A long-time prevention research champion, Pontiano Kaleebu, heads the Uganda Virus Research Institute, the largest government research institution in Uganda. He helps direct the country’s HIV policy, leads multiple North-South HIV research collaborations and represents Uganda on panels shaping global responses to the epidemic. We asked Pontiano to share his perspective on where we are in the HIV response as a new decade begins and what we can all expect to learn at HIVR4P 2020.
The Uganda Virus Research Institute works in both urban and rural areas. How do HIV prevention challenges differ across those two very different settings?
There are similarities and differences. Our studies show higher HIV prevalence and incidence in our urban settings, which was also the finding of the most recent Uganda Population-based HIV Impact Assessment. Incidence in rural populations is less than 1%, although in areas where we have activities like fishing, the incidence is much higher. And, surprisingly, in the population-based impact assessment, there was more active syphilis in rural than urban settings.
In both groups, we need to intensify our efforts around ABC (which stands for Abstinence, Being faithful and Condom use), treatment, PrEP and circumcision. There are also different challenges in rural and urban communities. In the rural population, women are more vulnerable, less educated, poorer and marry earlier, which makes them more vulnerable to acquiring HIV. Among female sex workers in Kampala, high rates of engagement in other behaviours that increase vulnerability, like alcohol and drug use, increases risks for infection and affects adherence to treatment and prevention.
We have completed a study using HIV phylogenetics and transmission networks that shows transmissions moving from the general populations in more rural areas to fishing communities to sex workers and back to general populations. With all this information, I think it means that we need to intensify prevention approaches and work to increase access and adherence in all populations, rural and urban.
You are part of a number of North-South research collaborations. What have we learned through the HIV experience that could make these partnerships even more productive?
Both the global North and South have something to offer each other. Most funding and advanced technology come from the North, but in the South, we have the epidemic, the populations that need the interventions and increasing research capacity. So we need to work together. We want more research done in the South, where the epidemic is, and for sustainability. We are also happy that funders are encouraging these truly collaborative partnerships. An example is the European and Developing Countries Clinical Trials Partnership, which has funded many projects in Africa, led by African scientists but with collaborators in the North. If more capacity is built in the South, greater equity and better partnerships will follow.
HIVR4P 2020 anticipates broad participation from African research leaders. What still needs to be done to raise the profile of African-led research internationally?
More funding is essential for building human and infrastructure capacity in Africa. With this capacity, we can then conduct more high-quality research. A challenge has been retention of well-trained African scientists. If there are no well-funded institutions or funding for research opportunities at home, they either go elsewhere or leave science. African governments need to invest in science and strengthen research career opportunities. We are also encouraging universities to take research seriously and reward those who do good science.
Uganda presided over one of the most effective efforts to reduce HIV prevalence ever, but has also seen rebounds in infection rates in recent years. What can the world learn from Uganda’s experience?
With ART and the expectation that HIV-positive people will live longer, new infections would be a better measure than prevalence of the success of the HIV response. Uganda has registered significant reductions in new HIV infections, from 135,000 in 2010 to approximately 60,000 by 2016 in men and women, and from 26,000 to 4,000 in children over the same period. However, it is true there are concerns about high rates of new infections in some groups.
Prevention efforts must be sustained. Even with our attention to treatment, we need to have sustained access to other prevention technologies, such as condoms, circumcision and the right information and messages. We need to continue with our messages of ABC. That may have dropped off with the advent of better treatment, and this caused a problem in Uganda.
Now we have the “Presidential Fast-Track Initiative on Ending AIDS in Uganda by 2030”, the first of its kind in Africa. It spells out tackling HIV and AIDS in Uganda through a five-point plan to: engage men in HIV prevention and close the tap on new infections, particularly among adolescent girls and young women; accelerate implementation of test and treat and the attainment of 90-90-90 targets, particularly among men and young people; consolidate progress on eliminating mother-to-child transmission of HIV; ensure financial sustainability for the HIV response; and ensure institutional effectiveness for a well-coordinated multisectoral response.
We are in the midst of an exceptionally diverse and promising period in HIV vaccine research. Which mysteries are we closest to solving? And what vaccine research challenges still remain?
We still need to better understand the best protective immune responses and how to induce them. If we think that’s broadly neutralizing antibodies (bNAbs), then we need a candidate vaccine that can induce these antibodies. We all look forward to the trials using these antibodies passively to prevent infection. If this works well, we’ll have a proof of concept that a vaccine that can induce these antibodies will be effective.
In Uganda, we have a diverse HIV epidemic now dominated by recombinant viruses. We have done studies that show that some of our viruses are not neutralized by the existing bNAbs. So we are advocating for the development of candidate vaccines that will be effective for the epidemic we’re facing.
Another challenge is identifying populations to test future vaccines. With more prevention tools in our hands, it will be very expensive to conduct efficacy studies. We are already seeing this. Most of the populations that we have engaged in prevention research studies in the past now have low rates of incidence. That’s good for the epidemic, but a challenge for the introduction of new tools.
What makes you most hopeful about the future of HIV prevention?
I’m excited about the long-acting ARVs and PrEP. I’m also excited about the bNAbs and advances to make candidate vaccines that can induce them.
Which HIV prevention challenges would you most like to see addressed at HIVR4P 2020?
My list of top challenges for HIVR4P includes ART and PrEP access, adherence, long-acting drugs and long-acting PrEP, including those to use as microbicides, how HIV resistance will impact treatment and prevention, and understanding where we are with vaccines. I expect that we’ll dive into all of these issues in Cape Town. It’s going to be a great meeting.