Every year a special event brings together leaders in the public and private sectors, top academics, researchers and institutions and associations, this is the annual South African AIDS Conference. AIDS Conferences usually offer a rich diversity of themes, from clinical aspects of HIV and AIDS to best models and practices in addressing the epidemic. The fourth SA AIDS Conference certainly lived up to this legacy. Initiated under the theme of “Scaling up for Success” the AIDS Conference saw a surge of overwhelming support from the delegates who took part in the six tracks presented as set by the scientific and organizing committee. Here are the main findings presented as summaries of presentations by the Track Rapporteurs and members of the Scientific Committee.

Track 1: Basic Sciences.
Two major themes were highlighted from the studies in the track Basic Science: Firstly, renewed emphasis was placed on the identification of correlates of HIV control and protection. Secondly, the research community has begun to focus research efforts on two special subsets of infected individuals: elite controllers and individuals in the acute phase of infection. 

Elite Controllers
Dr Bruce Walker (Ragon Institute of MGH, MIT and Harvard) presented a talk in the plenary session entitled: ‘Elite Control of HIV: Implications for Treatment and Vaccines’. In his talk Walker suggested that elite controllers might be able to act as a successful model for T cell vaccination. He reported that the CD8 T cell response is responsible for inducing the less fit virus found in elite controllers. Walker emphasized that it is the interplay between adaptive immunity (CTL neutralization), host genetics (HLA) and Viral genetics (fitness) that is responsible for determining infection outcome. Data was presented showing that CTL are shaping HIV evolution, and that strongly targeted

epitopes are being lost at the population level. More information on his efforts and those of his fellow researchers can be found at www.elitecontrollers.org.

Early infection:
Andile Nofemela (UCT) presented an excellent talk entitled ‘Characterisation of transmitted HIV-1 ENV Variants from Mbeya, Tanzania’) where he highlighted the observation that 73% of new infections are caused by infection of a single virus. This ‘bottle-neck’ effect supports the findings of others that also show that the viral populations in the majority of newly infected individuals are largely homogenous. Gama Bandawe (UCT) reported that shorter and less glycosylated V1 loops were associated with enhanced entry efficiency of certain isolates. Many groups reported on work carried out investigating the immune response in the acute phase and reported on a common theme that early immunological events are complex, and that some may predict viral set-point and disease progression.  It is important to remember that a number of factors may play a role in the control of HIV including: CD4 T cell immunity, CD8 T cell immunity, Innate immunity, Neutralizing antibodies, viral genetics and host genetics.

Antibodies and innate immunity:
Lynn Morris (NICD) presented a great talk on ‘Limited Neutralizing Antibody Specificities Drive neutralization escape in early HIV-1subtype C infection’ which demonstrated that the immune system can make antibodies that have an effect on viral load. There was however a paucity of presentations and scientific discussion on the role of antibodies and the innate arm of the immune response. 

In summary:
The key points from this track of the conference are: elite controllers may hold the key to understanding HIV immune control; in acute infection immune system damage occurs early and predicts the course of disease; further research on the role of antibodies and innate immunity in immune control is required.
Acknowledgements: Chairs: Thumbi N’dungu, Jo-Ann Passmore, Rosemary Musonda
Rapporteur: Victoria Kasprowicz and team

Track 2: Clinical Sciences
Antiretroviral treatment 
There were a number of presentations that looked at successes of antiretroviral therapy (ART) programmes including Alison Riddick’s study from rural Hlabisa. This study showed a reduction in adult medical admissions from 2002 to 2007 following the introduction of ART with no deaths recorded secondary to ART toxicity. The International epidemiologic Databases to Evaluate AIDS (IeDEA) cohort, which included 6078 children from seven hospitals in Johannesburg, Cape Town and Durban, showed good survival, clinical, immunological and virological outcomes among children initiated on ART. Of concern was the inequity of access with 20% of South African children being treated at these seven urban sites. Reassuring data from Khayelitsha showed that women who switched from Efavirenz to Nevirapine at a CD4 cell count greater than 250cells/mm3 did not have more adverse events than those who initiated Nevirapine at a CD4 cell count less than 250cells/mm3. The numbers in the high CD4 cell count group however were too small to show statistical significance, and this should thus be done cautiously if required.

Systems
A study done in KwaZulu Natal and Limpopo evaluating the Integrated Management of Childhood Illness (IMCI) showed that while HIV is common in children presenting to primary care facilities and the HIV algorithm performs well in identifying HIV infected children, IMCI trained healthcare workers do not routinely use the algorithm and do not test for HIV regularly among sick children. A presentation from the Africa Centre suggests that HIV exposed infants are less likely to be vaccinated than HIV unexposed infants. It was suggested that maternal HIV is responsible for this. A number of presenters showed the devastating effects of HIV, particularly for younger infants (<6 months of age), through the retardation of early infant growth, increased susceptibility to infections and a higher case fatality rate. It is vital to reduce vertical transmission and identify and treat HIV infected infants early for opportunistic infections and with ART. Data from Chris Hani Baragwanath Hospital highlighted shortcomings in the PMTCT programme with 15.1% of women with positive infants reporting that they tested HIV negative in pregnancy (likely late seroconverters or confusion secondary to the complex coding system) and only 36% of mother-infant pairs received single dose Nevirapine.

Tuberculosis
A file review from the Hlabisa district showed that mortality in patients on ART was doubled in the presence of prevalent or incident tuberculosis. Following improvement of infection control, including basic administrative, environmental and personnel measures, in Tugela Ferry, admissions of XDR and MDR tuberculosis decreased significantly (p=0.02) from 2006 to 2008.Community infection control remained an unaddressed challenge though.  

Opportunistic infections
Preliminary data from Ngwelezane Hospital showed no differences in wound infections between HIV positive and negative patients who had open fractures treated with internal or external fixation. A study from the Africa Centre reported on HIV and HBV co-infection in KZN that showed rates as high as 10%. Of concern was that less than 50% of patients started on Nevirapine had follow-up alanine transaminase monitoring. A review of 23 years of records from hospitals in KwaZulu Natal showed a dramatic increase in incidence of Kaposi’s sarcoma (20 times in males) and an age shift towards a younger population.

New developments
Lesley Scott presented a paper on the use of dried blood spots compared to plasma for viral load analysis. Results also suggested that dried blood spots be utilized to monitor response to ART among patients. With a proposed shift towards decentralizing ART services, this is an important finding.

In summary:
Antiretroviral therapy continues to have a significant impact on morbidity and mortality in both the adult and paediatric HIV epidemic in South Africa. There are operational issues around scale up however which need ongoing monitoring and evaluation. The TB epidemic continues unabated and exerts a major impact on ART scale up and now added surveillance and infectional control to limit multidrug resistance. New point of care diagnostics for diagnosis and monitoring remain areas requiring ongoing research.
Acknowledgements: Chairs: Doug Wilson, Vivian Black, Moses Sinkala
Rapporteur: Claire Von Mollendorf and team

Track 3: Epidemiology, Prevention and Public Health Systems.
Measurement:
Several papers discussed the need for rigorous methods for measuring incidence(rate of new HIV infection). These include laboratory assays to estimate incidence (McWalter), assays from cohort studies (Hargrove), and modeling incidence from antenatal survey data (Dorrington). Johnson presented a mathematical model measuring the effects of different types of sexual risk behaviour on the spread of HIV. He demonstrated that the highest transmission rates were in multiple concurrent heterosexual partnerships (MCP’s). He estimated that reducing unprotected sex in nonspousal relationships could reduce the HIV incidence in South Africa by a third over the next ten years.

Epidemic drivers:
A regional study by Soul City confirmed that multiple concurrent partnerships (MCP’s) are common practice, and HIV risk and MCP messages from communication strategies are not internalized. Zembe found that transactional sex amongst young South African women is seen as normative behaviour, and is associated with alcohol use and intimate partner violence [IPV]. High levels of intimate partner violence were associated with males older than 35 years, with multiple sexual partners, high alcohol intake, and failure to use condoms (Townsend).

Prevention interventions:
The session focused on male circumcision in different settings, including Orange Farm (Taljaard), Kenya (Loolpapit) and the Eastern Cape (Peltzer). Male circumcision is feasible in these settings, acceptable and had a high uptake. The importance of linking the medical intervention with the cultural context of initiation practices was emphasized. In South Africa, service is doctor dependant, although the Orange Farm team approach reduced dependence on doctors. In Kenya other categories of trained health workers performed the surgery. Scaling up in South Africa may require such alternative models of delivery.

PMTCT:
The session described the operational effectiveness of a dual therapy PMTCT regimen, and long term ART as an intervention for PMTCT. Studies demonstrated improved outcomes in cohorts of pregnant women on long-term ART, with reductions of MTCT to 2.7% at Frere Hospital (Bera) and 5.1% in a community based clinic cohort (Fitzgerald). Good quality local trials of the effectiveness and timing of ART in pregnancy to prevent MTCT will provide additional evidence. Although, few studies were presented on postnatal transmission, important data on the low rate of adherence of HIV positive women to early breastfeeding cessation (24 weeks) was presented. Cessation of breastfeeding after 24 weeks may be more feasible, and that further research is needed into prophylactic regimens to protect infants from infection during the breastfeeding period (Goga).

Health systems & program evaluation:
A review of 3 years of antiretroviral therapy at multiple NGO sites, identified factors associated with increased mortality, poor adherence, and loss to follow up. The first six months of treatment had the highest loss to follow up, and adolescents initiating HAART were identified as needing additional support (Fatti). Good patient adherence to antiretroviral therapy was associated with reduced health care costs and investment in interventions to improve adherence and monitoring of adherence is recommended (Nachega). The International Epidemiologic Database to evaluate AIDS (IeDEA), a large cohort study collecting individual patient data in the region, identified a trend for men and children to access treatment late. Sentinel surveillance of patient based data could provide important clinical information in the monitoring of the national ARV programme, (Cornell M). Integration of services, including HIV services with family planning, STI clinics, cervical screening, and TB services, were found to be acceptable to clients and providers, and resulted in increase in uptake of HIV testing and other services. (Menziwa ME, Chabikulu N, Leon N, Bomela N).
Acknowledgements: Chairs: Virginia Zweigenthal, Guy de Bruyn
Rapporteur: Lilian Dudley and team
Contributors: Catherine Slack; Ann Strode; Nicola Barsdorf; Jenny Koen;
Zaynab Essack; Michaela Clayton and Vasu Reddy

Track 4: Social and Economic Sciences, Human Rights and Ethics.
Track 4 examined how social-behavioural, economic, & legal/ human rights factors shape both the epidemic and responses to it. In the track there were a number of key interventions that were continually raised due to the social-cultural and human rights implications. There were also a number of vulnerable & marginalised groups that were focussed on.

Key interventions:
HIV Testing: Three sessions focused on testing where it was noted that uptake of testing is still low & resources are limited. In the main, there was greater acceptance that more than one model is needed. Client initiated testing - needs to be re-tooled and taken to people in innovative ways. It needs to be compressed in a way that doesn’t short-change on consent or confidentiality. The merits of self-testing were noted provided there was adequate support through, for example, telephone counsellors. It was also observed that the health-system may not be ready to manage a routine offer of testing & will have to be strengthened to so.  

Male Circumcision: Two sessions focussed on MC. It was noted that this priority for scale-up will require attention to the consent, counselling and confidentiality (the 3 C’s); that monitoring behaviour & the ability of men to abstain until wound-healing is key part of roll-out; and that providing this service to adolescents will require understanding the legal framework and parental involvement in many instances.

Partner reduction: The need to reduce multiple concurrent partners or MCP came up repeatedly in satellites, plenary and oral sessions. Key issues included the need to proceed to implement & monitor MCP programs in the absence of perfect tools; the need to acknowledge that culture is a highly contested construct and cultural practices can be challenged; that MCP programs will compete with messages from the commercial media and that involving celebrities in de-norming MCP will be important.

Key groups:
Children: A special session on children demonstrated innovative research into the lives of children in the SADC region. It was noted that the full range of children made vulnerable by HIV must be recognised; that a significant number of children remain invisible because they are not registered at birth and remain marginalised from education and support systems; that children living on the streets need far more tailored services and protection; and that children are best assisted by strengthening their families and a key way to do this is through social protection policies. Migrant populations: A dedicated oral session & satellite highlighted the needs and rights of migrant populations. Their relative poverty, lack of services, separation from regular partners and stigma increase both HIV risk and impact for this group.. People Living with HIV: It was noted that far better integration of HIV and sexual/reproductive services is needed for people living with HIV and that policies and programs need a far better focus on discordant couples.

Men who have sex with men: A dedicated satellite looked at the needs and rights of men who have sex with men. It was noted that stigma and in some cases criminalisation of same-sex relationships drive MSM from services, and better surveillance is needed, as well as programs for this group. In terms of prison populations, a dedicated satellite session focussed on their increased risk. It was argued that HIV care, management and prevention in prisons must be better integrated into policy instruments and funding is needed for service-delivery to this vulnerable group. In terms of sex workers, one presentation highlighted how criminalisation of sex work limits their uptake of services, and argued that such work should be decriminalised and a customised package rolled out. Several sessions addressed the needs and rights of research participants in large-scale HIV trials, and the communities from which they are drawn. Research literacy was advanced as a tool to offset power imbalances between investigators and participants and involve communities more authentically in research. A special session was devoted to SADC countries’ implementation of key human rights norms. It was noted that major gains have been made, for example, all 14 countries have a law or national policy that prohibits unfair discrimination against PLHIV. A key concern was that in 4 out of 14 countries there are specific laws making the intentional transmission of HIV a crime, and in 9 out of 14 countries there are laws criminalising same sex relationships, heightening stigma & undermining services. It was noted that such laws contribute to the structural conditions that fuel HIV.
Acknowledgements: Chairs: Catherine Slack, Vasu Reddy, Michaela Clayton.
Rapporteur: Catherine Slack and team 

Track 5: Best Practices and Programs 
The following themes emanated from the Best practices & programmes Track which covered evidence based policy and practice, and models of prevention, treatment, care and support activities in communities, the workplace and the media. 

Education, the Youth and HIV:
J. Grierson et al found that peer networks are not consistent across the population but cluster according to key socio demographic characteristics. More targeted interventions that recognise gender differences & the role of partner violence are needed in peer education programmes (M. Rogan et al.). In an evaluation of adolescent programs, B. Nkala et al. found that although adolescents are aware of the risks of HIV transmission, they were not personalizing it and the repeated pregnancy testing at the clinic was indicative of unprotected sex. Once the adolescents tested HIV positive, they were lost to follow up. There is a substantial gap in tracing adolescents who become infected but have never tested (M. Chagan et al). In high-risk hospital catchment areas, testing strategies for children needed to be conducted in both health facility (OPD, ward) and mobile community settings (N.Chabikulietal). Reporting on the establishment of a male clinic, M. Mgwele et al found it to be the first port of entry for men into the public health system. Critical success factors were in terms of the location, operating hours, staff and the services that were offered. In terms of intergenerational sex, C.Pretorius et al found that a variation in age difference results in persistence of the HIV epidemic. The establishment of more gay-friendly services was also advocated in the “Men and HIV” theme.

Decentralization & Nurse-based services:
There was support for the down referral of patients to primary care level as well as integrated healthcare. However, standardised guidelines were still felt to be lacking (N. Mabaso et al, E. Carolus et al, M. Vintges et al). The issue of nurse prescription and pharmacy support were still a concern. The re-defining of roles of health care workers was one way of addressing the increasing workload and waiting lists (B. Draper). The generally poor or non-existent state of health services in prisons was highlighted (United Nations).

Best Practices and Health Systems:
Innovative strategies were about the use of cell phones for mass messaging (P. Benjamin) and also targeting the youth with online, interactive MTV-like programs using celebrities as role models with HIV messages about prevention & testing (K. Pahl et al). Men were the focus of `One Man Can´ & `You Can Count on Me´ initiatives to facilitate and encourage awareness about HIV/AIDS (C. Colvin et al, R. Becker et al).The need for dedicated HCW programs that offer psychosocial support, encourage HIV testing & TB screening as well as HIV treatment & support if HIV positive, was raised (T. Vazi et al). Mobile clinics aimed at the asymptomatic, males, defaulters, elderly, underserviced areas that not only offer VCT but also screening for chronic disease were promoted (N. Van Schaik et al). Overall, there was a call for health systems to document best practices (R. Eghtessadi et al) and the importance of partnerships for sustainable, measurable & quality programs was highlighted.
Acknowledgements: Chairs: Astrid Dearham, Nigel Rollins
Rapporteur: Astrid Dearham and team
Other contributors: Meg Osler, Maria Sibanyoni

Track 6: Community Exchange Encounters
At the 4th South African AIDS conference there were unprecedented numbers of People living with HIV PLWHIV & HIV activist delegates. Instead of just covering Community Exchange Encounters track, rapporteurs for Track 6 attended almost every session on the programme; as well as evaluating all six tracks from a community, PLWHIV perspective. It was felt that this unprecedented turnout was in keeping with the sentiment that activists must scale up participation in AIDS conferences to ensure that the experiences and needs of HIV-positive communities remain at the epicenter of TB/HIV research projects and programmes.

Financing: HIV is not in recession’.
The current global economic recession has meant a strong backlash due to possible budgeting cutbacks for HIV programmes. The lessons learned from HIV interventions continue to transform organisation and delivery of all health services. HIV treatment must become part of primary healthcare. The Department of Health budget allocation for ARVs through the current HIV/AIDS conditional grant to provinces is at least R1 billion short of the amount initially budgeted to treat 220,000 people this year. Therefore a great need exists to work collectively to achieve these ambitious targets and ensure that sufficient resources are mobilised and properly managed. In November 2008 the National Department of Health instituted an ARV moratorium in the Free State province. There are already similar shortages manifesting in other provinces across South Africa, including Gauteng South Africa’s richest province.

Task-Shifting:
MSF and RHRU presented compelling data that task shifting is essential due to the overburdened state of clinics and chronic nature of ART management.The presented ways for task shifting being implemented are unfair to community healthcare workers, nurses and doctors. Current laws and regulations that separate the roles of community healthcare workers nurses and doctors must change. Government must implement policy on task-shifting based on extensive consultation with healthcare workers, health systems experts and community activists to address the lasting inequalities which continue to see health resources and responsibilities concentrated in hospitals, urban areas, and the hands of doctors. 

ARV Treatment
We need more “bang for our bucks”: Nachega’s Excellent Adherence to ART Predicts Lower Direct Health Care Costs for HIV-Infected Adults: poor ART adherence is a major predictor of virologic failure, resistance, disease progression and death. There is a need for communities to access ARVs that do not cause drug toxicity but which are more expensive. Dr Francois Venter presented an interesting plenary, “Key Drugs for the Next Five Years” and made the point that toxicity drives ARV regimen switches, particularly resulting from D4T. Tenofovir is good replacement for D4T but is unaffordable to the majority at current prices. Communities must embark on a larger campaign for access to essential medicines, including other exciting new ARVs e.g. Etravirine, Raltigravir and Tipranavir.

Opportunistic Infections: TB
A plenary presented by Robin Wood on HIV/TB control indicated that despite reasonably functioning TB programs, TB rates continue to rise to unprecedented numbers in HIV hyperendemic areas There is still not enough progress in health systems or scientific developments to combat HIV associated TB. TAC, TB/HIV Care and other organisations are mobilizing for better, more integrated TB/HIV programs and improved treatments; but government must join in this struggle beyond mere rhetoric. There is a great need for vastly increased resources in terms of biomedical, financial and human in order to integrate TB and HIV treatment. 

Opportunistic Infections: Cervical Cancer
Development in Progress: A Policy Analysis of the National Cervical Cancer Screening Policy Factoring in HIV/AIDS {Bomela} described strong community support for the integration of cervical cancer programmes into HIV care and highlighted that financial resources are lacking, women are not educated about how and where to access cervical screening services and nurses are not adequately trained to implement guidelines. This advocacy seeks to mobilize women in communities to increase screening and is advocating for public access to HPV vaccines.

Youth
HIV awareness programmes in schools are poorly funded. There is a strong need for peer-to-peer programmes in HIV education and a greater emphasis on skills development. A satellite session on Progress Towards Achieving NSP Targets for Children exposed shortcomings of the Department of Health and Department of Education. There are no specific policies on teenage pregnancy or circumcision. The Department of Education has recommitted itself to the ABC strategy yet condoms are not made available in schools thus failing learners. Communities must mobilise to ensure that condoms and accurate information on their use are readily available to sexually active youth.

Conclusion
There may be a mistaken perception that the battle for healthcare in South Africa has been won but this perception is incorrect. We must ‘improve access and quality of services where it is needed most if we are to achieve the NSP goals But… growing financial constraints; necessity of task-shifting, and rising rates of TB prove that The STRUGGLE CONTINUES! NOW is the time for communities to refocus and mobilise around these critical issues!Acknowldegements: Chairs: Victor Lakay, Peter Mathebula, Pauline Sambo.
Rapporteur: Victor Lakay and team
Content Submitted by Professor Linda-Gail Bekker on behalf of the AIDS Conference Scientific Committee.                                                               back to top >>