Interview: Co-Chair Linda-Gail Bekker
HIVR4P 2020 Co-chair Linda-Gail Bekker needs no introduction to most HIV prevention researchers and advocates. She is, in a word, “tireless,” both in terms of the schedule she keeps and her dedication to the patients she serves. We sat down with Linda-Gail to get her perspective on where we are and where we’re headed in prevention research and on how HIVR4P 2020 can benefit the field.
At last, a conference you don’t have to travel for… HIVR4P 2020 will be held in your home town. What can the world learn from how Cape Town is responding to the epidemic and how can the conference help strengthen the local HIV response?
I’m delighted that the conference is going to be in Cape Town and we are thrilled to welcome everyone to this beautiful city. While South Africa is at the epicentre of the HIV epidemic, with the greatest number of people living with HIV in the world, I’m proud to be in the Western Cape Province and the city of Cape Town, which have over the years been very responsive in terms of both treatment. The Western Cape has a large treatment programme and Cape Town has been a leader in mother-to-child prevention.
Where we have struggled is in primary prevention. We have been slow in rolling our oral pre-exposure prophylaxis. Many of the reasons relate to policy and funding… it’s hard to position the need for PrEP against the need to support a large treatment programme. Our challenge is in bringing forward a suite of new prevention interventions when we still have work to do in treatment. How do we bring those two very important aspects of the HIV response together in a seamless, uncompetitive way? With HIVR4P coming to Cape Town, I think that some mutual learning can happen with having the world’s best prevention experts here in our backyard.
Much of your work focuses on young people. How well is the HIV research establishment responding to the realities of their lives?
Too slowly! That would be my urgent and activist response. Happily, we are coming around to the fact that young people are really key to the response, and if we don’t pay them meaningful, realistic and authentic attention, we will not win this fight. This is a drum we have been beating for a long time and we are starting to see some results. Today, more and more studies are including participatory research practices and saying, “We can involve adolescents safely in this research.” But we can still learn a lot here and I’m hoping that HIVR4P 2020 is going to bring that home in a very real way.
One of your research focuses is reducing HIV and STIs among girls and young women. What is that work teaching you and how should that knowledge impact other HIV prevention efforts?
It’s taken us a long time to understand that the HIV response isn’t optimal when functioning in a silo. It is so much stronger if we position our HIV response in a sexual reproductive health catalogue or suite of interventions. We know that applies also for other co-infections, such as TB or hepatitis B and C. When it comes to STIs and reproductive health, those aspects synergise very well. And when we approach them in that way, the response gets so much stronger. We know, for example, that young women often come to PrEP services because they are seeking contraception. They then stick with PrEP because they want to be screened and treated for STIs. It’s the same for young men who have sex with men. People’s lives are integrated and that’s the kind of service we need to bring to them. We go out there with single messages or single strategies at our peril. There is still much to learn in this regard, for example, how to screen and how to manage STIs, moving beyond syndromic management in the context of PrEP. HIVR4P 2020, I hope, will shine a focus on STIs and HIV. We need much more tangible implementation science on the STI front, and so I hope colleagues will submit lots of exciting data.
South Africa is a leader in HIV vaccine research. How are the Uhambo and Imbokodo studies progressing and what should we look for in the results?
Uhambo is a pivotal study to complement the results we saw in Thailand. Building on this, we are hoping for success. That means a vaccine point efficacy of more than 50%. If we get to that, it could be absolutely fantastic for the global HIV vaccine effort. It would also confirm some of the correlates of protection that we have been trying to understand better and open up the next level of bridging studies, as well as a concerted effort then to look at increasing durability and streamlining the vaccine regimen. The current regimen involves multiple vaccinations, which is obviously not our best target profile. But success will open a floodgate of enthusiastic research and work.
Imbokodo is the Johnson & Johnson-sponsored Ad26 mosaic proof-of-concept study. That was originally going to involve African women only, but the Mosaico study has added sites for a similar vaccine regimen for men who have sex with men in the Americas and Europe. If there’s success there, it opens up huge opportunities to optimize that regimen.
We’re excited that both studies are fully enrolled and in the follow-up phase. There have been no safety concerns to date, and we’re very excited to see what the future holds for HIV vaccines.
You were part of the IAS-Lancet Commission on the Future of Global Health and the HIV Response. Of all of the findings in that report, which seem most relevant to you as we enter the 40th year of the epidemic?
There are really two take-away messages that are completely relevant for HIVR4P. One is that we cannot rely on treatment alone. Universal test and treatment is a critical strategy, but insufficient for epidemic control. We have to bring primary prevention full scale into the picture. And where better to discuss that than at HIVR4P? The second is that it’s a mistake when we think of things in silos or as single entities. The Lancet Commission tried to say it is time for the HIV response to bring its lessons forward not only for the long haul, but also in terms of other aspects of global health and health access. It’s about finding those common-cause responses. The obvious opportunity here is in sexual and reproductive health, but we also need to identify opportunities for shared responses with other co-infections, NCDs, and health in general. That makes good sense and will position us for the long haul.
HIVR4P is unique in terms of its size, interactive nature and prevention science focus. What advice would you give to someone attending their first HIVR4P conference?
Because it is wholly focused on prevention, the good news is that delegates don’t have to make that tricky decision between prevention or treatment. My advice is to try to get a broad experience of all kinds of prevention because we know that they are interrelated. If you are focused on vaccines, it’s useful to go to the PrEP sessions. If you’re a behavioural scientist, it’s good to go to the biomedical sessions. Prevention is going to be about all of these different modalities coming together. When we go to a restaurant, we expect the waiter to be able to tell us about the appetizers, the entrees and the desserts. A preventionist should also be able to deliver the whole menu or at least understand every aspect of it. When we’re sitting in front of a client, we need to offer differentiated delivery of prevention services. So, my advice would be to take in as many prevention opportunities as one can.
Finally, what three things should HIVR4P 2020 attendees be sure to do outside the conference hall?
They will be coming to one of the most beautiful cities in the world, so it’s very hard to find only three things to recommend. However, I’d recommend that everyone find a way to get up our beautiful mountain – it’s our signature, our beacon and what makes Cape Town unique. Personally, I advocate a nice walk up, or perhaps a cable car up and a walk down. Next, if you come to Cape Town and don’t get to one of our beautiful coastlines, that’s a shame. If you are into wilder and more natural coastline, then you go to our Atlantic side. If you’re more into the quaint fishing villages with interesting shops and good fish to eat, then you go to the False Bay side. You’re on a peninsula, so there literally are two oceans. Finally, for a completely different experience, get out into the wine country. Even if you’re not a wine imbiber, it is beautiful countryside and, in October, there should be some lovely days on which to explore. And be sure to interact with the people. Capetonians are fun, laid-back and very easy-going people. Be sure to meet them if you can.