According to Ben Young, chief medical officer of the International Association of Providers of AIDS Care (IAPAC), the world has everything it needs to end the HIV/AIDS epidemic and related deaths. He told TheBody.com that new data from CROI 2015 in Seattle, Washington, reinforce the vision of the Fast-Track Cities Initiative, and that the biggest barrier is not a lack of data or tools, but a "shortage of imagination."
Ben, what is the Fast-Track Cities Initiative, and what data did you find here at CROI 2015 to support this global strategy?
The UNAIDS/UN-Habitat/IAPAC Fast-Track Cities Initiative is a seemingly ambitious, but also critically important, initiative. It joins our three organizations with the mayor of Paris, Anne Hidalgo, in an initiative to get cities in the global North and the global South, in the East and West, to commit their municipal governments, medical organizations, civil society leaders and other affected individuals to the idea of ending [HIV/AIDS epidemic-related] death in their cities in five years, by the end of 2020.
The way to do that is to commit ourselves to a transparent process, a verifiable process, that leads toward the achievement of the 90-90-90 targets that UNAIDS set forth at the General Assembly last year. In brief, 90-90-90 is 90% of people living with HIV tested and knowing their status; 90% of them on treatment; and 90% of treated people with undetectable viral loads.
The initiative has signed over 30 major cities around the world, including Amsterdam and Paris; including Kingston, Jamaica, and Port-au-Prince; including Kinshasa, Durban and Nairobi. It includes Delhi and Bangkok and, as of last week, San Francisco.
We mean business. We mean, in doing this, to end the epidemic of death that has happened and ravaged our planet. And most specifically -- and this aligns with Ambassador Birx's presentation about doing the right things, in the right places, at the right times -- it's focusing efforts, not by excluding people who might be less crushed by the epidemic, but rather by focusing it where the people are, where there's the greatest burden of disease.
That is what PEPFAR 3.0 is about. It's about the geographical understanding, and using new technologies to understand that -- but, mostly, about finding the right places.
In this case, we're saying that many of those right places exist in a relatively short list of major cities around the world. And commensurate with getting cities on board is getting regions, and perhaps even nations, to believe that epidemic death can end. If you believe it, then you will do something about it.
Consistent with that, one of the most important sets of presentations at this conference was when we looked at amazing data on pre-exposure prophylaxis [PrEP] from the PROUD and IPERGAY studies. The presentations from Sheena McCormack and by Jean-Michel Molina were really important because they confirm to us that PrEP does work, at least in men who have sex with men. And the IPERGAY study suggests that daily administration is not necessary to achieve the targets of HIV prevention.
Most importantly, the two studies came up with very similar numbers on the number needed to treat [(NNT)], which is less than 20 individuals. That means that 5% of people, or even more than 5% of people, who are given PrEP in high-risk populations will actually benefit. Namely, they will not get HIV. From a public health perspective, both in low-income countries and high-income countries, that's an incredibly important number. But also that number means that this should be implemented.
So you take those two studies, and you add to that the presentations from Jared Baeten and Bob Grant. Baeten’s presentation on an implementation pilot project in Kenya and Uganda, says that combination PrEP and treatment-as-prevention dramatically protect people from getting HIV -- and, oh, by the way, help prevent death, and dying, and disease. So that's a demonstration project in low-income countries in East Africa. And then Bob Grant's magnificent presentation on the experiences of scaling of therapy and prevention in the city and county of San Francisco tells us that these things work.
The aspirations of Fast-Track Cities in achieving 90-90-90 are not just aspirations; these are things that can, and actually -- as Bob Grant showed us -- have happened, in at least one city. And other cities are actually approaching these numbers. So, collectively, we're beyond the tipping point. The data and the science is now there. It's compelling. From a public health standpoint, it's met at least some of the benchmarks for the quality necessary to do this.
The San Francisco experience says that even in the post-2008 recession, where public health departments and city governments were facing declining revenue and declining budgets, that public health departments can actually expand the number of people tested, expand the number of people in care, expand the number of people getting treatment and, ultimately, make AIDS and AIDS death rare, making new infections less. These are doable things.
That's what Fast-Track Cities is about. It's about cities around the world -- global North, global South, rich countries, poor countries -- getting their municipal governments to support and believe the idea that we can actually end epidemic death. That's Fast-Track Cities.
Anything else, in terms of what's at the conference that you think is particularly notable for fast-tracking?
One of the things that's important about fast-tracking is the idea that there is not a liability in treating more people. There are a number of studies and cohort analyses here about the benefits of early treatment. Coupled to that, of course, is the idea that newer drugs are part of the story. So we see data here particularly on some of the newer drugs like the new tenofovir, or TAF, formulation.
There's a lot of interest, both at the meeting, but also from large international organizations. As Ambassador Birx talked about, both PEPFAR and the UN programs have expressed strong interest in at least exploring the possible benefits of long-acting medications, whether they're injectable or oral, and therefore overcoming some of the issues related to supply chain and adherence. So we're seeing a lot of advancements on that side. But the medicines that we have today are sufficient to get us a long way down the road -- actually, not just down the road, but actually to the goal of eliminating epidemic death.
Tell me more about what that means: eliminating epidemic death.
So many of us have seen and witnessed epidemic death. I've been both lucky and somewhat burdened by the fact that I've seen this in dozens of countries around the world. The idea that it can stop is sometimes so hard to comprehend. But once you do comprehend it, it's transformational. Once you understand that it can be achieved, the failure to actually believe it, the failure to deliver it, means that we're actually institutionalizing health inequities -- institutionalizing those health inequities among marginalized populations, people of either economic, or racial, or ethnic differences.
That fundamentally gets back to health inequity, human right inequity, principles that were articulated by some of whom were championed here, and most specifically, Joep Lange and his partner Jacqueline van Tongeren. I think it's almost insulting to their memory -- and to the memories of the hundreds of thousands of other people who have worked so hard and advocated so hard and so long to get us to the very point now where we can actually do something about this -- if we don't actually finish the job ending this epidemic.
So, as we're speeding along this fast-track road, and going with all due speed, what are the biggest potholes or traffic jams? If you could fill any particular potholes, what would you fill first?
The first one is actually believing that it could be done, and therefore, that it should be done. Many people actually don't believe that ending the epidemic is possible -- even people who otherwise you would think would be champions of this cause. They haven't been able to visualize the idea that death, epidemic death, can stop.
In my city of Denver, epidemic death has stopped. It's actually stopped for many years now. In other major U.S. cities, this has happened. What we haven't had the courage to say is that it has happened, and that it should happen elsewhere. It's a shortage of imagination first -- first and foremost.
We have the tools. We have the knowledge how to do these things. What we need, first and foremost, is the imagination that it can happen. Once we get to that conceptual idea, it's leadership -- which is why, to me, the Fast-Track Cities Initiative is so compelling and breathtaking. Because we are now getting municipal leadership around the world to do this.
How about data? Is there any particular data gap that you think would be crucial in speeding this along?
I think that the preponderance of data already gets us there. People ask if we can achieve what we achieved in the North in the South. The fact of the matter is that several nations have already embraced this. At the BRICS conference this summer, health ministers from Brazil, Russia, India, China and South Africa embraced 90-90-90 targets as nations. Now, whether they achieve that is an important requirement. And that requires transparency. It requires quality monitoring. It requires an ability to provide feedback into the system. And this is part of the Birx PEPFAR construct as well; no disagreement there.
Some countries require additional information or, for their regulatory purposes, a lot more information for this drug or that drug. There's a lot of controversy about if low-income countries' regulatory agencies can accept data that was generated in high-income countries. And there's a disconnect between the scientific efficacy done in large, randomized, high-quality clinical trials versus the effectiveness or health economics aspect of this. That's an area that's under a lot of investigation. We heard a whole session here at CROI 2015 around some of these implementation science issues. That's really where the challenges are.
But do the molecules exist? Do the diagnostics exist? Do we know how to train care providers? Do we believe that we could do task shifting, and assign some of these tasks to non-physician providers?
Those answers are in. There's very little question about that. And do those tools offer opportunities to improve? Absolutely.
That's why we talk about TAF; that's why we talk about long-acting injectables. But we ended the epidemic of death in many U.S. cities long before we had TAF, and long before we had long-acting drugs. It's really around the imagination to have it happen.
We're challenging the rest of the world to say, "Are you willing to imagine that? If you are, come join us."
Julie "JD" Davids is the managing editor for TheBody.com and TheBodyPRO.com.