Eric Goemaere wrote:
The Southern African HIV Clinicians Society conference (24-27 Sept 2014, Cape Town) was attended by more than a 1000 people, mainly from South Africa, to discuss the latest developments in clinical management of HIV and tuberculosis.
MSF was keen to participate in this conference and as a result, we had a speaker in ~1/3 of the sessions including plenaries. Vivian Cox, the Field Coordinator of our Khayelitsha project, made a brilliant presentation in the plenary session on the 2nd day (‘MSF models: What works and what doesn’t in HIV and TB’), describing different ‘fix it tools’ across the HIV care cascade from linkage to care, to long term retention in care, while addressing those failing treatment. This and others illustrate the strong role that MSF can play in shaping policy.
For my part, I was one of the panel members for the opening day debate entitled ‘Can we treat our way out of the epidemic?‘ together with Graeme Meintjes and others, squeezed between heavyweights Dick Chaisson (representing the ‘No side’) and Gary Maartens (representing the ‘Yes side’). While I argued that we will not succeed at the existing pace due to mediocrity of health services (e.g. poor retention in care and poor suppression of HIV viral load), I tried to articulate that it was possible to do much better using certain MSF-supported sites as examples, but that we would still need additional new bio-medical prevention tools for countries like South Africa in order to prevent an ‘epidemic within the HIV epidemic’, namely that of young women. For example, a recent Epicentre survey reporting a 0.4% overall HIV incidence rate in Chiradzulu, Malawi demonstrates what we can do with existing tools… following 15 years of heavy MSF investment, that is.
I must say that I regretted afterwards to have been sitting on the ‘No’ side, as their argument was stuck in the 350 vs. 500 CD4 threshold debate, obsessed with the idea that there was no evidence from a randomized controlled trial (RCT) of individual benefit above a CD4 count of 350 cells/mcl. This was afterwards reinforced by people from the crowd, e.g. Marcus Low of the Treatment Action Campaign (TAC), who created a strong case for the ‘No’ side when the chair asked for a public vote, making the ’90-90-90’ targets of the UNAIDS campaign (90% diagnosed, 90% on treatment, and 90% virally suppressed so as to end the AIDS epidemic by 2030) sound like they are completely disconnected from reality. Such aspirational targets versus a ‘reality check’ would be a good future debate for MSF!
I was also part of another panel later in the conference convened by TAC asking, ‘How feasible is VL testing and how does it contribute to adherence?’. During this session, it was concerning to hear about the financial problems of the National Health Laboratory Service (NHLS) while it was easy for me to claim VL testing as a ‘luxury ‘ in South Africa, as it is being newly discovered in surrounding countries where it offers an excellent way to improve retention on ART, especially if well understood and claimed by patients themselves.
Gilles van Cutsem wrote:
The major dramatic news at the conference was the announcement of the extreme financial difficulty that the Treatment Action Campaign (TAC) currently is in, so much so that many of the presentations ended with a slide asking for donations to TAC. If nothing changes before the end of this year, TAC activities will only be able to run at a third of their current volume, drastically reducing the scope of the organization and potential to promote change. If TAC dies, South Africa will lose the major avenue for the voice of patients. And as Mark Heywood said, this would cost lives…
There were interesting points made during several presentations and panels on the ‘test and treat’ model. It is now clear that we could slowly treat our way out of the epidemic using the MSF/Epicentre surveys as an example, which showed incidence rates of 0.4/100 person-years in Chiradzulu, Malawi and of 1.4/100 person-years in KwaZulu-Natal (KZN) province in South Africa. Chiradzulu is a perfect example that with intense scale-up using a CD4 count eligibility threshold of 350 cells/mcl, paired with a focus on quality to prevent losses to care and poor adherence, it is possible to control the epidemic. Conversely, the ongoing high incidence among young women in KZN shows that additional interventions are needed to reach this population, as pointed out in many of the presentations. Young women are currently ‘priority number one’ for prevention, testing, and treatment; other priorities include MSM, CSW and older men. As Eric said during the panel discussion, “We have pushed for quantity, now is the time to focus on quality too”…
Let’s scale-up without screwing up!