research studies. Representatives from MSM communities have been invited by CGMR-C to take part in research activity discussions that ranged from research design and study protocol development through publication to ensure their meaningful Community Engagement and Ownership in research. With the formation of national and local research advisory groups, MSM organizations have been able to more actively participate in research implementation. Most recently the Coastal group, Utafiti Pwani, was invited by CGMR-C to co-author a paper in KEMRI Bioethics Review Newsletter: “Collaborating with GMT organizations on HIV prevention and care research in Coastal Kenya.”

CGMR-C has also worked successfully to facilitate safe access to healthcare for the MSM community. In 2011, IAVI supported CGMR-C, in collaboration with the Kenya National AIDS and STD Control Program (NASCOP), to develop most-at-risk populations (MARPS)-Africa (develop www.MARPS-Africa.org), a first ever modular on-line training tool that provides awareness and sensitivity training to healthcare workers about MSM health issues. To date, nearly 1200 healthcare workers (including over 500 government employees) have completed the training. And, recent studies say it is working to reduce homophobic attitudes, open a dialogue on how to best treat MSM and initiate first ever MSM support groups4.

IAVI and CGMR-C have generated important evidence, provided services and helped build advocacy capacity, while also empowering another vehicle for change in Kenya via the LGBTI community itself. These individuals continue to put themselves on the frontline of struggle for over a decade to ensure, among many things, more tolerant healthcare. In a recent interview with IAVI, a brave Kenyan MSM described the progression of his work:

“Beginning with my own encounter in the streets during 2004 – alone, scared and in hiding– I was invited to learn more about health – my health. A visit to a newly established clinic gave me counseling, condoms and lubricants – as well as somewhere to turn – someone to talk to as many of my peers were sick and dying. At the very first National AIDS Control Council gathering in 2005, I remember their surprise to see actual MSM ready to be counted as part of this epidemic. Finally, our faces emerged from the shadows to be seen. In 2006 I became a trained organizer in the community where in the field I would hand out condoms, lubricants and information while urging my fellow MSM to come to the clinic to find safe spaces and for the first time, lifesaving healthcare. Person by person we help change the lives for MSM- one clinic visit at a time. As part of the National AIDS Strategic Plans 3 and 4, I watched the MSM health conversation evolve from one line in the plan to an entire paragraph in plan 4 (2013.) Now – even care in government run hospitals is possible. With IAVI’s help, networks continue to form, policy changes are implemented, and care for MSM in Kenya becomes more tolerant.”

More than 30 years into the pandemic, it is clear that a vaccine is essential to achieve and sustain the end of AIDS. Fortunately, clinical research does not exist in a vacuum and these efforts are already producing dividends that extend beyond the immediate search for an HIV vaccine. While IAVI’s mission is the development of a safe, effective preventive HIV vaccine, the development process itself also offers immediate benefits to those most in need.


1The Outlawed among us by Kenya Human Rights Commission 2011
2Kenya HIV Estimates Report, MoH, 2014 and MOT 2009
3Sanders, E.J. (2007) ' HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya' AIDS 30(21):2513-2520
4van der Elst EM, Smith AD, Gichuru E, Wahome E, Musyoki H, Muraguri N, et al. Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. J Int AIDS Soc. 2013;16(4)

Sustainable change for girls and women, especially in Sub-Saharan Africa, and a true end to HIV/AIDS requires more choice and improved prevention. Given the complex web of biological, physiological and socioeconomic factors increasing women’s vulnerability to HIV infection, a comprehensive response to HIV/AIDS today requires new prevention approaches to complement existing prevention and treatment options. An AIDS vaccine would help girls and women to independently protect themselves and their children from HIV infection, strengthen their power over their lives, and ultimately offer a long-term solution to the epidemic.

While the number of new HIV infections and AIDS-related deaths is declining globally, this progress eludes severalClinic 1IAVI groups of people, including adolescent girls and young women in eastern and southern Africa who are infected at rates two to five times higher than boys and men their age. According to the latest joint report from the United Nations and the African Union young women and adolescent girls in Africa “are still being left behind” particularly in cultures that limit women’s knowledge about HIV and their ability to protect themselves and negotiate safer sex.1  These failures are most acute in poor countries and among the poorest women in all countries. Globally, half of all adults living with HIV are women. In Africa this rate is even higher where women represent 60% of people living with HIV. This percentage is even higher among young Africans. Currently, 82% of all adolescents (ages 10-19) with HIV reside in Africa, and the majority of them (58%) are girls and young women. Among newly infected adolescents in eastern and southern Africa, 71% are female where approximately 850 girls and young women between 15-24 are now acquiring HIV each day.2  

AIDS is the number one cause of death among women of reproductive age in Sub-Saharan Africa and worldwide. These grim statistics have ramifications for the broader social fabric of affected communities since a mother’s death greatly impacts her entire family. According to UNICEF, children are 10 times more likely to die within two years of their mothers' death.3

Women and girls’ increased biological vulnerability to HIV infection, coupled with a lethal mix of legal, social and economic inequities, fuel the epidemic in resource-poor nations. Entrenched gender norms and inequalities result in power imbalances in relationships, affecting women’s ability to control or negotiate the terms of sexual relations and condom use. Poverty and reliance on men for economic support also

limit women’s power to protect themselves and force some to turn to transactional sex for survival. Cultural norms that preclude girls’ and women’s access to knowledge about sexuality and HIV, and the threat of violence or loss of economic support can impede their ability to communicate with their partners about HIV prevention. In addition to the impact of the disease itself on HIV-positive women, the burden of caring for those with HIV-related illnesses and for children orphaned by AIDS typically falls on women and girls. HIV-affected women and families are increasingly impoverished, further exacerbating their vulnerability to infectious diseases.  Stigma and discrimination remain acute for many HIV positive people, but because of their low social standing, women are especially vulnerable to ostracism, abuse, and even destitution.

Findings from studies done in Kenya4, South Africa5, and Tanzania6 showed that women living with HIV had consistently higher rates of intimate partner violence. In 2014, UNAIDS published a collection of essays written by women living with and affected by HIV about their experiences of violence by intimate partners and health-care institutions. In some settings, up to 45% of adolescent girls report that their first sexual experience was forced7; young women who experience intimate partner violence are 50% more likely to acquire HIV than women who have not and young women are more likely to experience gender-based violence than older women. Fear of violence can also affect whether or not a woman feels able to use counseling and testing services. Among girls aged 15–19 years who reported having multiple sexual partners in the past 12 months, only 36% said they used a condom the last time they had sex.8

The gap in addressing women and girls in HIV/AIDS responses is not a new discovery, but recent data has raised the profile of this issue and demands a new and more aggressive approach to this population. While women and girls in developing countries may be among those most vulnerable to HIV, they also are effective agents against the epidemic’s further spread. Many women in poor, rural villages are leading efforts to address how their communities take care of families and children affected by HIV/AIDS. And, in all responses to the epidemic – whether at the village or national level – it is imperative that women’s unique vulnerabilities to HIV are integrated into prevention, support and treatment programs, as well as into the research and development efforts toward new options for them. (For more on how to better align HIV prevention R&D agendas with the needs of women and girls in Sub-Saharan Africa, see our Policy Brief, Research and Development of New Biomedical HIV Prevention Tools for Women and Girls.)

PUNE.092IAVIA comprehensive response to HIV/AIDS today requires a scaling up and strengthening of existing prevention and treatment approaches as well as the research and development of new options. Current interventions include access to HIV and sexual and reproductive health education, particularly for young people; efforts to positively shift gender norms and combat sexual coercion and violence; initiatives to increase access and availability of male and female condoms; promotion of mutual fidelity and abstinence, where feasible; increasing access to voluntary HIV counseling and testing with referrals to appropriate treatment, care, and support; and programs for the prevention of mother-to-child transmission.

Recent initiatives like Determined, Resilient, AIDS-free, Mentored and Safe (DREAMS) recognize that urgent and bold action is imperative to better address girls and women and ultimately avoid a rebound of the epidemic. The two-year, $210 million pilot program launched jointly by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the Nike Foundation focuses on “hot spots” in 10 countries where HIV incidence is highest among girls and young women. This innovative, groundbreaking program offers a long overdue critical focus on girls and women.   Even with this heightened focus, we may still fall behind as millions of women and girls will still be newly infected with HIV and die from AIDS in the decades to come. Sustainable change for girls and women and a true end to HIV/AIDS will also need to build on the DREAMS momentum to demand more choice and improved prevention including new and better long-term prevention tools—especially methods that women can initiate or control.

An AIDS vaccine would help girls and women redress lethal imbalances and serve as a truly transformative tool by helping to circumvent gender-power and behavioral obstacles to HIV prevention and protect women’s health. An effective vaccine, as part of a comprehensive response, offers a long-term solution to the epidemic. Women would be able to access and use a vaccine with or without their partners’ knowledge. Adolescent girls, who are particularly vulnerable to infection, could potentially be vaccinated as pre-adolescents before the onset of sexual activity. Delivered confidentially, before exposure to the virus and invisible to partners and peers, a vaccine could help empower women to protect themselves — and their families and societies.

motherandbaby webVanessa Vick/IAVIA vaccine is also likely to reduce dependence on behavioral change and adherence. While the use of anti-retroviral drugs for Pre-Exposure Prophylaxis (PrEP) has proven highly effective in preventing infection if regularly used, studies demonstrated high dependence on adherence among young, unmarried South African women for oral or vaginal products. A holistic approach that also includes longer-acting tools that can be used confidentially, such as long-acting injectable anti-retroviral drugs, implants and vaccines, and finding ways to engage with girls and young women will support greater adherence. Our ability to end the AIDS epidemic will depend on a combination of powerful approaches and a vaccine will greatly bolster the full spectrum of prevention, treatment and care. No infectious disease in history has ever been eradicated or effectively controlled without a vaccine, and AIDS is no exception. Current data modeling suggests, that under reasonable assumptions, a vaccine could reduce annual infections by 78-85% by 2070 depending on how effectively other interventions have been implemented, and would be cost-effective in low-income countries under any background scenario.9     

The International Aids Vaccine Initiative (IAVI) vaccine work extends to women around the globe. IAVI works diligently with its partners in Africa and elsewhere to ensure that women are involved in the research and development of vaccine candidates, and in the clinical testing of such candidates and makes efforts to engage women’s health stakeholders globally, and in other countries where IAVI works. Gender work initiated in India has served as a foundation for IAVI’s gender efforts globally. IAVI adapted its well-received India gender training curriculum for clinical trial staff for use in East Africa and has conducted social research in Kenya on gender-related barriers to women’s and men’s participation in vaccine research and social impact of participation. IAVI-led efforts also ensure women can make voluntary, independent decisions to participate and receive the drugs and health services they need. Local scientists, including many women, play a crucial role in research, and local Community Advisory Boards (CABs) to help educate the community on vaccine development and other issues including gender sensitivity. Through a partnership with International Community of Women Living with HIV (ICW), IAVI is also helping to build the capacity of a core group of advocates to mobilize and educate more women to increase participation in HIV research, policy and advocacy to ensure equitable access to products by women and girls and enhance the understanding of the specific needs of girls and women for new products among researchers.

A well-implemented AIDS vaccination program could prevent millions of potential new infections with HIV– millions of men, women and children would then have a greater opportunity for a healthy, productive life. In its latest report, the UNAIDS-Lancet Commission calls for the world to urgently step up efforts to expand access to HIV/AIDS treatment particularly among vulnerable and marginalized people like women and girls and to “get serious” about prevention, including supporting development of an AIDS vaccine or face more HIV infections and deaths than five years ago. Preventing HIV infection in women secures families and economies. By protecting women and young girls from HIV, a vaccine will help unleash their potential and protect their development. Healthy girls are more likely to be able to finish school, healthy women can continue to work and provide for their families, and HIV negative mothers can be freed from the fear of passing the virus on to their children.

IAVI continues to work hand-in-hand with people and communities who need a vaccine the most by conducting and supporting groundbreaking research that will bring girls, women and the world an AIDS vaccine and help meet other global health challenges for many years to come.


1 UNAIDS/African Union. “Empower Young Women and adolescent girls:  Fast-Tracking the End of the AIDS Epidemic in Africa.” 2015. Available at: http://www.unaids.org/sites/default/files/media_asset/JC2746_en.pdf 

2 Fleischman J, Peck K. Addressing HIV Risk in Adolescent Girls and Young Women. Center for Strategic and International Studies. 2015. Available from: http://csis.org/files/publication/150410_Fleischman_HIVAdolescentGirls_Web.pdf 

3 UNICEF Millennium Development Goals, Available from: http://www.unicef.org/mdg/maternal.html

4 Increased risk of HIV in women experiencing physical partner violence in Nairobi, Kenya. Fonck K, Leye E, Kidula N, Ndinya-Achola J, Temmerman M AIDS Behav. 2005 Sep; 9(3):335-9.

5 Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD Lancet. 2004 May 1; 363(9419):1415-21.

6 Maman S, Mbwambo J, Hogan N, Kilonzo G, Campbell JC, Weiss E. HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania. American Journal of Public Health. 2002;92(8):1331–1337.

7 UNAIDS. “The Gap Report 2014: Adolescent Women and Girls.” 2014. Available from: http://www.unaids.org/sites/default/files/media_asset/02_Adolescentgirlsandyoungwomen.pdf

8 Joint United Nations Programme on HIV/AIDS (UNAIDS). Fast-Track: ending the AIDS epidemic by 2030. UNAIDS. 2014. Available from: http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf

9 Exploring the impact and cost-effectiveness of a vaccine as part of the Enhanced UNAIDS Investment Framework to end AIDS Available from: http://www.epostersonline.com/hivr4p2014/node/4521

 

 

 

 

 

 

IAVI works to both understand and empower people and those communities hardest hit by HIV/AIDS with a  focus on women, men who have sex with men (MSM) fishing communities and discordant couples, especially in Sub-Saharan Africa, the epicenter of the global AIDS epidemic.

Working closely with academic, clinical, government, industry, community and civil society partners worldwide, IAVI creates and shares knowledge to inform research and policy agendas while strengthening skills and technology by: 

  • Gaining critical scientific and social insights
  • Ensuring that those who most need a vaccine are an integral part of the research process
  • Understanding and empowering marginalized groups
  • Helping African and Indian institutions and scientists play an increasingly important role in HIV vaccine research.

More than 30 years into the pandemic, it is clear that a vaccine is essential to both achieve and sustain the end of AIDS.

Read on to learn more about how clinical research efforts to develop a safe, effective, preventive HIV vaccine are already benefiting those most in need by producing dividends that extend far beyond the vaccine search.

Thanks to significant recent progress in HIV vaccine research and development, scientists are increasingly confident that HIV vaccines will someday become available for general use. The only question is when that will happen. Getting there will require both sustained support for global HIV vaccine R&D and a policy environment that continues to encourage and enable such efforts. Cognizent of those needs, IAVI and its partners strive to:

  • Contribute to the evidence base demonstrating the potential value and impact of HIV vaccines and other new HIV prevention technologies, and the research required to develop these tools. 
  • Create a more supportive policy environment for HIV vaccine R&D at the global, regional, and national levels—one that encourages innovation, collaboration, and a sustained commitment of resources to all such efforts. IAVI seeks to accomplish this in a variety of ways, including its participation in the HIV Vaccines and Microbicides Resource Tracking Working Group.

To achieve these goals, IAVI works in concert with its advocacy and technical partners, including AVAC: Global Advocacy for HIV Prevention, the Futures Institute, the Global Health Technologies Coalition, the International Partnership for Microbicides and theJoint United Nations Programme on HIV/AIDS (UNAIDS).