In this issue, we highlight youth perspectives from Zambia and Zimbabwe on the importance of stepping up the financial, scientific, and community support for HIV prevention research; insights from Kenya and Nigeria on what can be done to enhance inclusivity of at-risk populations in the HIV response; and the significance of HVTN’s Mosaico vaccine efficacy trials to the development of a globally accessible effective HIV vaccine.
This year’s World AIDS Day was dedicated to communities across the world who continue to play a leading role in ensuring that the HIV response is relevant, people-centered, and leaves no one behind. The annual commemoration of World AIDS Day on 1 December serves as a platform to raise awareness on important issues in the global HIV response, recommit to efforts to prevent new HIV infections, and support those living with HIV. The 2019 theme, “communities make the difference,” embodies the centrality of communities at the international, national, and local levels.
The theme of “communities at the center” was echoed at the 20th International Conference on AIDS and STIs in Africa (ICASA) in Kigali, Rwanda (2-7 December 2019). Conference deliberations included conversations on community leadership; inclusivity of vulnerable populations; involvement of youth; ethical conduct of research with communities; and gender equality.
In keeping with this theme, this issue of VOICES highlights youth perspectives from Zambia and Zimbabwe on the importance of stepping up the financial, scientific, and community support for HIV prevention research; insights from Kenya and Nigeria on what can be done to enhance inclusivity of at-risk populations in the HIV response; and the significance of HVTN’s Mosaico vaccine efficacy trials to the development of a globally accessible effective HIV vaccine.
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Associate Director Advocacy, Policy, and Communications
The views and opinions expressed in this newsletter are those of the authors
and do not necessarily reflect the official policy or position of IAVI.
By Dr. Cheikh Eteka Traore, public health and diversity consultant CEO GOAE Nigeria/senior medical adviser Go Africa LLC
As a focal person for MPact Global Action for Gay Men’s Health and Rights in West Africa, I have observed or contributed to the design of several health and rights programs for men who have sex with men (MSM) and sex workers. The decade-long history of engaging Nigerian MSM and female sex workers (FSWs) in HIV prevention research has been colored with shifts and turns occasioned by developments in global and national policy and changes in funders’ priorities.
One of the most impactful policies now shaping the HIV response is the “90-90-90” UNAIDS policy (90% of people living with HIV know their status; of whom 90% are on treatment; of whom 90% are virally suppressed). In a short time, it has revolutionized the way we plan and evaluate our HIV response by placing greater emphasis on efficiency in HIV testing and prompt enrollment in care for newly diagnosed individuals. Still, Nigeria has a long way to go, particularly with the first “90” among at-risk populations who experience stigma, discrimination, and criminalization. Due to existing harsh punitive laws and hostility toward MSM, FSWs and people who inject drugs (PWIDs), it is difficult to significantly boost the scale and visibility of programs designed to enhance testing, treatment, and care among these populations.
In view of this situation, the key to greater successes in early detection may come from a radical shift in our thinking. So far, the principle of 90-90-90 targets has been applied with a predominantly bio-medical model, sometimes at the expense of existing community dynamics. Our peer-education and outreach models once viewed as very successful are increasingly being viewed as agents of a health system. In my opinion, many community-based organizations led by sex workers have become overly focused on fundraising, are caught up in the complicated administrative procedures of donor-driven programing, and have become distant from the constantly evolving sex industry. As we try to get more individuals living with HIV to know their HIV status, the limits of biomedical approaches will become more evident as the number of peer outreach workers stagnates. It is high time we rethink our approach and turn the focus back to meaningful community engagement. We should be thinking of how best to deepen ownership of the response among communities.
With sex workers, we need to recognize the existence of an ecosystem that goes far beyond our existing small NGOs. It is time to enhance the participation of key private sector actors running the night time economy of our major urban centers — bar and club owners, DJs, bouncers, cab drivers. It has been acknowledged that brothel-based sex workers are more vulnerable to HIV, and yet brothel owners have not been formally involved in HIV prevention efforts. It is time to meaningfully engage sex workers’ collectives and the night time ecosystem which sustains their work, as opposed to only reaching out to the individuals conducting sex work. With Nigerian gay men, we need to engage our numerous social media influencers. Working more closely with the gate-keepers and the opinion leaders within each of these communities may unlock the door to attaining the first “90.”
If we are to succeed in increasing adoption of new biomedical prevention technologies — such as self-testing and PrEP — it is time to re-imagine the shape of prevention, build on past accomplishments, and put the communities of key populations back at the center of HIV prevention.
By Mercy Mutonyi, project coordinator for DREAMS Innovations Challenge project at the Bar Hostess Empowerment & Support Programme (BHESP) and AVAC 2019 fellow
Growing up in an informal settlement in Western Kenya, I lived in a society that labelled young women working in bars as “bad girls” who would teach the good ones “bad manners.” Nobody, not even their families, wanted to be associated with them. My family took in a cousin of mine who had been excommunicated by her family for working as a bar waitress in our hometown. I loved her dearly — she was my hair and fashion stylist and we got along very well as she was just three years older than I.
I always thought HIV was a disease that could never touch my family or anyone close to me. And then my dear cousin, who was then 18 years old, became infected with HIV and later died due to AIDS-related complications. After her death, I realized anyone can be infected with HIV, and everyone needs access to quality HIV treatment and prevention services irrespective of what they do for a living. My cousin, my friend, and my hair stylist need not have died due to something that could be prevented, treated, and managed.
The stigma and discrimination surrounding HIV are major barriers to ending the epidemic. The stigma toward certain categories of people like bar hostesses and sex workers makes things even worse. For five years, I have been an advocate for female sex workers (FSWs) and vulnerable young women in Kenya, making sure that they have access to HIV prevention and treatment services. These two categories of women are among the groups of people at a higher risk for contracting HIV. Due to stigma and criminalization, they are often unable to access the services they need.
Growing up and through my work, I have had FSWs share their personal experiences with me. I got to understand better the many challenges they face and how they contribute to the high prevalence of HIV. I started working at the Bar Hostess Empowerment and Support Program (BHESP) in 2015. BHESP is a community-led organization whose mission is to influence policy and facilitate provision of quality health services, human rights awareness, legal services, and economic empowerment for sex workers, women who have sex with women, women using drugs, and bar hostesses in Kenya. When I joined BHESP, the clinic that was supposed to provide HIV comprehensive prevention, care, and treatment to most at-risk populations, or Drop in Centre (DICE), did not yet have the capacity to offer the anti-retroviral treatment (ART) package. Often, I would refer women to the public facility for ART initiation, but many would drop out of treatment due to negativity and judgmental treatment from the health care workers and stigma and discrimination from the community. Other times, my clients were unable to stick to their treatment because they had been arrested for sex work and were denied drugs while in police custody. I felt driven to do more to address their unique challenges by advocating for strategies that would enhance their access to and acceptance of HIV prevention and treatment interventions. Through consultations with the Kenya National AIDS and STI Control Programme and the county government and by training of law enforcers on sex workers’ rights, the key population DICEs were expanded to offer comprehensive services including ART services.
I later found myself serving as a project manager for the PEPFAR-funded Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Innovation Challenge. My new role gave me the opportunity to represent young people and FSWs in technical working groups and task forces addressing the structural HIV interventions such as policies, environment, and harmful social norms. Additionally, as a member of the county adolescent girls and young women technical working group, I have been able to share the needs for youth-friendly services and information as well as the right to be treated with dignity and not to face discrimination by health care workers.
As I was growing up, my dream was to be a nurse advocate like Florence Nightingale. I am glad that through living my dream, I can make a difference in the lives of many young women who shouldn’t be made to suffer like my dear cousin did.
By Joan Mubanga, youth volunteer with Agents of Change Foundation and Voluntary Services Overseas (VSO) in Zambia
I first learnt about sexual reproductive health and rights through a training conducted by Agents of Change Foundation Zambia. I knew right away after attending the training that I wanted to help champion young people’s rights to better sexual and reproductive health through access to resources and control over their bodies.
I am currently undertaking my VSO–International Citizen Service Project post placement work in a project which aims to equip adolescents with knowledge that helps them make informed decisions regarding their sexual and reproductive health and rights. I am also an advocacy fellow under the Africa Free of New HIV Infections (AFNHi) Youth Cohort, part of a movement of youth advocating for research that will give youth the different HIV prevention interventions they need to accelerate the progress towards zero new HIV infections.
In my view, biomedical prevention interventions represent a pathway to addressing the high rates of HIV transmission and infection among African youth. Globally, over 30% of new HIV infections occur among the youth (ages 15-25 years) and approximately 19% of the global youth population is in Africa. Multiple socio-cultural factors contribute to the higher risk of HIV infection among this group including low testing rates, meaning more young people have undiagnosed HIV and may unknowingly pass HIV to others; substance use, which has been linked to a variety of sexual risk behaviors such as sex without a condom; transactional sex; and multiple sexual partners.
The youthful stage of life is when most people want to explore their sexuality, and as such, behavior-dependent prevention approaches may not be effective for this age group. Developing different options of biomedical prevention interventions would ensure youths are able to make choices that suit their own unique circumstances and can take charge of their sexual health.
As a youth, the possibility of scientists developing a safe, effective, affordable HIV vaccine gives me hope that we can attain zero new HIV infections. In the recent exercise to replenish the Global Fund to Fight AIDS, Tuberculosis and Malaria, African governments pledged twice as much as they did in the previous year. Now they need to ensure they fulfill their pledges and support research that will protect their youth — the continent’s greatest economic resource.
By Munashe Mhaka, sexual reproductive and health rights advocate, Africa free of New HIV infections (AfNHi) Youth Cohort
“From dust we come and to dust we shall return,” the priest concluded his sermon as he softly threw some soil into the grave. I watched solemnly as the Mwasayi family paid their last respects to Netsai, their only daughter and child. Netsai had just turned 21 when her parents finally decided to inform her that she was HIV positive. Unfortunately, their assumption that she was old enough to handle the news was wrong, and just a week after they broke the news to her, she committed suicide.
Many new HIV infections occur through unprotected sex between married or cohabiting partners. According to 2016 estimates by the Joint United Nations Programme on HIV/AIDS (UNAIDS), 85% of people living with HIV in Eastern and Southern Africa knew their HIV positive status but only 79% of these (67% of all people living with HIV) are on antiretroviral treatment. Furthermore, the World Health Organization (WHO) estimates that as many as half of all HIV-positive people in long-term relationships globally have HIV-negative partners (sero-discordant couples) — out of these, there are many people in relationships, like Netsai’s parents, who do not know their partner’s status. Netsai’s mother only realized during her pregnancy that she was HIV positive. Unfortunately for the family, no one was there to advise them about protecting their unborn baby from infection. This is how Netsai ended up being born HIV positive.
Netsai took her life because she could not bear the thought of living with HIV. Unfortunately for her no one informed her that she could live a fairly healthy, productive life if she started antiretroviral therapy. Her story made me reflect deeply on the different structural, institutional, and socio-cultural issues surrounding HIV prevention in Africa.
First, I was struck by the vulnerability of Netsai’s mother. In many situations, women are socially or culturally restricted in their ability to avoid sex or convince partners to engage in condom use or other safe sex practices. Hence, female-controlled preventive methods are needed, particularly products that provide dual protection against pregnancy and sexually transmitted infections. Would an HIV vaccine have protected Netsai’s mother from infection by her partner who had not disclosed his status?
Secondly, I realised that there are still gaps in educating the community on existing HIV prevention methods and influencing real behaviour change. Therefore, even if a safe and effective HIV vaccine was available, there would be a primary challenge in supporting uptake by consumers to reach adequate population coverage.
This incident motivated me to become a youth champion advocating for more meaningful engagements with communities on behavioural, biomedical, and structural intervention methods to prevent HIV. I believe that it is not enough that the HIV-prevention interventions exist, but that they are developed in partnership with the communities. This would ensure that they respond to local priorities and preferences and will foster adherence and maintenance of behaviour change over time.
As new approaches to HIV prevention are being researched, there is an urgent need for meaningful engagement between researchers, policymakers, funders, and communities to ensure the design, delivery, and future access to biomedical preventive technologies correspond to the contexts of the communities that most need them. Additionally, approaching HIV prevention from a wellness perspective that reinforces HIV as a chronic disease, and gives more emphasis to community sites and leaders would go a long way in positively addressing stigma, fear, and other behavioural barriers to HIV prevention.
HIV Vaccine Trials Network (HVTN) makes strides toward HIV vaccine development
By Nicole Na, HVTN communications program coordinator
Despite the severity of the HIV epidemic in eastern and southern Africa, progress is being made toward achieving the UNAIDS 90-90-90 targets that will put the world on course to ending the HIV epidemic by 2030 — 90% of all people living with HIV knowing their status, 90% of people who know their status on antiretroviral therapy, and 90% of those achieving viral suppression by 2020. According to AVERT1, the region has so far achieved 85-79-87.
To reduce new infections and accelerate the attainment of the 90-90-90 target, a safe, effective, and accessible HIV vaccine is needed in the HIV prevention toolkit. Such a vaccine must be cost-effective and available to at-risk populations in the developing world. An affordable, accessible HIV vaccine could help circumvent barriers that continue to prevent people from accessing HIV services and testing: Stigma and discrimination driven by cultural practices; biases against certain race, socioeconomic status, sexual orientation or gender identity; or other grounds.
In November 2016, the HIV Vaccine Trials Network (HVTN) launched the largest and most advanced HIV vaccine clinical trial ever to take place in South Africa — HVTN 702, also known as Uhambo. This study, which completed enrollment of 5,400 men and women in June 2019, is being implemented in a country where more than 1,000 people acquire HIV every day. Uhambo is studying an HIV vaccine candidate based on clade C, the subtype of HIV that circulates in southern Africa and is responsible for over 50% of HIV infections worldwide. Though this region is clade C-dominant, the diversity of HIV subtypes globally necessitates a more comprehensive vaccine.
A year after launching the Uhambo study, the HVTN initiated another large-scale HIV vaccine efficacy trial called HVTN 705, or Imbokodo. The trial that kicked off in November 2017 is testing a ”mosaic” vaccine candidate — a vaccine candidate comprising elements from multiple HIV variants aimed at inducing immune responses against a wide variety of HIV strains. The study enrolled at-risk women in southern Africa, a population that accounts for 56% of adults living in the region.
Most recently, the HVTN has joined a new public-private partnership that sets in motion a large-scale Phase III efficacy clinical trial, dubbed Mosaico (HVTN 706/HPX3002). The Mosaico study will test another promising vaccination combination based on mosaic immunogens: a similar regimen to the one studied in Imbokodo, with the addition of a supplementary mosaic gp140 boost. This mosaic vaccine design was tested extensively in Phase I/IIa human studies, APPROACH and TRAVERSE (HVTN 117/HPX2004), and more recently in ASCENT (HVTN 118/HPX2003), with each trial showing improvement on the design. Like the Imbokodo and Uhambo studies, the Mosaico study is being implemented among populations that bear a disproportionate burden of the HIV epidemic.
While these previous two studies test a vaccine in at-risk populations in eastern and southern Africa, Mosaico will be carried out with men who have sex with men (MSM) and transgender people at 55 clinical research sites in the United States, South America, and Europe. Gay men and other MSM accounted for an estimated 17% of new HIV infections globally in 2018, including more than half of new HIV infections in western and central Europe and North America; 40% in Latin America; 30% in Asia and the Pacific; 22% in the Caribbean; 22% in eastern Europe and central Asia; 18% in the Middle East and North Africa; and 17% in western and central Africa.
If successfully licensed, these HIV vaccines would represent a step toward scalable additions to the HIV prevention toolkit that would be especially beneficial to the populations bearing the brunt of the HIV epidemic.
“We are committed to ensuring that HIV vaccine trial results are generalizable to the populations that carry the greatest burden of HIV infection,” said Susan Buchbinder, M.D., Mosaico protocol chair and director of Bridge HIV at the San Francisco Department of Health.
1 https://www.avert.org/infographics/hiv-and-aids-east-and-southern-africa accessed 10/9/2019
Steven Wakefield – Director, External Relations, HIV Vaccine Trials Network
Dr. Morenike Ukpong-Folayan – Coordinator, New HIV Vaccine and Microbicide Advocacy Society
The views and opinions expressed in this newsletter are those of the authors
and do not necessarily reflect the official policy or position of IAVI.