Risk Wise

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type 5 antibodies, had more HIV infections. A second phase-2 proof-

of-concept trial of a T-cell vaccine candidate, the Phambili study in

South Africa, was interrupted as a result of the findings of the Step

Study. The failure of the T-cell vaccines has led to a re-examination

of the HIV vaccine field, and the need to broaden research directed

at answering fundamental questions in HIV vaccine discovery through

laboratory, non-human primate, and clinical research was recognized.

The world’s leading scientists have stopped talking about vaccine

targets, instead favouring terms such as ‘incremental advances’. The

only timeframe mentioned with any confidence is 2031 – the end

point for a United Nations Aids research programme, when a vaccine

‘could be available’. But that does not mean that the quest for a

vaccine, and the funding it requires, should be diverted in any way.

The development of a polio vaccine was decades in the making. In

the 1930s claims of imminent success began to circulate, but polio

continued to cripple thousands of children every year in industrial-

ized countries. However, soon after the introduction of effective

vaccines – OPV – in the late 1950s and early 1960s, it was practi-

cally eliminated as a public health problem in the western world.

Microbicidal gels could be the key to HIV control, but they will

never have the blanket disease eradication power of a vaccine. A

medication that relies on repeat applications by an individual remains

open to considerable human error. The vaccine can generate herd

immunity to the point where, with a single jab, whole populations

can live free of the condition. It may take another 20 years, but it

will be worth the wait; the historic success of vaccines argues that

HIV vaccine research must be continued and accelerated.

Beyond the HIV vaccine

The Lancet editorial continues: “We must increase the health-systems

strengthening element to our policy and practice. We must continue

to argue for more funding. We need to rethink our approach to eval-

uating prevention. And we must find better ways to enhance

coordination between international and national actors. The very

distinction between treatment and prevention is false. Both are inex-

tricably connected. Countries need to develop context-specific

national preventive strategies, not off-the-shelf slogans dreamt up by

donors. Prevention needs to embrace the political,

economic and social determinants of risk too. The

HIV/Aids community must be more honest about admit-

ting its failures – the absolute amount of preventive

practice and science has simply been too little. The mix

of interventions has been wrong. Leadership and

management of programmes to deliver these interven-

tions have been weak. It is fair to say that, despite greatly

increased resources, the state of the response to Aids is

currently at a vulnerable moment. Implementation of

prevention strategies has been, at best, uneven across

countries – in too many instances, almost non-existent.

There is still a risk of complacency. Even Aids activists

have badly neglected prevention advocacy.”

Twenty-five years after Aids was first reported, an

institutional, commercial, professional, and even civil

society industry now controls the global response to

Aids. Each party, in good faith, has a position to defend,

a strategy to advance, and probably someone to oppose.

It is time for new voices in Aids to ask questions, to

disrupt axes of power, and to disturb the air.

The

lessons learned over the past 25 years should be used to

provide the foundation on which to build comprehen-

sive, sustainable, nationally owned responses that are

vital to the ultimate control of this pandemic.

The question of rights of participants, access to stan-

dard of care and of possible research injury in HIV

biomedical prevention trials

are relevant, considering the

unfavourable results of HIV vaccine trials thus far and the

risk of becoming HIV positive. The role of ethics commit-

tees, data and safety monitoring boards and community

advisory boards in this context is therefore critical, where

the participants are usually socio-economically deprived.

The South African HIV/Aids Research and Innovation

Platform (SHARP) has recently been established by the

Department of Science and Technology and is being

managed by LIFElab. It has the objective of increasing

the number and quality of South African developed

products and services for the prevention and treatment

of HIV/Aids through increased support for basic and

applied research, development and innovation in the

areas of anti-retrovirals, microbicides, vaccines and

diagnostics.

“In recent weeks we have seen governments across the

world working together to solve the global financial

crisis,” says Stephen Matlin of the Global Forum for

Health Research. “No one country can ignore what has

been happening, and by working together, governments

know they have more chance of affecting real change. In

the same way, the global community must act together to

invest in health research and achieve global health gains.”

Similarly, the academic and biotechnology sectors glob-

ally need to partner and collaborate in seeking the elusive

holy grail of a safe and effective HIV vaccine. Further,

the recent USD100 million gift to create an institute to

jumpstart the search for an HIV vaccine in Cambridge,

USA, is a positive development in view of shrinking

endowments and broke donors, as a result of the global

economic slump.

HIV prevalence (%) in adults (15-49) in Africa, 2007

Source: UNAids Report 2008