By guest blogger and friend of RESULTS, Associate Professor Patricia Price, Curtin University.

The first Durban AIDS conference in 2000 was dominated by the breaking news that HIV was devastating Africa and that treatment was unaffordable. It was my first AIDS conference and I was co-sponsored by a drug company that spared no expense in entertainment.

It was a strange experience.

On a bigger scale, it focused the world on the need for universal access to antiretroviral drugs – often through the production of generics. Now we can see how the HIV epidemic has evolved from Durban to Durban. In theory, all HIV patients now have access to treatment, though next generation and second-line therapies remain expensive and many people don’t know they are infected.

The 2016 conference took treatment a step further advocating prophylactic treatment for sex workers and discordant couples. Treatment on first diagnosis (“test-and-treat”) was acknowledged as the best approach for the individual and the community as it reduces transmission.

Four issues remain that dominated the meeting.

Issue 1. Antiretroviral drugs (ART) convert HIV disease into a chronic infection but do not cure it. This creates a need for continued education to prevent risk behaviours and maintain adherence to therapy. Both are difficult whilst there is stigma associated with being HIV positive.

Issue 2. A cure was indeed achieved in one individual, but babies who appeared to be cured retained low levels of HIV and eventually needed ART. The speakers made it clear that a cure must be feasible and scale-up-able. This rules out stem cell transplantation and the presently  available drugs that activate HIV latent in long-lived T-cells. Rather the focus was the importance of minimising the levels of virus replication in the first few days to reduce the lifelong “viral set point”.

Issue 3. A vaccine remains just over the horizon but there is progress building on the successful 2009 RV144 trial in Thailand. The new trials recognise that exposure to HIV does not induce protective immunity (as measles does), so it won’t be possible to create a useful vaccine by mimicking natural infections. The goal now is to deduce what a protective response looks like and create it artificially. This begins with a study of the rare individuals who are exposed and remain uninfected or display very slow disease progression. Adoptive transfer of a monoclonal antibody from such an individual as post-exposure prophylaxis (“PEP”) is now being trialed.

Issue 4. The disease induced by HIV is affected by the bacteria that we all carry in our mouths and digestive tracts. New genetic technologies allow simultaneous identification of hundreds of bacteria and show how these populations are affected by diet, lifestyle and sexual activity. Breakdown products from these bacteria cause chronic activation of the immune system and so enhance T-cell depletion and may explain the acceleration of diseases of aging seen in people living with HIV and AIDS.

Want to read more? See our Campaigns Director Leila Stennett’s blog about meeting the Deadly Duo of TB-HIV at AIDS 2016.