INTEREST 2021 conference: is Africa still hoping against hope in the fight against HIV?

The International Conference on HIV Treatment, Pathogenesis, and Prevention Research of 2021 (INTEREST 2021) was held virtually between 12 and 14 October 2021. INTEREST is a premier conference on HIV in Africa. INTEREST 2021 featured exciting updates on HIV and COVID-19, novel HIV prevention and treatment technologies and the future of HIV in Africa. However, one could not help but notice the glaring inequalities that are still faced by people with HIV (PWH) in Africa. ¹ Despite the tremendous progress observed in sub-Saharan Africa (SSA), the region is still the worst-affected and most countries are unlikely to achieve targets for annual HIV testing and condom use by 2030. ² The ongoing COVID-19 pandemic has not helped the situation. Interruptions in the supply and access to antiretroviral therapy (ART) and other HIV services were projected to have catastrophic effects in SSA. A 6-month interruption of ART supply across 50% of PWH was projected to result in an excess of 296,000 deaths over a period of one year. ³ Furthermore, interruption in services was projected to increase new HIV infections at the population level and results in overall poorer clinical care for PWH due to overstretched health systems. However, health systems in SSA have proven to be resilient by re-orienting HIV health care services. Programmes have adopted multi-month dispensing of ART, telephone and social media counselling, community distribution of ART by mobile vans, delivery of HIV services at home and scaling-up of self and home-based HIV testing. ⁴ It is however unclear how sustainable these interventions will be if countries cannot access the COVID-19 vaccines that would otherwise obviate the need for improvisation. As of June 2021, only four countries in SSA had vaccinated more than 5% of their populations with at least one dose of the COVID-19 vaccine. ⁵ At INTEREST 2021, Dr. John Nkengasong, the director of the Africa Centres for Disease Control and Prevention, woefully remarked how this is not due to vaccine hesitancy in the region but rather a lack of access. In fact, < 1% of vaccines are manufactured in Africa, leaving the continent vulnerable to future pandemics. ⁶ The lack of access to novel therapies is a story all too common in SSA. While ART coverage was  > 80% in certain middle-income countries in the mid-2000s, only 17% of eligible PWH in SSA were on ART. ⁷ As such, countries in SSA had to ration ART using criteria mostly set by international funding agencies. ⁸ One is left to wonder whether the new HIV prevention therapies presented at INTEREST 2021 will be readily available and affordable, particularly for women in Africa who continue to bear the brunt of the HIV epidemic.

INTEREST 2021 put well-deserved emphasis on women. In SSA, five out of six new HIV infections among adolescents are among girls. Young adolescents and women (15–24 years) account for 24% of new HIV infections. ¹ Therefore, young women need discrete and fashionable long-acting pre-exposure prophylaxis products that foster adherence and may be integrated with reproductive health products. ⁹ The dapivirine vaginal ring, injectable cabotegravir, and the islatravir implant promise the possibility of doing away with ‘the rattling pill bottle’. Whether programmes in SSA will successfully roll out these products on a large scale is yet to be seen. Programmes will need to be responsive to the evolving preferences of women as well as have efficient pharmacovigilance mechanisms for side effects. Clearly, clinical trials for new products need to put pregnant women and women of bearing age at the centre of study designs. However, programmatic data tend to reveal side effects that study data do not, thus the need for pharmacovigilance. INTEREST 2021 also reminded us how the burden of cervical cancer still mirrors that of HIV in SSA. In southern and eastern Africa, as many as 64% and 27% of women with cervical cancer are living with HIV. ¹⁰ Notwithstanding, the capacity for DNA/mRNA testing for the human papilloma virus (HPV), the putative cause of cervical cancer, is low. ¹¹ Similarly, the uptake of the HPV vaccine is still dismal.

The future of the fight against HIV looks promising. Life expectancy of PWH is almost comparable to that among individuals without HIV. ¹² In addition, the search for a ‘pan-clade’ HIV vaccine is active and long-acting ART therapies are now approved or in the pipeline. However, SSA still contends with high rates of mother-to-child transmission of HIV. As such, half of new global child HIV infections are in Nigeria, Mozambique, South Africa, Tanzania, Democratic Republic of Congo, Zambia and Uganda. ⁵ None of the countries that have been validated as having eliminated mother-to-child transmission of HIV is in SSA. Unfortunately, innovation in paediatric HIV care typically lag those in adults. Another challenge that needs to be addressed is the low ART retention rates in SSA; one in five PWH stop ART by 5 years. ¹³ Novel approaches to retention are needed. Nice and patient-centred health providers are likely to be the most important component of care that fosters retention when compared to shorter distances and waiting times, multi-month ART refills and incentives. ¹⁴ But how do you realise a nice and patient-centred health workforce when facilities are understaffed and health providers are over worked, poorly remunerated and unrecognised? ¹⁵ It appears that health systems in SSA have an uphill battle to retain both PWH on ART and health workers in HIV care programmes.

INTEREST 2021 began and ended with heart-warming testimonies in memoriam of the profound contribution that Dr. James Hakim Gita ¹⁶ and Dr. Charles Boucher ¹⁷ made to HIV clinical research and care. Their work challenges us to stand with PWH as close kin, passionate advocates, compassionate caregivers, ardent researchers and dedicated leaders in the fight against HIV in SSA.