Attendees at the 18th International AIDS conference held in Vienna in July 2010 felt a tremor of hope when Prof. Salim Abdool Karim received a standing ovation following the announcement that a vaginal gel containing the anti-HIV drug tenofovir could reduce the risk of HIV infection by 39%. The groundbreaking results came out of the CAPRISA clinical trial conducted amongst 900 women in rural Vulindela district (KwaZulu-Natal) and urban Durban, South Africa. Euphoria followed in the audience, online and later in the printed media. After 30 years of limited success, the field of HIV prevention could potentially add a new powerful tool to circumcision, condoms, and the prevention of mother to child transmission. Most remarkably, that tool is in women’s hands and the story could unfold with even more good news if it weren't for a small setback: funding the next clinical studies.
2010 will be remembered as the year when the results of the CAPRISA trial that followed those of the Thai vaccine trial in 2009 reshaped the biomedical approach to HIV prevention. These are also the years in which HIV prevention has been both at a turning point and in turmoil with repeated assaults on populations at risk, notably in countries with high HIV prevalence and an economic crisis rewriting the funding agenda. Further trials of new prevention technologies (such as Pre-Exposure Prophylaxis) and a recognition that treatment can contribute to prevention, all happening against a background of economic recession are creating confusion and dilemmas amongst advocates, funders and beneficiaries as to what should be done next to successfully contain and quell the HIV epidemic.
The tenofovir-based microbicide tested in the CAPRISA trial is an obvious way forward but it is widely acknowledged that more trials are needed to confirm the study’s results and to ensure that the effect observed in this one trial can be confirmed in different settings and countries and to assess easier ways to use the product. If confirmed, this microbicide would be the first women-controlled HIV prevention tool.
But this is where promising clinical science has hit a snag. A number of trials have been in the planning pipeline for some time already, even before the results of the CAPRISA study were known. All have the potential to provide critical information about the product acceptability, use and effectiveness, information that is necessary to license the product. But less than 40% of the money needed (about USD 150 million) to conduct these trials has been committed or pledged by donors.
This is neither satisfactory nor acceptable. Insufficient funding could not only limit and slow down the development of the product, but it also leaves scientific decisions at the mercy of economics rather than hard scientific evidences. And haven’t we been told enough that scientific and clinical research should be evidences-based?
Whilst INGOs, donors, politicians, and philanthropists are being cajoled into supporting these much needed studies with money that is mostly ours, more than 7,000 new infections are occurring every day, a large majority of them in Sub-Saharan Africa, disproportionately affecting women whose urgent need for an HIV prevention tool they can control could be fulfilled with an efficient tenofovir-based microbicide.
In addition, the reticence towards identifying and committing funds to cover the necessary studies places scientists in a position where they have to support one study rather than another because funding is limited and investments need to be prioritised in times of global recession and a massive bank bailout. The message is clear: there is no money for HIV, only for bankers, as only they can help the economic recovery.
The irony is that a small investment in the tenofovir trials could make a huge and rapid economic difference. Many scientists, NGOs and activists (with some exceptions) have bought into the argument that there is not enough money to adequately address the HIV epidemic and are prepared to compromise on the science fearing that raising concerns or calling for more support may jeopardise the little money available.
As a scientist, activist, advocate, and an individual directly affected by the HIV epidemic, I can’t accept giving up or caving in to the general apathy, resignation and funder’s whim. The HIV epidemic can be dramatically curbed within a few years if we decide to give priority to prevention and match funding and policy accordingly. Letting ourselves be led by economic interests or twisting science’s arm will not buy us out of the epidemic.
The views expressed in this article are the author’s and do not necessarily reflect the views of his employer or of the organisations he works for.