The global response to AIDS is in trouble. There are yawning gaps in funding for proven prevention and treatment and a crisis in political will for continued support of AIDS programs. Those of us working on the AIDS epidemic face skepticism about whether disease-specific funding for AIDS is cost effective. Those of us working on AIDS vaccines face skepticism about whether limited funds for AIDS should include funding for AIDS prevention research. This May 18th -- HIV Vaccine Awareness Day -- we have to meet this skepticism with honesty about what we know and clarity about the cause for hope that exists today in a way that it never has before.
This year, for the first time, we mark the Day with hope based on evidence from a trial in humans that shows that an AIDS vaccine is possible. This hope flows from the announcement, in September last year, of a modest level of protection among participants in the Thai Prime-Boost trial who received the vaccine.
The results were complex, in part, because the difference in numbers of HIV infections in vaccine and placebo recipients in the trial is small. AVAC and others have spent the past eight months working to explain the uncertainty within these results and the need for follow-up research.
We will keep on explaining the complexities, but it is potentially disastrous if all that advocates, potential donors and future HIV vaccine trial volunteers and researchers think about the trial is that it gave a murky result, that it "failed" (to quote a recent New York Times article) or that it left us no closer to an AIDS vaccine than we had been before.
So on this HIV Vaccine Awareness Day, our most important message is that the Thai Prime-Boost trial changed the game for AIDS vaccines. It offered evidence that scientists have been chasing for more than twenty years. The result itself was surprising, so, perhaps, it is no surprise that it prompted skepticism from some researchers, advocates and reporters.
The vaccine combination tested in the trial isn't licensable, and the results don't provide a clear road map for the way forward in vaccine research. But researchers would be foolish to ignore the clues offered by this trial. There are many complexities, and years of research that lie ahead of us in the search for an AIDS vaccine, but today we say simply and clearly:
- An AIDS vaccine is possible.
- An AIDS vaccine is as urgently needed as it has ever been.
- There is reason to hope, and to back up that hope with strategic choices about science and the funding, political will and community engagement needed to continue the search.
The Thai trial result starts a new chapter for AIDS vaccine research. We must now do three things simultaneously:
- Work aggressively to see what information can be gleaned from further analysis of the biological samples from more than 16,000 Thai men and women who participated in the trial and hope that we might learn why this vaccine combination worked at all.
- Build on this result, testing similar vaccines and combinations in different populations.
- Ensure that we diversify the scientific portfolio to continue to develop and test entirely different approaches.
As we turn this page in AIDS vaccine research, we also face the harsh economic realities of the fight against AIDS. There are limited resources to cover an ever-expanding list of priorities. US government funding for AIDS treatment and care programs has not increased proportionally with need, and many developing countries are facing shortfalls, waiting lists and wrenching decisions about who should start, or remain on, antiretroviral drugs.
Against this backdrop, there is a risk of reemergence of false dichotomies that pit prevention against treatment, or proven prevention against research into AIDS vaccines and other new HIV prevention strategies.
In light of current realities -- economic and scientific -- does it really make sense to continue research for a vaccine and other interventions that may be years or even decades away?
There is no question that more resources are needed for existing AIDS treatment and prevention programs. People living with HIV deserve treatment and care, not waiting lists and death. But people who are at risk of HIV infection also deserve new ways to protect themselves.
Fully funding HIV treatment and prevention programs and HIV research would be a wise investment for the long-term economic stability of families, communities and nations. And it is affordable, especially if researchers and implementers commit to greater efficiency and prioritization: triaging current projects, jettisoning some, cutting costs within others, scaling up still others, and developing a clear strategy for collaborative action on key goals. The field must be able to define how it would function without new funding and what it would spend additional resources on, if and when they become available.
The world needs a fully funded, comprehensive and strategic approach to AIDS prevention and treatment, which includes finding new HIV prevention options, such as AIDS vaccines and antiretroviral-based HIV prevention, including pre-exposure prophylaxis (PrEP) and microbicide gels that could be used by women and men to protect themselves from HIV infection.
In the coming months, we expect to see results from the first ARV-based microbicide effectiveness trial and from two PrEP effectiveness trials. We hope for good news from these trials, but we know with certainty that none will provide a magic bullet to end the AIDS epidemic. We also know it is entirely possible that these trials could produce flat results or a level of efficacy similar to the Thai vaccine trial -- intriguing for scientists, but not yet usable in the field.
So, is a modestly effective AIDS vaccine and the possibility that other HIV prevention effectiveness trials will yield some kind of positive results reason for hope and not skepticism?
Yes. The Thai vaccine trial result was momentous. It is grounds for persevering in the search for an AIDS vaccine. And whatever the result of the next wave of HIV prevention trials, there are more vaccines, more microbicides, more formulations of PrEP in early human trials and in a laboratory testing.
The search for the end of AIDS will surely take more twists and turns, but we cannot afford to give in to cynicism and despair. There is both reason for hope and, more importantly, an obligation to continue the search.
To mark this HIV Vaccine Awareness Day, AVAC is launching The Thai Way Forward, which tells the story of the world's largest AIDS vaccine trial using the voices of the people on the ground who made the trial happen. The report is available online at www.avac.org/avacreport.