Name of person responsible /Facilitator: Esther Nakkazi
Café Name/Title: HIV Prevention
- Freddie Mukasa Kibengo; MRC/UVRI&LSHTM UGANDA RESEARCH UNIT
- VINCENT BASAJJA: MRC/UVRI&LSHTM UGANDA RESEARCH UNIT
- SYLVIA KUSEMERERWA; MRC/UVRI&LSHTM UGANDA RESEARCH UNIT
Date Cafe held: June 20, 2018
Café objectives (The learning objectives should be tailored for each specific café)
- To enlighten more about Prep and its conditionalities associated with it.
- To understand other prevention methods like Pep and new technologies being developed by researchers like Multi- Purpose technologies.
HIGHLIGHTS, KEY QUESTIONS /THEMES
Dr. Freddie Mukasa Kibengo, Scientist said a brief introduction about Medical Research
Center. MRC is a collaboration between Uganda and UK governments. MRC UK started 100years ago, so the collaboration was to help prevent HIV in Uganda. Since 1989, research is centered on HIV, but we have expanded to noncommunicable diseases and infectious diseases. Currently doing research in HIV preventive work at Entebbe, Masaka, Mengo, and Kyamulibwa. Under these categories of preventive tools include proven ones; HIV became known to the World from Uganda; from Kasesero in Rakai.
Dr. Lwebuga presented the ‘slim disease ’ as associated with loss of weight and it was since coined from there. On average of 3years, victims are well, signifying that the body is containing the virus however 4 -5 years the virus breaks down the system. After understanding that HIV was sexually transmitted and not witch craft myth, the President rolled out ABC that means Abstinence Be faithful Condom use, to minimize sexual transmission of HIV. He classified this under behavioral methods of prevention. Scientists know that behavioral methods aren’t effective and sustainable. For instance, there is behavioral change after alcohol intake; some people gain boldness to do what they couldn’t do.
The research focused on biomedical preventive methods. HIV was complex; changing concepts since it changes very fast and has different subtypes or recombinants/clades of HIV. In 1999. JCRC performed the first HIV test.
“Some of the proven methods include voluntary Medical Male Circumcision, not cultural circumcision. Its clinical trial was conducted in Rakai, Orange State in South Africa and Kisumu in Kenya and proved 60% effective on protection. However, the government adopted the policy but hasn’t moved with the speed expected.” According to the Ministry of Health report in March, only 47% had undertaken VMMC.
He adds a policy on Prep was put in place and made available in government health facilities to aim at high-risk population like female sex workers and discordant couples. Truvada is given to prevent HIV infection nonetheless a large percentage of people find it difficult to take drugs when they aren’t sick. Pep is given especially to the first group of medical workers who are easily exposed or pricked by the same instruments like needles used on infected persons. Also, Pep is given to raped victims depending on their willingness to comply to give conditions that include accepting to test HIV with the person that led you to exposure. Also counseling them after testing and refer them to start on ART.
In 2015, studies revealed an HIV infected person on treatment, has their viral load suppressed after testing and fewer chances of transmitting the virus. Hence treatment acts as a preventive tool.
Denmark registered no new infections, up to last December because treatment presented 96% prevention. Last year, our guidelines changed to testing everyone who is HIV positive.
There are therapeutic vaccines that help to stop the progression of the virus in an infected person. There is an injectable prep called cabotegravir that is given once a month or every three months.
Preventive methods have slowed down disease progression. According to WHO, 80,000 people get HIV infected annually. There is no silver bullet for HIV but with a vaccine, it is cost effective; one shot covers a long period of time as opposed to daily intake. There are signs that vaccines work for instance small pox infectious disease was estimated to have killed over 47million people in 100 years but was eliminated. This inspired us and is possible to eliminate HIV if we added it on the arsenal of technology that we have.
Thai study proved the first HIV vaccine possible and effective at 30%, associated with subtype B. East Africa has more of Subtype A than D. Masaka has D more as opposed to A. Uhambo studies aimed at 5400 participants, currently enrolled 80% and results expected in 2020.
Using slightly different technology, scientists came up with the mosaic concept; bits of the clades/subtypes are combined to induce antibodies within HIV infected people so that they are able to neutralize all available types of HIV.
Antibody mediated prevention, new technology under research for protocol C, largest set up on HIV, started enrolling in 2004 in open study B, discordant couples were recruited and didn’t have Prep. Some of the preventive methods used included condoms and counseling. When one got infected, they would enroll in a new study.
Three years down the road, the broadly neutralizing antibodies are produced to fight evading organisms. Like the anti-tetanus serum, scientists will produce antibodies and introduce them to infected persons so that they can fight since there is a delay in the body making them. One type shown is VRCO1 was tested in studies at South Africa among men having sex with men.
PREPVACC is a Phase II trial involving 1668 people focusing on testing the vaccine using prep in the background, 600 participants in Masaka and others are in other districts. The GREAT trial concerned with the mosaic concept will occur in Maska next year.
Dr. SLYVIA KUSEMERERWA started with a question on how many contraceptives are available for women on the market? IUDs, injectables, pills, implants, tying tubes, diaphragm, coils, and others.
Women are more scared of pregnancies than HIV. Microbicides are a form of Prep, that help kill the organisms at the point of acquiring it from sexual transmission. The first microbicide failed after chemicals were put together. In 2010, tenofovir (microbicide with ARVs) proved 39% effective in South Africa at a big trial known as Virginal and Oral Interventions to Control the Epidemic trial (VOICE) targeting 15 – 49 years, women didn’t apply the jerry and pills because they were more interested in the stipend.
Also, Follow-on African Consortium for Tenofovir Studies (FACTS) used tenofovir but failed; while using the jerry before and after sex. In 2012, dapivirine placed in a virginal ring was done at Makerere University John Hopkins University. In 2 years’ trial, it could prevent women from HIV in the clinical trial held. They used it properly it yielded to 65%among women and the general was 30%
In February 2016, during feasibility studies, open label extension studies showed efficacy and improved adherence at 54% from 31% among young women who had accessed the ring.
“We still need to give people a chance to choose from a range of services. Thus, we are working on a new phenomenon; multiple purpose technology that will perform trio duties at once encompassed in a ring or tablet. For instance, it will prevent HIV, STI, and pregnancy at the same time. Apparently, the ring was developed for 30 days but plans to make them 60 days inclusive with an ARV and contraceptive,” She said.
Vincent Basajja, Community Liaison Officer:
He says that our attention should focus on working together to promote what we have to the best of our knowledge as opposed to what we don’t have. There should be an adjustment with other interventions like community sensitization, use a wide spectrum of media to inform the public as we wait for HIV vaccines.
Questions from the Media attending the cafe:
Where are the MPTs going to be carried out? Also, so much research is going on, won’t it overlap the process?
It isn’t yet established where at the moment. There is an international partnership of microbicides in the USA still in Phase 1 on MPT. However, scientists have listened and solved multi problems to provide convenience, fit in different interests and likes. We want to provide a wide range of choices to meet different preferences.
Do you think we still need other methods?
We need ABC, proven methods and more. Despite great work, we need treatment that cures malaria but that doesn’t mean we have been able to eliminate malaria. Currently, our focus is looking for an effective vaccine
What makes VMMC different from the Islamic circumcision?
This is a scientific proven HIV strategy; research was done through clinical trials. It is a medical procedure done in a safe environment, aimed at promoting and helping people make informed choices. It is done by medically trained personnel who understand the foreskin very well since the virus hides in it.
In many instances, other forms of circumcision either do it partially or shaft the penis that leads to scars and affects one’s sexual performance. It is associated with infection hence tools used are sterilized and the government starts at 12 years of age. Besides HIV prevention, other reasons for circumcision include for prevention of HPV, cancer of the cervix, STD and cleanliness
There is a new practice called ‘stealthing’ among young boys who pull off the condom during sex with beautiful girls especially in Kalangala, Rakai, and Masaka. What is your comment about that?
We encourage people to have an HIV test before sex. They should be careful with the choice of partners and play it safe. Some are involved in such behaviors with different ill intentions.
Like discordant couples are there people with natural immunity that fight off the virus?
There are different kinds of people, for instance, a Human Immune Virus attaches to the body cell in two places; the CDR receptor (fighter of HIV) and CCR receptor. However, people without CCR gene, don’t get HIV and normally these groups aren’t among black people because the cells(CCR) help prevent malaria.
Elite controllers get infected on a slow progression. The virus doesn’t multiply as expected; the CD4 doesn’t fall beyond 1000 and has less than 2000 viruses albeit it can still transmit. Subtype A progresses slower than D.
Are you part of the panty condom research in an effort to prevent HIV?
We are not part of research in panty condom due to a wider scope of HIV prevention but we wish them a success if there is evidence backing them on the matter.
How long does it take to manifest that I have a virus after a nights’ stand?
HIV enters the cells and goes into the lymph nodes thereafter the rest of the body. It is vital for one to run to a facility in the first 30 minutes, or in the 2 hours and least in 72 hours to be given Pep so as to prevent the establishment of infection in the cells and increase the effectiveness of the drug. There is a limit as to when we give Pep. HIV can’t survive without cells, it keeps multiplying with the cell. We do an HIV test to know your status thereafter know if one is at very high risk. If found HIV positive, one is subjected to Anti-Retroviral Therapy.
Where can one find PEP?
All Health Center IIs and government hospitals offer PEP but have terms and conditions set to analyze who is on merit to deserve the service, for instance, ones’ acceptance to have an HIV test and then if possible bring the person who exposed you for HIV testing and counseling. You need to be followed up for assessment on adherence and efficacy. However, if you have it more than once for self-defense cases, it may become drug resistant. It has its own side effects, so we do assess all that.