Researchers, policymakers, advocates, and people living with HIV converged in Montreal July 29 to August 2 for the 24th International AIDS Conference, the first such confab since the 2020 meeting, slated for San Francisco and Oakland, pivoted to a completely virtual format due to COVID-19. This year's hybrid format included 9,500 in-person and nearly 2,000 virtual participants.
Despite remarkable gains in HIV treatment and prevention, barriers stand in the way of universal access. Key populations including gay and bisexual men, adolescent girls and young women, transgender people, sex workers, and people who use drugs continue to face stigma that keeps them from accessing the tools they need. And now, monkeypox poses a new threat to some of the same communities hard hit by AIDS. Even access to the conference itself was restricted, as many would-be participants were denied visas to enter Canada.
UNAIDS released a new report on the state of the global pandemic, showing that "the AIDS response has been blown off course," said UNAIDS Executive Director Winnie Byanyima, who herself was nearly denied entry into the country.
According to the report, 38.4 million people were living with HIV and 650,000 people died of AIDS in 2021. About 1.5 million new HIV infections were reported in 2021, exceeding the global target by more than a million. While three-quarters of people living with HIV were on antiretroviral therapy in 2021, the number of treated people grew slower than it has in over a decade.
"The latest findings reveal that the response to the AIDS pandemic has been derailed by global crises, from the colliding pandemics of HIV and COVID to the war in Ukraine and the resulting global economic crisis," Byanyima said. "Progress has been stalled, inequalities have widened, resources have shrunk, and millions of lives are now at risk."
Speaking at a session July 31, National Institute of Allergy and Infectious Diseases director Dr. Anthony Fauci concurred, stating, "There has without a doubt been a backslide in the HIV response."
Progress in treatment and prevention
Among the scientific highlights of the meeting was a report that a Southern California man appears to be cured of HIV after receiving a stem cell transplant from a donor with a rare mutation that makes cells resistant to the virus. As the Bay Area Reporter previously reported, this risky procedure is not appropriate for the vast majority of people with HIV who do not have life-threatening cancer, but advocates saw more hope in the news that a woman in Spain maintained viral remission for 15 years after stopping antiretroviral therapy.
With the availability of highly effective treatment, people who maintain an undetectable viral load do not transmit HIV, a concept dubbed "undetectable equals untransmittable," or U=U. U.S. officials including gay men Harold Phillips, director of the White House Office of National AIDS Policy, and Dr. Demetre Daskalakis, director of the Centers for Disease Control and Prevention's Division of HIV Prevention and newly appointed national monkeypox response deputy coordinator, announced their full support of U=U, as did Canada's chief public health officer Dr. Theresa Tam.
Also on the treatment front, researchers, including a team from Zuckerberg San Francisco General Hospital and Trauma Center, reported success using long-acting cabotegravir/rilpivirine (Cabenuva), a new treatment that can be administered by injection every other month.
Long-acting cabotegravir injections alone (Apretude) are also highly effective for preventing HIV. The World Health Organization added the new regimen to its recommended PrEP options, and ViiV Healthcare and the Medicines Patent Pool announced a voluntary patent licensing agreement to enable generic manufacturers to make injectable PrEP more affordable worldwide.
But there was also discouraging news on the PrEP front, as CDC researchers reported that disparities in PrEP use have widened over time, with Black and Latino people — the groups at highest risk for HIV — being less likely to use it.
Despite the mixed news, new International AIDS Society President Dr. Sharon Lewin ended the conference on a note of optimism.
"From our perspective as those engaged in the global HIV response, it is easy to take a pessimistic view and to fear that the rise of another pandemic has drawn energy and attention from our work," she said. "I like to take a more optimistic view. ... Let us capitalize on the global surge in awareness around infectious diseases and their impact on human rights."
Monkeypox on the agenda
Turning to the latest global health crisis, leading experts and public health officials discussed the growing monkeypox outbreak at a hastily organized media roundtable on July 31.
"Having worked in HIV for so long, we want to make sure that some of the mistakes in the early response to HIV are not going to be repeated in this situation," Lewin told reporters.
As of August 5, the CDC has identified 7,510 monkeypox cases in the United States. Worldwide, there are now more than 28,000 cases. California reported 1,310 cases and the San Francisco Department of Public Health counted 444.
While anyone can get monkeypox through close physical contact, cases remain overwhelmingly concentrated among gay, bisexual, transgender, and other men who have sex with men.
"The epidemiology is becoming more clear as time goes on," said Dr. Meg Doherty, WHO's director of global HIV, hepatitis and sexually transmitted infection programs.
On August 4, U.S. Department of Health and Human Services Secretary Xavier Becerra declared the growing monkeypox outbreak a national public health emergency, as the B.A.R. reported. The designation follows California Governor Gavin Newsom issuing a state of emergency August 1 and San Francisco's public health department declaring a public health state of emergency July 29.
Reporters asked numerous questions at the media roundtable, but Dr. Marina Klein of McGill University in Montreal acknowledged that many of them don't yet have answers. The exact mechanisms of transmission aren't known, nor is it clear whether the respiratory route is important or whether people can transmit the virus before they develop symptoms. There's little data showing how well the new Jynneos vaccine works or whether treatment with TPOXX (tecovirimat) reduces symptoms or lessens viral shedding.
Health officials, clinicians, and advocates agree that the global monkeypox vaccine supply is not keeping up with demand. Two doses of Jynneos are needed a month apart. Due to supply constraints, many cities, including San Francisco, have resorted to a one-dose strategy to give twice as many people partial protection as soon as possible, rather than holding second doses in reserve. But given the shortage, it is unclear whether people will be able to get their second dose on schedule.
Becerra told reporters at an August 4 telebriefing that the federal government has shipped more than 602,000 Jynneos doses to states and has allocated a total of 1.1 million doses. The government anticipates that an additional 150,000 doses will arrive next month, but Daskalakis said the supply and demand mismatch will probably continue through the summer and into the fall.
On Saturday, August 5, SF DPH announced on Twitter that the city has been allocated another 10,000 doses from the federal supply, more than double the previous two shipments.
1/3 SF has been allotted 10,000+ doses of monkeypox vax from the state via the federal supply. This is more than double the previous two allocations. The @ZSFGCare walk-in clinic will reopen 8/9-8/12 from 8am — 12pm. The clinic will also be open 8/13 from 8am — 3:30pm.— SFDPH (@SF_DPH) August 6, 2022
But advocates say this is not enough. As Daskalakis started to speak at a monkeypox symposium in Montreal on Monday, August 1, dozens of protesters — including many veteran AIDS activists — stormed the stage, demanding wider and more equitable access to vaccines and therapeutics in the United States and worldwide.
"We need to act now," said James Krellenstein of PrEP4All, which has taken the lead on monkeypox advocacy. "We're in a worsening outbreak that could have easily been prevented."
The activists' list of demands includes "decisive leadership" from WHO and the United Nations on global monkeypox vaccine and treatment access, including efforts to scale up production. They called for "immediate transfer of intellectual property, know-how and technology" to manufacturers around the world that can make vaccines, treatments and diagnostics.
The activists also demanded that higher-income countries make good on their commitment to be a "vaccine arsenal for the world." Advocates are loath to see a repeat of the inequitable global distribution of COVID-19 vaccines.
In an effort to stretch the limited vaccine supply, the U.S. is exploring an alternative administration method in which a single-dose vial of Jynneos, which is now given as a subcutaneous injection, is split into five doses injected under the upper layer of the skin, known as intradermal administration. The skin contains plentiful immune cells that can recognize viral antigens in the vaccine, triggering a strong immune response.
"There are some advantages to intradermal administration, including an improved immune response to the vaccine," Dr. Robert Califf, a commissioner with the Food and Drug Administration, said on the teleconference call. "It's important to know that that overall safety and efficacy profile will not be sacrificed with this approach."
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