5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - basic sciences.

Basic science studies at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) provided important new information that has implications not only for treatment, but also for better understanding the complex dynamics of HIV infection, epidemiology, and the impact of biology and genetics on vulnerability to HIV infection, disease progression and the risk of vertical transmission. There was renewed interest in strategies on how to eliminate residual viremia, bolster the immune system and potentially achieve viral eradication given recent evidence that antiretroviral therapy (ART) is effective at minimizing viral reservoirs if administered early in acute infection.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - clinical sciences.

Studies in several sub-Saharan African countries demonstrated that the expansion of antiretroviral therapy (ART) access is not only beneficial for people living with HIV, but also results in significant declines in tuberculosis and malaria incidence and prevalence, bolstering arguments for earlier and increased ART access and contributing to a growing understanding of co-epidemic dynamics. Several studies demonstrated that using standard triple-drug ART in resource-limited settings can reduce vertical transmission by as much as less than 1% if continued throughout breastfeeding.The Nevirapine Resistance Study (NEVEREST) results provided proof of concept that nevirapine could be used as part of a paediatric second-line regimen, despite exposure to nevirapine prophylaxis for vertical transmission, following successful suppression on a lopinavir/ritonavir-based regimen. A South African study found that high pre-treatment levels of inflammatory and coagulation markers were strong predictors of death, reflecting similar findings in high-income countries and reinforcing the shift towards viewing HIV as a chronic, inflammatory disease. An early study of a new integrase inhibitor (S/GSK1349572) indicated strong potency and limited cross-resistance with raltegravir, the only integrase inhibitor currently approved for treatment.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - biomedical prevention.

No major findings were reported at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) on currently enrolled microbicides, pre-exposure prophylaxis (PrEP) or vaccine trials, although important findings in all three areas of biomedical prevention research are expected within the next few years.A study found that daily acyclovir did not reduce HIV transmission, but was a factor in modest reductions in viral load, which could confer some clinical benefit. Research demonstrating rapid viral replication in mucosal tissue and subsequent dissemination throughout the body suggested that research priorities should shift towards a mucosal vaccine. Findings reported in Track C indicated that, in addition to reducing vertical transmission, antiretroviral therapy (ART) also lowers the risk of prematurity, stillbirth and abortion.Challenging concerns about the potential "disinhibiting" effect of ART as prevention, a Kenyan study found that widespread ART encourages greater use of condoms and does not increase the rate of risky sex. Another Kenyan study found that pregnancy increases the risk of HIV transmission in a cohort of serodiscordant couples. Although three randomized trials have conclusively demonstrated that circumcision reduces HIV transmission among heterosexual men, research presented at IAS 2009 found no evidence of a preventive impact for women.

5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention: summary of key research and implications for policy and practice - operations research.

Operations research was added as a fourth scientific track to the pathogenesis conference series at the 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2009) in recognition of the importance of this growing research field and the need for applied research to inform and evaluate the scale up of some key interventions in HIV treatment, care and prevention.Several studies demonstrated how task shifting and the decentralization of health services can leverage scarce health care resources to support scale-up efforts. For example, a Ugandan study comparing home-based and facility-based antiretroviral therapy (ART) delivery found that both delivered equivalent clinical outcomes, but home-based delivery resulted in substantial cost savings to patients; and a retrospective cohort analysis of an HIV care programme in Lesotho demonstrated that devolving routine patient management to nurses and trained counsellors resulted in impressive gains in annual enrolment, retention in care and other clinical indicators.Studies also demonstrated how the use of trained counsellors and public health advisors could effectively expand both clinical and public health capacity in low-income settings. Studies evaluating the impact of integrating HIV and TB care resulted in improved treatment outcomes in coinfected populations, the development of environmental interventions to reduce TB transmission, and uncovering of the extent of multi-drug-resistant and extremely drug-resistant tuberculosis (MDR-TB and XDR-TB) in KwaZulu-Natal, South Africa.Some mathematical modelling and cost-effectiveness studies presented at this meeting addressed interventions to increase retention in care, and strengthened the evidentiary basis for universal voluntary testing and immediate ART on reducing HIV transmission; debate continued about the relative merits of clinical versus laboratory monitoring. Finally, a provocative plenary presentation outlined the shortfalls of current prevention interventions and argued for more cost-effectiveness analyses to guide the selection of interventions for maximum benefit.

XVII International AIDS Conference: From Evidence to Action - Epidemiology.

As the epidemic matures, accurate information about where new infections are occurring, and in which populations, is becoming increasingly critical in designing effective, targeted interventions relevant to current epidemiological trends. Although the quality and accuracy of HIV surveillance data and methodology have improved, in many cases the second generation WHO/UNAIDS surveillance system has not been fully implemented at the national level. National surveillance systems in many low and middle-income countries often do not collect disaggregated data on some most at risk populations, which is critical to developing targeted prevention interventions.While the majority of new infections occur in low- and middle-income countries, the dynamic situation in high-income countries demands renewed attention.

XVII International AIDS Conference: From Evidence to Action - Basic science.

This article focuses on the sessions in which basic science research was presented at the XVII International AIDS Conference (AIDS 2008). It also provides an analysis of basic science issues which generated significant discussion and debate at the conference and are likely to have implications for future laboratory and clinical research. Data presented at AIDS 2008 confirmed the speed with which HIV establishes latent viral reservoirs following infection and the resulting challenges to viral eradication given how effectively HIV proviral RNA inserts itself into human DNA within these reservoirs. Studies also raised questions about the source of residual viremia and how these might be targeted by novel therapeutic approaches.

XVII International AIDS Conference: From Evidence to Action - Clinical and biomedical prevention science.

The question of whether to initiate ART at higher CD4+ cell counts than currently recommended by World Health Organization (WHO) treatment guidelines received much attention at the XVII International AIDS Conference (AIDS 2008). If studies presented at the conference ultimately lead to a revision of WHO treatment guidance, the estimated number of people who will need ART globally will increase substantially. Task-shifting is emerging as an important strategy for dealing with the acute shortage of health care workers in many high-burden countries, and several studies presented at AIDS 2008 demonstrated the impressive health system efficiencies garnered by using nurses or other health care providers to deliver HIV care and treatment. Other key presentations and discussion at the conference focused on the optimal time to start TB treatment in HIV-infected patients, the growing risk of resistance in high-burden countries, including its impact on future treatment options, and several large cohort trials testing optimal drug regimens in resource-limited settings.Biomedical prevention research continues to confirm the long-term, protective benefits of circumcision. Several studies involving HIV serodiscordant heterosexual couples have produced data suggesting a strong protective effect of ART for HIV-negative partners. Disappointing results from recent vaccine and non-ARV based microbicides trials are nevertheless providing important data to this field, and the expanding number of pre-exposure prophylaxis (PrEP) trials and ARV-based microbicides appear to provide the best hope for a new, efficacious biomedical prevention intervention.

XVII International AIDS Conference: From Evidence to Action - Regional focus.

This article summarizes the challenges, opportunities and lessons learned from presentations, discussions and debates addressing major policy and programmatic responses to HIV in six geographical regions: Sub-Saharan Africa, Asia and the Pacific, Eastern Europe and Central Asia, Latin America, Caribbean, and Middle East and North Africa. It draws from AIDS 2008 Leadership and Community Programmes, particularly the six regional sessions, and Global Village activities.While the epidemiological, cultural and socio-economic contexts in these regions vary considerably, several common, overarching principles and themes emerged. They include: advancing basic human rights, particularly for vulnerable and most at risk populations; ensuring the sustainability of the HIV response through long-term, predictable financing; strengthening health systems; investing in strategic health information; and improving accountability and the involvement of civil society in the response to AIDS.Equally important is the need to address political barriers to implementing evidence-based interventions such as opioid substitution therapy (OST), needle and syringe programmes (NSPs), comprehensive sexuality education for youth, and sexual and reproductive rights. Finally, these regional discussions emphasized the need for legislative and policy reforms related to structural barriers facing women and girls, MSM, IDUs, sex workers and migrant populations.

XVII International AIDS Conference: From Evidence to Action - Social, behavioural and economic science and policy and political science.

AIDS 2008 firmly established stigma and discrimination as fundamental priorities in the push for universal access to HIV prevention, treatment, care and support. Conference sessions and discussions reinforced the tangible negative effects of stigma on national legislation and policies. A strong theme throughout the conference was the need to replace prevention interventions that focus exclusively on individual behaviour change or biomedical prevention interventions with "combination prevention" approaches that address both individual and structural factors that increase vulnerability to HIV infection.Several high-level sessions addressed various aspects of the debate over "vertical" (disease-specific) versus "horizontal" (health systems) funding. The majority of evidence presented at the conference suggests that HIV investments strengthen health systems through the establishment of clinical and laboratory infrastructure, strengthened supply and procurement systems, improvements in health care worker training, and increased community engagement.Human rights were a focal point at the conference; several presentations emphasized the importance of securing human rights to achieve universal access goals, including workplace discrimination, travel restrictions, gender inequality, and the criminalization of homosexuality, drug use, sex work, and HIV transmission and/or exposure.

XVII International AIDS Conference: From Evidence to Action - AIDS 2008 and the global response to AIDS.

The impact of the XVII International AIDS Conference (AIDS 2008) was reflected in a number of commitments from political and business leaders, who announced initiatives ranging from implementing comprehensive sexual education for young people in Latin America to reducing regulatory barriers and the price of drugs in the host country. The unprecedented media coverage brought attention and public awareness to the epidemic in Latin America.Several meetings and sessions at AIDS 2008 also addressed the potential for the International AIDS Conference to play an even stronger role in tracking progress towards universal access and in improving accountability in the global response to AIDS, particularly given some of the inherent weaknesses in the United Nations General Assembly Special Session (UNGASS) review process. The impact of AIDS 2008 was strongest in Mexico, the host country, and in Latin America. Highlights included the policy changes announced by President Calderon on pharmaceutical manufacturing to the focus on sex workers and gay and other MSM in marches, activism and the conference programme.The next two years will determine whether the successes reported in Mexico are sustained and whether there is progress in addressing the barriers that continue to hamper an evidence-based response to HIV/AIDS. The next International AIDS Conference is scheduled for the universal address deadline of 2010.

Ensuring a broad and inclusive approach: a provincial perspective on pandemic preparedness.

The SARS crisis revealed critical gaps in Ontario's health emergency response capacity, and identified, in the starkest terms possible, the need for improved emergency response planning. This article reviews the development of the Ontario Health Plan for an Influenza Pandemic (OHPIP), released in June 2005. Some key points arising from the provincial planning process include the necessity to: ensure a broad and inclusive development process; ensure the pandemic plan identifies: 1) clear roles and responsibilities of federal, provincial/territorial and municipal levels of government, 2) the approach to occupational health and safety issues and ethical decision-making, 3) a communications strategy linking all affected sectors and levels of government and health sector; 4) any commitments to antiviral stockpiling, vaccine and antiviral allocation and use, and an approach for drug delivery from provincial stockpiles to local public health units; 5) health human resource management and supplementation; and 6) key programs/services to be scaled back to maximize surge capacity; address best practices (e.g., involve all sectors of the health care system at the outset, acquire strategic expertise, coordinate/advocate with broader emergency response system, etc); and, outline future stages that include strengthening the delivery of clinical care to influenza cases; clarifying the role of primary care practitioners during a pandemic; leveraging Ontario's significant e-Health investments.