My first concrete experience with HIV research took place in 2007. I had applied, interviewed and been selected to participate in a 2-month research and volunteer internship in the country of Namibia. The internship program that I joined had been established several years prior and had a reputation for being an incredible learning experience for those selected to participate. Undergraduate students from various faculties within the University of Toronto were selected to travel to Namibia to conduct research and volunteer within a local AIDS service organization (ASO). 

With very little applied training or education (in research methods, on HIV in a Namibian context, on community-based approaches to research), I flew overseas and landed first in Windhoek before driving eight hours north to a rural town called Ongwediva.

For the volunteer portion of my internship, I worked within an organization that provided microfinance loans and HIV education to women who were supporting orphans and/or other vulnerable children (OVC). OVC are defined as a child 18 years of age or under who has lost one or both of their parents or primary caregivers and  is in need of protection. In Namibia, more than 28% of those 18 years of age and under are classified as OVC with a shockingly high percentage of children orphaned because of HIV and AIDS. 

The first time I travelled to Namibia in 2007 (1), the national HIV prevalence rate was hovering around 15%, which is a high despite the fact that the population of the country was just under 2 million at the time. Although the country’s population isn’t large, dealing with thousands of people living with HIV in the context of a weak infrastructure is challenging. While the HIV prevalence in Namibia has shifted slightly since 2007 (the latest report shows a national prevalence rate of 13.1%), Namibia still ranks amongst the top ten worst countries globally in relation to adult HIV prevalence. I believe that the history of a consistently high HIV prevalence rate was the reason the internship program was established in Namibia. 

Outside of some readings completed prior to departure, we were not required to complete any courses or training to prepare us for the research projects we were about to undertake. On top of this, students traveling abroad were expected to create a research project that we would embark upon once we arrived in Namibia without consultation from our Namibian “partners”.

At the time, I remember feeling frustrated with these expectations; how could I be expected to develop a research project not only without the necessary training in methodologies but also without ever having been to Namibia or communicated with any of the potential organizations or ASOs that I might end up working with? 

Though I did not realize this at this time, I was operating within a colonial research structure which placed me, the undertrained, naïve, and eager (yet ignorant) undergrad, in a position of authority over the research including who would be involved and what and who would be studied. This structure positioned me as the research “expert” regardless of my inexperience both in research and in Namibia. Yet my overall academic immaturity and ignorance was irrelevant and became secondary to the incredible experience I was about to undertake. 

Critical considerations about how to ethically engage in an international research expedition were not a focal point and emphasis was placed on ensuring that the experiences of the University of Torontop (Western) students were monumental. Though I was aware that entire bodies of critical literature existed on research methodologies and approaches, HIV engagement and international work yet community-based research and ideas around the greater involvement of people living with HIV and AIDS (the GIPA Principle) failed to make an appearance in the internship program or research structure we were being churned through. 

(The Greater Involvement of People Living with HIV & AIDS (GIPA) Principle was introduced and formalized at the 1994 Paris AIDS Summit when more than 40 countries committed to “support a greater involvement of people living with HIV at all ... levels ... and to ... stimulate the creation of supportive, legal and social environments”. )

The GIPA Principle aims to ensure people living with HIV and AIDS are the backbone and key contributors to program development, policy-making and implementation and that this involvement is meaningful rather than tokenistic. This principle seeks to highlight the rights and responsibilities of those living with HIV and AIDS including the right to self-determination and the ability to play an active role in decision-making processes that impact their lives. Despite the widespread acceptance and global approval of the GIPA Principle, there is still much work to be done in order to more fully immerse this approach into various sectors including international student research on HIV and AIDS. 

While the benefits of applying the GIPA Principle are evident, there are often many challenges which stand in the way of successful implementation/involvement of people living with HIV including HIV-related stigma, inexperience with research, distrust of researchers, and that involvement in research may not be prioritized compared to other components in life (social, health, family, etc.) (2) Within the context of academic, social research, community-based (participatory) research (CBR) has emerged and solidified itself as a methodological process for conducting research in a way that positions itself in opposition to many of the more historically conventional approaches. CBR not only emphasizes the involvement and collaboration of community members at all stages of research (from project design and development to data collection and analysis to knowledge dissemination and translation) but rather understands meaningful community involvement as imperative and integral to the research process; in essence, meaningful community involvement is non-negotiable. 

Theoretically and depending on the goals and objectives of a research project, CBR represents an almost utopian approach to research which moves away from some of the more historically troubling aspects associated with some research practices. In practice however, CBR is far from perfect and – like the GIPA Principle – faces barriers in practice. The insider-outsider dilemma is often sited as a consistently challenging issue for CBR as is the general distrust that communities often/may have towards researchers. (3) 

My own university experiences with international research on HIV prevention serve as a case study to demonstrate not only the invisibility of the GIPA Principle and CBR in practice but the near complete absence of them. Many Western universities not only offer but promote student involvement in exchange or abroad programs which provide these students with infinite opportunities to expand their minds, experience different socio-cultural perspectives, increase their chances of accessing additional opportunities and importantly, aggrandize their CVs. This was my experience in both my undergraduate and graduate degrees at two academic institutions in Canada; this was also the experience of many of my university peers. 

While I felt I had learned many valuable lessons on my first excursion to Namibia during my undergraduate degree, in hindsight, it is evident that many more lessons remained unexamined. While I made the effort to think more critically about my social and global location in the work I was participating in, this critical thinking did not permeate my thought process in a way that drastically impacted my actions as I still actively chose to pursue a graduate degree which included traveling back to Namibia to conduct research. 

While I take full responsibility for my actions and choices within both my undergraduate and graduate degrees, I think it is also important to recognize that I was operating within a system which very much facilitated my goals of engaging in international work yet simultaneously did not provide adequate training in order to do this work critically, ethically or meaningfully.

As one would expect, my initial experience of travelling overseas to conduct “research” in Namibia created a slew of subsequent opportunities. Even though several years have passed since both my excursions to Namibia, I am still reaping the benefits of them via conference presentations and publications. Conversely, I doubt very much that the organizations and participants I worked with are fairing as well.

(1) I travelled to Namibia a second time in 2009-2010 to conduct my MA field research. This time, I travelled to Walvis Bay, an area in Namibia that experiences high levels of mobility via two transnational highways and the country’s only deep-water port where international boats can dock. In addition to high levels of mobility, Walvis Bay also experiences rates of HIV around 10-15% higher than the national prevalence rate (25-30%); it was for this reason that I chose to conduct my research in this town.

(2)Travers, R., Wilson, M.G., Flicker, S., Guta, A., Bereket, T., McKay, C., van der Meulen, A., Cleverly, S., Dickie, M., Globerman, J., & Rourke, S.B. (2008). The greater involvement of people living with AIDS principle: Theory versus practice in Ontario’s HIV/AIDS community-based research sector. AIDS Care. 20: 615-624. 

(3)Fockler, L.A. (2010). Community researchers’ experiences with community-based research. (Unpublished master’s thesis). McMaster University: Hamilton.

Terrence Higgins Trust, generally considered the UK's leading HIV and AIDS organization, and the largest in Europe, is promoting treatment as prevention, including for gay men, on its new “It Starts With Me” campaign.

"England", it says, “can halt HIV within a generation”.  The campaign is the largest scale by THT to date, running until Spring 2015. Read their press release here. 

Cary James, Head of Health Improvement Programmes at Terrence Higgins Trust says “While a cure or vaccine for HIV remains stubbornly out of reach, what many gay men don’t realise is that medical advances mean it is now within our community’s grasp to stop the virus in its tracks. By getting as many people with HIV as possible tested and on effective treatment, we should see new infection rates fall rapidly

Says the campaign website “We are at the start of a new era in stopping the spread of HIV. We know that the combination of regular testing, HIV treatment and condom use is the key to success.

You can be part of something that changes HIV history. You are the key to stopping HIV in your own life and in the community.”

This kind of strategy marks a transition from what was commonly called poz prevention  - a concept that essentially suggested that HIVers maintaining good sexual and emotional health were better placed to make sound decisions and in doing so, help reduce new infections – to a more direct approach which stresses the benefits of treating HIV to both improve health and reduce viral load, and thus make transmission much less likely.

The campaign makes no specific mention of when to start treatment, although treatment as prevention advocates routinely suggest the earlier the better, not only as a prevention technique, but primarily because the weight of evidence now suggests it produces better health outcomes for the HIVer.

Current UK guidelines recommend treatment for all individuals with CD4 counts below 350, but if a patient with a CD4 cell count above 350 wishes to start treatment, this decision should be respected and treatment be started.

On the issue of infectivity, gay mens' sexual health sites, in the absence of hard data relating to MSM, are currently all over the map. THT says what most experts believe, that “Someone on treatment has an extremely low risk of passing on HIV if their viral load has been undetectable for six month and they are free from sexually transmitted infections. Unlike other sites, there is thankfully no talk here about that perennial red herring, virus in the semen, which tends to be found only in “trivial” amounts according to leading researcher Myron Cohen.

Using the slogan “We Can Stop HIV” the THT campaign is also interesting for drawing on issues of community solidarity and GIPA. Not that this hasn’t been employed before, but more traditional poz prevention campaigns like HIV Stops With Me worried some critics with the perception that they sent mixed messages about personal and shared responsibility. The THT campaign seems to avoid that trap.

One "off" note: the THT website includes the “official” recommendation that all gay and bisexual men test at least once a year. It's arguable that for sexually active men with multiple partners that isn’t nearly enough. Vancouver’s Health Initiative for Men (HIM) for instance says “guys who are more at risk should test every three months.”  We concur with the latter recommendations.

In Canada, only B.C. has adopted treatment as prevention strategies  in the form of test and treat and is enjoying some success in reducing new infections as are other jurisdictions such as New York, San Francisco and Washington, D.C. The issue of the efficacy of TasP for MSM is a controversial area, though, as it has been difficult to reduce incidence in that population.  Dr Julio Montaner, the leading proponent of TasP maintains the issue is not whether TasP works in MSM but how much.

Toronto, Canada – A Tanzanian youth, with links to a Toronto-based charitable organisation, was today announced as having created the winning logo design for AIDS 2014 - the 20th International AIDS Conference – being held in Melbourne, Australia in July 2014. This follows a global competition for youth aged between 10 and 30 years old launched by the International AIDS Society. 

Yohana Haule (21) is a young artist who has been working with the organisation Africa’s Children-Africa’s Future (AC-AF) since October 2011 through their office in Dar es Salaam. AC-AF first met Yohana at his secondary school graduation. Current Executive Director, Dave Christie and founder of AC-AF, Gita Jaffe, were attending as guests of the school and another youth in their programming. Drawn to Yohana’s talent, he would become the first recipient of the AC-AF Youth Leadership Award. The award looks to strengthen the youths’ skills to develop promising talent into concrete actions that can help the youth achieve their dreams. Since then, he has become the resident artist for the organisation, producing artwork used in programming resources for children and in awareness materials currently being used in Canada.

As Christie explains, “This is an incredible achievement for a young man from Dar es Salaam who, like many youth in Tanzania, has faced many hardships to get to where he is today. When we first met Yohana, we were not only struck by his talent, but by the messages that he was portraying through his art. One of the first images he showed to us was a depiction of the roles women play in Tanzania – both in the strength they bring to the country but the burdens they also face. In Sub-Saharan Africa, the burden on women in the AIDS epidemic is particularly harsh, and here was a young man willing to confront some of those issues.”

Toronto has strong links to the International AIDS Conference having hosted the 16th conference in 2006. As a legacy to that conference, the Global AIDS Initiative was established by the City of Toronto, to fund programming concerning HIV and AIDS undertaken by organisations working in sub-Saharan Africa. For the last two years, AC-AF has been part of the coalition of organisations utilising these funds for its work in Tanzania with children and youth. As a result of the budget passed in January at City Hall, this funding will end in August 2013. Although the financial legacy of AIDS 2006 is coming to an end, the work that the City of Toronto has enabled AC-AF to undertake, including with Yohana, will ensure that the contribution of the people of Toronto will have a lasting impact on AIDS 2014.

For AC-AF, this provides a moment of pride in the accomplishments of the youth they work with. At the heart of their programmes and ethos is a continual focus on the potential of children and youth. As Christie explains, “Our programming does not look to just help children; it is aimed at ensuring children and youth help themselves, both now and in the future. They need encouragement to increase their independence, ensuring that they can support themselves, their families and their community, while fulfilling their dreams. Yohana exemplifies this. Although we are able to provide him with some of the initial opportunities, it is ultimately his effort and talent that has brought him this recognition by the International AIDS Society.”

Yohana will continue to work with AC-AF before travelling to Australia in July 2014 to be officially thanked at the conference for his design. This will be the first time that he has travelled outside of Tanzania.

For more information about Africa’s Children-Africa’s Future (AC-AF) visit: www.ac.af.com.

For more information about the AIDS 2014 conference visit: www.aids2014.org.

This report by Gus Cairns first appeared on aidsmap.com here. 

The US National Institute of Allergy and Infectious Diseases (NIAID) has announced that it is discontinuing the HVTN 505 HIV vaccine trial. This trial, which started in July 2009, has involved 2,504 gay and transgender volunteers in 19 US cities. Since the successful conclusion of the RV144 vaccine trial in September 2009, HVTN 505, as a randomised, placebo-controlled phase IIb trial, has been the only ongoing HIV vaccine trial large enough to be a true test of vaccine efficacy.

NIAID stopped administering injections when the trial‘s independent data and safety monitoring board (DSMB) found during a scheduled interim review that there was no sign that the vaccine regimen was preventing HIV infection, nor any sign that it was reducing viral load among vaccine recipients who became infected with HIV.

The DSMB found that there were actually more HIV infections in volunteers receiving vaccine than placebo, but it is important to emphasise that this difference was not statistically significant and may have been due to chance. Statistically speaking, the vaccine had zero efficacy.

The HVTN 505 study was testing an investigational ‘prime-boost’ vaccine regimen developed by NIAID’s Vaccine Research Center. It involved a series of four injections. The first two, at the start of the study and four weeks later, consisted of a length of DNA – artificial genetic material – that ‘coded’ for proteins found on the surface and inside the HIV virus. The idea was to sensitise the immune system to the specific HIV genetic sequences.

The third injection, at eight weeks, involved a vector. This means the same HIV genetic material was wrapped inside the shell of a different virus, an adenovirus, one of the types that cause common colds. In this case the viral shell was altered so that it could not cause illness. The idea of a vector is that it causes a ‘fake infection’: the viruses can carry the genetic material through the cellular membrane and into the interior of immune-system cells. The two investigational vaccines tested in HVTN 505 cannot cause HIV infection because neither contains live or weakened versions of HIV.

The reason behind a prime-boost design is that it is thought to be the best safe way to stimulate both branches of the adaptive immune system: antibodies, which stop viruses getting into cells in the first place, and CD8 cells or cytotoxic T-lymphocytes (CTLs), which kill off virus-infected cells. Researchers hoped that if a prime-boost vaccine were successful, it might prevent infection altogether in the majority of people, but in the minority who were still infected, it might kill off enough virus-infected cells to permanently contain HIV replication and produce a consistently low HIV viral load.

The fourth injection, at 24 weeks, involved an injection of the viral vector alone, without any HIV genetic material. This was to gauge the level of immune response to the adenovirus shell rather than to the HIV material it contained. This is important because in one of the previous vaccine efficacy trials, the STEP study, the vaccine actually made people with high levels of pre-existing immunity to the adenovirus vector more, rather than less, vulnerable to HIV. In the case of HVTN 505, volunteers were required to have no pre-existing immunity to ad5, the adenovirus vector used.

In its April 22 interim review, the DSMB looked at volunteers who were diagnosed with HIV infection after having been in the study a minimum of 28 weeks and found that 27 HIV infections had occurred among the vaccine recipients and 21 among placebo vaccine recipients. Twenty-eight weeks was chosen because by this time the vaccine, if it worked, would have stimulated a sufficiently strong protective immune response. Including volunteers who had become infected less than 28 weeks after enrolment, there were 41 cases of HIV infection in volunteers receiving vaccine regimen and 30 cases in those receiving placebo.

Additionally, the DSMB found that viral load among the 30 volunteers who acquired HIV infection at least 28 weeks after entering the study, and who had been followed for at least 20 weeks after diagnosis, was no lower in vaccine than in placebo recipients. Study volunteers are being asked to report to their specific clinic sites over the next few weeks to find out whether they received the investigational vaccines or placebo. Individuals who became HIV-infected during the trial were referred to local services for appropriate medical care and treatment.

The HVTN 505 study will continue follow-up with study participants to further evaluate the trial data, and especially to see if the greater number of vaccine recipients who were infected is in any way significant.

For more information about the HVTN 505 study, please see the updated Questions and Answers page here.

To learn about what other vaccine trials are currently taking place, visit IAVI’s vaccine database here or AVAC’s summary here.