CAHR 2014 Mark Wainberg Lecturer Richard Elliott and Red Ribbon Award Winner Darien Taylor
This year’s Mark Wainberg Lecture was given by Richard Elliott, executive director of the Canadian HIV/AIDS Legal Network. He walked the audience through the ebbs and flows of the Canadian government’s response to the epidemic in the past and argued that current government policies exacerbate the epidemic and act on many levels to impede progress by disregarding scientific evidence. Tangible examples such as the criminalization of HIV non-disclosure and government opposition to harm reduction services (both in the public sphere and in prisons) pointed out the critical need for evidence based policies rooted in the protection of human rights. Finally, Elliott argued that HIV is exceptional as a public health challenge and warrants an exceptional public health response. He cautioned against integrating the response to HIV into other realms of health care and public policy. Rather, the knowledge and human rights gains made within the HIV movement should spread outwards.
The 2014 CAHR Red Ribbon Award was presented to Darien Taylor, women’s rights and HIV treatment advocate and co-founder of Voices of Positive Women. In her acceptance speech, she provided a retrospective of the advocacy work she and colleagues have pursued over the years. She described the vulnerability of being immersed in the research and advocacy community while simultaneously living with HIV. Despite her long list of achievements, she feels that her true contribution was as a counterweight to the inevitable power balance that exists between researchers and participants. By equipping themselves with knowledge about current treatments and research avenues in HIV, people living with HIV/AIDS are able to reduce this vulnerability and play a critical role in the research itself.
Special Session: Canadian Vaccine Trials Initiative-Vaccine Research Plenary
Dr. Catherine Hankins (Deputy Director Science, Amsterdam Institute for Global Health and Development) gave an overview of the current status of the epidemic and the prevention strategies in use today. She discussed prevention methods prior to 2010 (including male/female condoms, male circumcision, behavioural modifications) and more recent methods since the introduction of anti-retroviral therapies. Dr. Hankins discussed the use of oral and topical pre-exposure prophylaxis, and anti-retroviral medication as prevention methods but emphasized the need for consideration of issues and key requirements for these methods to work effectively. As the second speaker in the Vaccine Plenary, Dr. Marc Ouellette (Scientific Director of the Institute of Infectious Disease Immunity at CIHR) provided an overview of HIV initiatives at CIHR and information on CIHR activities in vaccine research. He provided a summary of funding streams in CIHR including innovation support and the Canadian Vaccine Initiative.
Clinical Sciences Plenary-Dr. Marina Kline
On the 10th anniversary of the Canadian Co-Infection Cohort Study (CCC), Dr. Marina Kline (McGill University Health Centre) provided a summary of the results of the CCC and future directions for the project. The CCC collects detailed data on socio-economics, drug/alcohol use, HIV co-infections, disease status and treatments from 1238 participants across Canada. Dr. Kline discussed the prevalence of Hepatitis C (HCV) in the cohort and emphasized that progression to liver disease is ongoing in the cohort and will likely continue unless HCV can be cured in participants. She described a revolution in HCV therapy with many new medications on the market, direct-acting antiviral agents, simplification of the medication regimen and reduced duration of treatment. Though cure rates are approaching 100%, expense is a barrier and re-infection can still occur if behavior is unmodified. She outlined the future directions of the CCC, citing the need for real world studies and an evaluation of direct acting agents, including an assessment of their short/medium term health and economic benefits.
Social Sciences Plenary-Dr. Richard Parker
Dr. Richard Parker (Columbia University, Mailman School of Public Health) explained how he believes that social science matters now more than ever in HIV research. He summed up the HIV epidemic as moving through stages as it progressed. Initial responses were community based and grassroots efforts were made to control the epidemic (through safe sex practices and condom use). Behavioural theories and interventions emerged next with formal organisations promoting safe sex practices and behavioural modification. Structural factors gradually came into play as it was realized that socio-economic status, poverty, racism and gender inequality among other issues affected the spread of HIV. Biomedical prevention came about with the development of new drug treatments, but Dr. Parker emphasized that these are not a magic bullet. Combination prevention has become the next stage, where behavioural, structural and biomedical prevention methods are used to complement each other. He pointed out that social science in HIV research is critical as it describes the complexity of the lived human experience and acts as a fundamental partner to other realms of research.
Basic Sciences Plenary-Dr. David Margolis
Dr. David Margolis (Professor of Medicine, University of North Carolina at Chapel Hill) gave an in-depth overview of biomedical treatment of HIV in his talk “Eradication of HIV infection: Finding the tools for the job.” He discussed resting (latent) CD T4 cells as being a hurdle to developing a cure for HIV and outlined their cellular mechanisms. Dr. Margolis discussed his research on vorinostat, a histone deacetylase inhibitor that flushes out HIV reservoirs where they can be targeted by ART. However, effects fade over time as vorinostat only flushes out a certain percentage of reservoirs, always leaving behind the potential for infection. Current basic science research into disrupting latency involves harnessing the immune response, understanding cellular pathways, developing technology and novel assays to validate and safely test in the clinic. He emphasized that as clinical trials take so long, eradication of HIV requires appropriate models such as the immunodeficient mouse and primates, and appropriate tools to test new methods in the lab.
Epidemiology and Public Health Sciences Plenary-Dr. Virginia Bond
In her talk “Silos, Science and Stigma: Community Experiences of HIV Treatment and Prevention in Zambia and South Africa” Dr. Virginia Bond (London School of Hygiene) provided an extensive overview of her HIV treatment and prevention research in South Africa and Zambia. She discussed the results of the POPArt study (surveys of 21 communities in Zambia and South Africa) and the SEPO study (functioning, disability and health surveys of women and men in Zambia). She placed the research within a theoretical framework of silos (treatment and prevention are not perceived as linked), science (as one of several paradigms through which treatment is viewed) and stigma (impact of treatment on stigma and vice versa). Dr. Bond discussed the results of the study, providing detailed examples of participant perceptions of treatment and prevention, stigma, challenges with access to treatment and knowledge of terms associated with treatment (PrEP, PMTCT). She suggests that we need to rethink treatment as prevention as they are not closely linked in the minds of participants. Dr. Bond advocates delinking treatment and prevention and rather focusing on each separately. Slippage from treatment to a sole focus on prevention risks transferring more stigma to those already living with HIV as there is a strong moral tone to the HIV epidemic in general.
Special Session-Cure and Controversy
Presenters Dr. Mark Wainberg, Dr. Ari Bitnun, and Dr. Adrian Levy presented unique perspectives on the topic of HIV cure development. Dr. Wainberg discussed his research with dolutegravir, a medication that has performed well in trials. From initial results it appears that resistance mutations in the HIV virus impede viral replication, and thus dolutegravir continues to be an effective medication for treatment. Because of this, Dr. Wainberg believes that dolutegravir has great potential to reduce HIV spread through treatment. Dr. Bitnun presented his research on early therapy for cases of vertical HIV transmission. He reviewed the case studies on sustained viral suppression that are ongoing and described the ethics and concerns of continuing these types of studies. He strongly advocated maternal diagnosis and treatment of HIV to avoid cases of maternal transmission altogether. Finally, Dr. Levy discussed the huge challenges of eradicating HIV, including the financial, political, social and practical issues with HIV treatment. He suggested that eradication is not possible, but elimination is something to aim for. On this last point, the panel—which included Dr. Marina Klein, Dr. David Margolis and Dr. Eric Cohen— took issue and the panel shared their views on cure development.
Special Session: IDU, HIV and HCV: Improving Access to Testing and Treatment for People Who Use Injection Drugs in Newfoundland and Labrador
Gerard Yetman, Executive Director, AIDS Committee of Newfoundland and Labrador, St. John’s, Newfoundland described to the audience the purpose of the Safe Works Access Program (SWAP), a harm reduction program in St. John’s. As the need for harm reduction has increased, a study was initiated to assess the extent of drug use in the province and how to adapt the SWAP program to meet these needs. Marie Ryan, Researcher Consultant at Ross-Gilroy Research Inc. described the results of the study. She provided a summary of the demographics of intravenous drug users and discussed the need for point of care testing and safe injection sites. She also emphasized that harm reduction was generally misunderstood amongst the public and education was needed in this regard. Zoe Dodd described the extensive services provided by the harm reduction program at South Riverdale Community Health Centre in Toronto. She pointed out the critical need for involvement of persons affected by HIV, HCV and drug use in the decision making process and described their role in the harm reduction program in Toronto. The final presenter, Dr. Timothy Christie (Regional Director of Ethics Services, Horizon Health Centre in New Brunswick) discussed the results of a study of participants in a methadone clinic. The clinic itself had excellent retention rates (due to low requirements for entry and no involuntary removal of participants) and yielded good results in terms of treatment and reduction of opioid use. Statistics on the criminal activity of participants lead Dr. Christie to suggest that standard methadone clinics, because of their strict criteria for participants, force people at their most vulnerable times onto waiting lists and remove them from treatment at a critical time in their recovery.
Future Tense: CIHR HIV/AIDS Research Initiative
The CIHR HIV/AIDS Research Initiative is initiating the development of a new strategic plan for 2015-2020. This special session provided the opportunity for input and dialogue on future strategic directions for the Initiative and HIV research in Canada. Jennifer Gunning, Associate Director for the CIHR for HIV/AIDS Research Initiative provided an overview of CIHR funding streams and HIV/AIDS research priorities. This included a discussion of the types of research awards available and funding priorities. The presentation was set as a open forum for audience members to contribute their views as the CIHR HIV/AIDS Research Initiative moves forward and establishes new research priorities. Mike Tomlinson with the Consulting Firm Strachan-Tomlinson in Ottawa led the discussion, questions and audience survey. Comments from the audience included the need for a global role for CIHR, dissemination of research to general public, research participants, students, flexibility in research award size and harm reduction funding.
Learning at the Front Lines: Community Rapporteur Session – CATIE Learning Institute participants
CATIE Community Rapporteurs provided their group overviews of each stream at the CAHR conference. Abby Jackman, rapporteur in basic sciences discussed the trend of focussing on reservoirs to ‘cure’ HIV. She discussed some of the presentations on viral genetics and transmission dynamics, elite controllers of HIV, and the debate of breastfeeding in HIV+ women. Luyomba Henry and Natasha Potvin summarized the clinical sciences stream. They felt that excellent results were coming from researcher/community collaborations but there was still disparity in access to services for some groups, especially women, Aboriginal communities, and non-English speakers. They discussed co-infections and how harm reduction services must be continued. Leigh Giberson provided a summary of the Epidemiology and Public Health stream. She discussed several aspects of the stream that rang with the CATIE team including the strained health care system, access to care, historical trauma (individual, national, cultural) and increased risk taking behaviours, and tailoring health care to community needs. Finally, Robert Birch summarized the social sciences stream and emphasized the critical role of persons living with HIV/AIDS and affected communities in determining the direction of research. He also discussed the team’s thoughts on barriers to care, criminalization of non-disclosure, criminalization of sex purchasers and the lack of consideration of trans-people.