Conference Theme - Combining Strengths in the Struggle Against HIV
CAHR2015 Mark Wainberg Lecturer
This year’s Wainberg lecture was presented by Dr. Bill Cameron, an accomplished researcher and physician from The Ottawa Hospital. His talk challenged the audience to seriously question both the knowns and the unknowns surrounding HIV thus far. He emphasized that before going forward with new research we should re-examine the things we know about HIV and look to the treatment/prevention of other diseases for ideas and avenues of study. He also suggested that we remember the lessons learned from the initial outbreak and keep in mind the ever-present potential for new sexually transmitted and blood borne infections to enter the population and the blood supply. He expressed his views on the unnecessary use of controlled placebo trials and proposed the ‘stepped wedge’ study design which he feels is more ethical and feasible with today’s medications. Finally, he pointed out that the basic sciences too often take the forefront in HIV research while it is the social sciences, those that elucidate the socio-political drivers of the epidemic, that are critical to prevention and treatment.
CAHR2015 Red Ribbon Award
The 2015 Red Ribbon Award was presented, posthumously, to Elisse Zack, co-founder and past president of the Canadian Working Group on HIV Rehabilitation. The award was received by Elisse’s friend and colleague Stephen Tattle and Lillian Zack, Elisse’s mother. Stephen spoke about Elisse’s tireless efforts to improve the quality of life of those living with HIV and other episodic disabilities and the network of collaborations and partnerships she helped to form. Ultimately, her efforts put HIV rehabilitation on the map in Canada and globally and her legacy will continue. Before accepting the award, Lillian Zack described a poignant moment from Elisse’s childhood where Elisse’s concern for others shone through.
Canadian HIV Vaccine Initiative-Vaccine Research Plenary-Dr. Marc Gurwith and Dr. Frank Plummer
This plenary had two speakers, Dr. Marc Gurwith (Chief medical officer of PaxVax) and Dr. Frank Plummer (University of Manitoba). Dr. Gurwith discussed his research looking at an orally administered HIV vaccine which uses adenovirus serotype vector 4 (Ad4). He primed the audience on the advantages of using replicating vectors in HIV vaccines, pointing out that they are likely to be safer that live attenuated vaccines. He outlined the potential mechanisms of its use and provided an overview of Phase 1, a proof of concept study using H5N1 flu virus and Ad4.
Dr. Plummer set the stage for his talk by outlining the current status and difficulties of HIV vaccine development to date. He specifically discussed his work in Majengo (Kenya) with a cohort of HIV resistant sex workers. He discussed the theories as to why they are resistant to HIV and the ways in which his team is investigating this phenomenon. This group of HIV resistant women over-express certain anti-proteases, some of which directly inhibit HIV infection and have strong anti-inflammatory properties. Based on this information, he outlined the ways in which an understanding of the mechanisms of HIV resistance could inform HIV vaccines or therapeutics.
Clinical Sciences Plenary-Dr. Deborah Persaud, Johns Hopkins University School of Medicine
Dr. Persaud’s talk, titled “HIV Latency in Perinatal Infection: Opportunities and Challenges towards Remission and Cure” gave an extensive overview of the current state of research into the treatment of perinatal HIV infection. Dr. Persaud described for the audience the different cure possibilities and outlined the hurdles in detecting viral loads and thus determining whether a ‘cure’ has truly been achieved. Currently, virologic rebound occurs in both children and adults within 2-3 weeks after discontinuation of treatment, and resting memory CD4+T cells are a major source of the virus during rebound. Dr. Persaud discussed her research on the Mississippi child, a case of undetectable viral load after discontinuation of anti-retroviral therapy. Ultimately, virologic rebound occurred after treatment cessation in this case as well, but it took much longer than 2-3 weeks. Based on this research and that of other unique case studies, she discussed some of the lessons learned in perinatal treatment of HIV infection. She emphasized the potential of very early treatment to reduce reservoirs and lower viral diversity in the patient.
Social Sciences Plenary: Dr. Viviane Namaste, Concordia University
Dr. Namaste’s talk “Interdisciplinarity and Construction of Objects of Knowledge” asked the audience to think deeply about the way HIV research is conducted. She set the stage of the talk with a discussion of the swinger community of Montreal, using it as an example of how biases in media or the public mind can completely exclude a population from research and prevention efforts. She framed her talk around six major “orientation” points to guide critical thinking about research. The first point was humility; researchers should know what they do not know and not make promises of success. From this, she suggested moving away from instrumentalist research—if we only pursue things we know will succeed we won’t learn from our failures. She asked that researchers sincerely reflect on their own perceptions and knowledge and recognize its biases and limitations. However, she pointed out that the speed at which results are expected to be produced is not conducive to this, which is problematic. She also discussed the importance of recognizing other ways of knowing, and that even language itself can filter out potentially important information.
CAHR 2015 Lunch Symposium: CIHR Designing for the Future
Dr. Jane Aubin and Dr. Marc Ouellette from the Canadian Institutes for Health Research both spoke at the Lunch Symposium and remained on the stage for a panel afterwards (which also included Dr. Michael Grant as Chair). Dr. Aubin introduced CIHR’s new strategic plan (Roadmap II), outlining the refreshed priorities that were formed through conversations with researchers, partners and other stakeholders. Dr. Aubin outlined the budget and discussed the allocation of funds. CIHR is transitioning from 12 different investigator initiated programs to two, (the Foundation Scheme and the Project Scheme) and Dr. Aubin discussed how this was to proceed and the programs to be phased out. She also provided preliminary data from surveys conducted regarding the new structured application/review process and outlined the College of Reviewers scheme. Dr. Ouellette introduced the new strategic plan for the CIHR HIV/AIDS Research Initiative. He spoke to the Initiative’s values (excellence, inclusiveness, innovation, collaboration and transparency) and discussed the five funding streams. Dr. Ouellette mentioned some highlights of recent and upcoming strategic investments in HIV/AIDS research including a partnership with the Gates Foundation involving mucosal immunology and a team grant on Boys and Men’s Health in partnership with Canfar and OHTN. He also discussed the Initiative’s support of research networks working coast to coast in Canada.
CAHR Symposium “Program Science: Innovations and Pragmatic Approaches to End HIV Epidemics in Canada”
This year’s symposium focussed on both the current paradigms and the practicalities of bringing research into the practice. Sean Rourke (OHTN), Christopher Bunting (CANFAR), Jennifer Gunning (CIHR HIV/AIDS Research Initiative) and Jessica Halverson (PHAC) welcomed the three keynote speakers of the panel. Dr. Nancy Edwards (CIHR) discussed the ongoing shift from mechanistic research to a recognition of more complex and humanistic factors. She presented her theoretical framework for implementation research and explained that foundational science should be included during many stages of the implementation process. She also provided examples of how CIHR is translating implementation research into funding opportunities for health research. Dr. Kenneth Mayer (Harvard Medical School) brought a real world example of implementation research to the discussion in his talk titled “Antiretroviral preexposure prophylaxis (PrEP): Moving from clinical trials to implementation.” He provided background on PrEP research and outlined some of the challenges in implementation, including the difficulties with achieving realistic results from clinical trials and the complexities of human behaviour. Dr. James Blanchard’s talk “Imagining a New Paradigm for knowledge generation and translation for HIV prevention” looked at the practicalities of implementing research into practice. He discussed the problems with the current paradigm and outlined how “program science” would differ from the current paradigm. Using sex work programs as an example, he explained how complex realities can be. Thus a program science component would need to be equally complex. Finally, he emphasized that embedded science enriches the ability to ask the right questions and overall enhances the impact of research. After these presentations, the panel was joined by Dr. David Hoe (OHTN) and Dr. Aslam Anis (UBC) and panel chair Dr. Peter Donnelly (PHO) who fielded questions from the audience.
Basic Sciences Plenary-Dr. Galit Alter (Harvard Medical School)
In Dr. Alter’s talk titled ‘Systems Serology to Profile Protective Immunity Against HIV’ she gave an extensive overview of the characteristics of the immune system that allow it to respond to different types of infections. Using cluster analysis, Dr. Alter described the immune profiles of patients involved in the various vaccine trials that have taken place in the last few years. She specifically compared the Vax003 trial and the RV144 trial and showed that each elicited very different immune responses, the latter being more effective. As the RV144 trial was somewhat successful in eliciting immunity, she discussed the immune factors that may have played a part in this. Through her research, she has determined that IgG3s and IgG1 antibodies are critical in the immune response. Additionally, antibody glycosylation can be tuned to adapt to infection by various methods including the types of adjuvants used. She argues that systems serology is an excellent way to determine the antibodies that are effective in controlling different types of pathogens. Thus, it offers an opportunity to identify correlates of protection for next generation vaccines.
Epidemiology and Public Health Plenary- Dr. Kate Shannon (University of British Columbia)
In Dr. Shannon’s talk titled “Criminalization, Sex Work and HIV: From Research to Policy” discussed the implications of punitive approaches towards sex work. She gave an excellent overview of the structural determinants that increase and/or decrease risk and prevalence of HIV in sex workers. Dr. Shannon discussed the results of several projects involving cohorts of sex workers which evaluated, both qualitatively and quantitatively, the impacts of criminalization and policing policies on factors such as violence, unprotected sex and health services. Dr. Shannon argued that criminalization of sex work has many affects including reducing access to health care, aids service organizations and increased exposure to violence, drug use and unprotected sex. She also argued that criminalization of clients (as seen in Bill C-36 in Canada) creates many of the same issues while decriminalization empowers the community and allows for sex worker-led initiatives. Ultimately, because of the interaction of structural factors that affect HIV risk, decriminalization could decrease HIV transmission by 33-46%.
Canadian HIV/Hepatitis C Co-infection Management and Treatment Guidelines Symposium
Curtis Cooper introduced the panel of experts which included Mark Hull, Marina Klein, Alex Wong, Stephen Shafran, Lisa Berrett, Alice Tseng and Pierre Giguère. Each panelist presented the guidelines along with brief summaries of the supporting literature where relevant. Each recommendation received a class designation based on the amount/quality of supporting literature/clinical trials. Mark presented the recommendations in the epidemiology category, including guidelines for screening and testing and timing of antiretroviral therapy initiation in patients with HCV. Marina discussed baseline evaluation, diagnosis, clinical assessment of HCV and the guidelines for non-invasive fibrosis and cirrhosis. Alex and Stephen outlined the recommendations for HCV therapy in HIV co-infected patients and preparation for HCV therapy. The interferon-free treatment guidelines for HCV Genotype 1 were discussed by Lisa and included a description of supporting literature (specifically the ION-4 trial). Though there is less data on Genotypes 2-6, the panel presented its recommendations based on the limited literature available. Alice and Pierre discussed drug-drug interactions and transplantation guidelines. The floor was then opened to the audience and the panel fielded questions.
Special Session on Community Practice Research: Oral Abstract Presentation
Chaired by Trevor Hart (Ryerson) and Francisco Ibanez-Carasco (OHTN), the special session on community practice research featured some excellent examples of community involvement, knowledge translation and collaboration. Nadia Obrien and Tracey Conway on behalf of CHIWOS presented their talk “Ensuring the voices, recognition and wellbeing of peer researchers in the application of GIPA/MIWA principles: ethical tensions in conducting research with women living with HIV in Canada.” This project looked at issues like peer confidentiality, meaningful involvement, PRA (peer research associate) expectations and capacity building. Next up were Haoua Inoua (AIDS committee of Ottawa) and Joanne Colas (CHEO) who spoke about their clinical institution and community based organization partnership which supports families living with HIV. Patients at CHEO meet with Haoua, linking them to social supports and health and social services. Presented by Patrick McDougal (Dr. Peter Centre), the next talk documented the Dr. Peter’s centre experience of recruiting, hiring, training, orienting, supervising and mentoring PRAs for a three year CBR project. The end result is a set of free online modules aimed to help guide community based organizations (CBOs) that wish to work with PRAs. James Wilton (CATIE) and Alan Li (Regent Park Community Health Centre) discussed their project “Exploring the roles of community based organizations in the rollout of PrEP among Toronto Gay, Bisexual and other MSM (gbMSM).” Their project sought to identify what services are needed and asked CBOs about their hopes and concerns for PrEP with a discussion of next steps. Vijaya Chikermaine and Shazia Islam with the Alliance for South Asian AIDS Prevention described the anthology of stories titled “More than Fiction: Poz women share their stories.” They discussed the experience, the benefits of storytelling for people living with HIV and highlighted some of the stories included. The final presentation given by Brent Oliver (Mount Royal University) looked at the benefits and challenges of vocational rehabilitation services in assisting people living with HIV to work successfully with a special emphasize on implications for community practice.
Learning at the Front Lines: Community Rapporteur Session. The CATIE-CAHR Learning Institute
The session started off with participants’ impressions of the Social Sciences Track summarized by Carol Galliot (Corner Brook, Newfoundland). Resilience was a recurring theme in the research, and can be increased by access to traditions, cultures, values and language. Cultural awareness has impacts on health care and assumptions of homogeneity in populations and structures rooted in colonialism do not serve people living with HIV. Carol discussed the theme of “living through transition” and some of the research on status disclosure. Dane Record (ACHO) covered the Clinical Sciences Track, which included research into complications, comorbidities and coinfection. He also mentioned areas where the research was lacking, including studies centered on heterosexual men and transgendered persons. Mbaka Wadham (Womens HIV AIDS Initiative), with the Basic Sciences Track, was impressed with the vaccine research plenary as it was an example of how to make basic science accessible to the public. She focused on research looking at initial point of infection, innate immune response and viral latency. The Epidemiology and Public Health Sciences track summarized by Jane Karago-Odongo (Somerset West Community Health Centre) covered a range of topics including community engagement, housing issues, mental health and criminalization. She also pointed out the increasing presence of integrated services such as shared care approaches, incorporation of cultural practices into service delivery, and HIV testing in STI screening.
HIV and Immigration
Chaired by Wangari Tharao, this special session provided a thorough overview of HIV status and immigration in the Canadian context. Andrienne Smith (Jordan Battista law firm) outlined the immigrations laws in Canada that pertain to HIV status. This included reasons for refused entry, which centre mainly on the costs of health care for a person with HIV relative to the national average. Andrienne also discussed the common scenarios that she deals with in her practice and the role of an immigration lawyer in ensuring the laws are followed appropriately by immigration officials. Jessica Halverson (Public Health Agency of Canada) gave an overview of Canadian immigration statistics including the number of applicants testing positive for HIV both in Canada and overseas. Maureen Owino (Committee for Accessible AIDS Treatment) described the difficulties that immigrants, nationals and refugees face when arriving in Canada including navigating the immigration process, acquiring access to social and health services, and dealing with stigma and discrimination. She presented the results of two studies conducted by CAAT and the positive outcomes of this work. Dr. Darrell Tan spoke about his research on HIV testing by designated medical practitioners (panel physicians) in the context of the immigration medical exam. The research looked at the knowledge, practices and needs of designated medical practitioners and opportunities for improvement. Dr. Alan Li was the final speaker of the panel, he discussed CHAMP (Community Champions HIV/AIDS Advocate mobilization Program) and their research/knowledge mobilization program to address HIV stigma. He discussed the study design and the results while emphasizing the importance of utilizing research to engage with communities and respond to their needs.
Special Session: Pre-Exposure Prophylaxis (PrEP)
To start off the session, Cécile Tremblay (Institut national de santé public du Québec) outlined the current state of knowledge around PrEP as a bio-medical approach to prevention. She discussed its role amongst other prevention methods, the difficulties with adherence, and the successes in using packages of prevention (provision of PrEP along with other services such as counselling and condom distribution). She discussed the IPERGAY trial of on demand PrEP which included a prevention package and had high rates of efficacy. Thomas Haig (UQAM) discussed IPERGAY from a social sciences perspective. He touched on the questions of risk compensation, treatment adherence and treatment adoption, while emphasizing the important of complete prevention packages. Finally, he discussed the Mobilise! Project which aims to get a more detailed understanding of the issue, and improve accessibility to PrEP and combination prevention. Darrell Tan (St Michaels Hospital) presented study results from the PREPARATORY study, which aims to address some big questions about PrEP, including the role of community based organizations, clinical outcomes, PrEP related stigma and efficient delivery of PrEP to those who can benefit the most. Troy Grennan (BC Centre for Disease Control) outlined some of the more practical aspects of PrEP rollout from a BC perspective. He discussed difficulties in determining who (levels of government or insurance) would pay for PrEP and how to determine suitability for PrEP. He also provided a summary of PrEP related activities in BC which includes a cohort study looking at real world use of PrEP in BC. To end the session, Cécile Tremblay discussed the Quebec perspective on PrEP where it is quite difference from the rest of Canada. As PrEP is reimbursed by the province, physicians prescribe it more readily and it has shown to be very cost effective relative to HIV treatment. The panel then fielded questions from the audience.