There was a strong undercurrent of resistance to the approach throughout the session. It finally erupted during the question period. One man asked the panelists whether they considered circumcision a form of mutilation, and what kind of counseling or support services they would put in place to offset the traumatic effects of the surgery? When Auvert pointed out that all the studies are looking at voluntary, adult male circumcision, the man retorted, "It's not because you're an adult that you might not be traumatized by the loss of your foreskin." This is an extreme example, but several social scientists chastised the panelists for "decontextualizing" the debate about circumcision, and rallied against the label "biological technology," as some of the panelists had referred to it.

All prevention efforts must take culture into consideration, but because of the extreme and irreversible nature of circumcision, and the intermingling of the practice with significant cultural traditions in many areas, clearly it's a tougher sell than something like condom use. Whether it will play a significant role in future prevention efforts or not is difficult to tell.

Readers who are scientists or who have some kind of science background will probably be famililar with the concept of a "pilot study." This is a study, generally small in scale, where new ideas are tested, and preliminary data are gathered. For example, a pilot study looking at how the ABCs of prevention work may take 100 individuals and split them into two groups: 50 who are taught about Abstinence, Be faithful, and Condoms, while the other group may be given no additional information, or be taught only about abstinence, for example. These two populations then can be followed and, depending on the study, outcomes measured. (Did they acquire HIV at a similar rate over, say, the next 2 years? Did faithfulness within a relationship increase in the group who were taught the ABCs? Did the abstinence-only group actually practice abstinence outside of the context of a marriage?) When the final data were examined, then, the researchers will decide whether the pilot study has achieved the outcomes specified in the beginning. If it had, these interventions could then be applied to a much larger group; it can be "scaled up" in terms of money and population.

"Scaling up" doesn't always mean going from a pilot study to a larger, more inclusive study, however. Imagine now that the researchers had now carried out that second-phase study, and wanted to implement these prevention measures nation-wide. This is another scale-up; moving from scientific research to public policy. There are obstacles at each scale-up, of course. Researchers need to prove their case in order to secure funding for large studies, which can be difficult. Even more difficult, generally, is scaling up from a scientific study to a matter of policy, because this involves, in some cases, major infrastructure building.

For example, using the ABC scenario I outlined above. If this becomes policy, who will fund the employment of educators to reach out to the population, especially those at high risk of acquiring HIV? How, exactly, will these educators even identify people to teach? Will this be done through existing clinics, schools, community organizations? Or will new physical structures be built to cater to this need?

Similar concerns exist for any kind of massive scale-up. For treatments, who pays for them? How are the drugs delivered? How are testing and anti-retroviral treatment coordinated? Can one create a comprehensive program for prevention, education, testing, and treatment, or are separate entities in charge of the various components?

"Scaling up" is the goal of many programs centering on HIV/AIDS, whether it's scaling up efforts aimed at prevention, treatment, or other facets that come into play. But going from demonstrated success in research studies to successful programs at the level of a nation (or even a city) is a difficult and massive undertaking, fraught with red tape and other trappings of politics.

As Hannah and Lindsay (and others around the blogosphere and news media) submitted their stories from the front lines, so to speak, a few things jumped out at me regarding how this conference seems to be a bit different from the ones I've attended.

Scientific conferences vary widely with respect to size. I've been to some national meetings where it's a very small niche, and there were just a few hundred people in attendance. (And of course, some local meetings are lucky if a hundred people show up). This was an international meeting on a very noteworthy topic, so the size reported (~20,000) is in line with that. That's pretty closely in line with the annual meetings of the American Society for Microbiology (technically a national meeting, but always draws many international researchers).

However, there are many notable differences between this week's AIDS conference and the annual ASM meeting. First, obviously, is the sheer amount of coverage in the press. While some talks and research news do occasionally get highlighted from ASM's conference, it's nothing like I saw this past week. Second, and most striking, is the level of involvement from celebrities and politicians. Much was made regarding Canadian Prime Minister Harper's absence from the conference. This is only notable because so many other politicians and celebs were their to affirm their committment to AIDS relief; this is something one defintely doesn't see at ASM, for a few reasons. One, that we're not focused on a single infectious disease, but on all of them; and two, because there's just not a lot of celebrity influence regarding most infectious diseases. Few notables here in the US speak out about TB, or malaria, or even growing threats like antibiotic-resistant staph. It's just not sexy.

But, neither do many of these diseases carry the stigma that HIV/AIDS still does--which is why Harper's no-show makes headlines. I think it's important to keep emphasizing the message that this is a critical worldwide problem, and that no one deserves to be treated as a second-class citizen merely because they have been diagnosed with HIV. So, the International AIDS conferences can keep their celebrities and I'll be content that, although my work doesn't garner quite so much attention, neither does it cause so much stigma for those who are affected.

Every week, our Seed overlords pose a question to us (originally titled, "Ask a ScienceBlogger.") This week's question is:

To what extent do you worry about AIDS, either with respect to yourself, your children, or the world at large?...

You can find the collection of responses here.

In more basic science, Sandra of Discovering Biology in a Digital World is starting a series on using HIV to prove some points about evolution. Looks like a great start to the series; be sure to check in as she updates it.

At the closing ceremony UN Special Envoy for HIV/AIDS in Africa Stephen Lewis called upon the governments of all nations to deliver on their funding promises.

"We are on the cusp of a huge financial crisis,'' Lewis warned the gathering, noting that the G-8 countries haven't lived up to the pledging promises they made to the Global Fund for AIDS, Tuberculosis and Malaria at their 2005 summit in Gleneagles, Scotland.

"No one is asking for any more than was promised,'' Lewis said. "Everything in the battle against AIDS is being jeopardized by the G-8.''

Will they?

I asked the woman, a South African, sitting next to me at the closing ceremonies what she thought of the closing session, of the conference. It's been good and well organized, but long, she said. "Finally!" she remarked when the co-chairs of the Toronto officially passed the emblamatic globe over to the chairs of the Mexico conference. Too many long speeches by officials, I sensed.

On the way out, I ran into a friend, a member of the Canadian AIDS Society, and asked whether she thought these conferences and the speeches did any good. It's inspiration, at least, to keep going until the next conference, she said, adding that Stephen Lewis's precise 15-point action plan is better than vague statements like "Empower women!"

To sum up his points:
1. Abstinence only programs do not work.
2. Harm reduction does work.
3. Circumcision should be promoted.
4. Microbicides must be made available.
5. Stop using second-rate drugs to prevent mother-to-child transmission of HIV in Africa and other parts of the world.
6. Fund the World Food Program with the money it needs to provide proper nutrition to those taking anti-retroviral treatment.
7. Stop violence against women. (There hasn't been enough talk of this at the conference, he added.)
8. Resolve the debate over HIV testing and counseling. (Watch the Know Your Status Campaign in Lesotho.)
9. Stop child sexual abuse.
10. Provide support to the orphans.
11. Recognize the contributions of grandmothers to society, and provide them with sustainable incomes, food and school fees.
12. Continue to roll out treatment...and speed it up!
13. Deliver the funding that has been promised.
14. Provide programs for youth.
15. Right gender inequalities, by establishing a UN agency for women's rights.

Lewis, whose term will conclude come year end, asked that his successor be African, but most importantly an African woman.

His speech was received with a standing ovation that lasted more than a minute. "Amazing. Just amazing," a woman behind me cheered.

Did they deliver? I think we'll still have to wait and see if the Global Fund's goal is met, if pseudoscience is washed away, if vulnerable groups receive the counseling and care they require, and if more human resources can be roused up to help in developing countries. Certainly, the public is more aware, but in a few months when the glow of the conference has dulled, perhaps a new slogan should be adopted: Time to Remember.

Mark Wainberg: "Many people have said that this was one of the best conferences ever at linking the north and the south. I hope they were not talking about the long walks that we have subjected you to between the two separate buildings of this conference site."

(To get from the Global Village, the Media Centre and the main entrance to the main session rooms, the delegates had to ascend one escalator, traverse a skybridge that crossed a dozen-or-so train tracks, and descend another three-or was it four-escalators.)

Later in his address, Wainberg reiterated his disappointment at the absence of Canadian Prime Minister Stephen Harper, yet praised the Government of Canada had been generous in its support of the conference before adding, "I think it is safe to assume that the president of Mexico will attend the next conference."

Stephen Lewis recounted a story from a recent visit to Swaziland: "He revealed that he was circumcised, I revealed that I was, and there was a joyous frenzy of male bonding among all the circumcisees."

Lewis recounted the story to denounce the bureaucratic shufflling that have delayed the official acceptance of circumcision as a prevention tool.

Many of the closing remarks addressed human rights--universal access to medical care as a human right; women's' rights as a human right--and the stigmatization of groups with a higher risk of contracting the virus. The chair of the 2008 Mexico conference, Dr. Luis Soto Ramirez, made a strong point: The only thing the virus asks is, Are you human?

While occupying the office, Achmat and the others apparently called for homicide charges to be pressed against two cabinet ministers for the death of an HIV+ prisoner in South Africa's Westville correctional center. According to The Associated Press, the prisoner was one of 15 inmates who had recently won a court case against the government forcing it to provide ant-retroviral drugs to the prison population.

Click here for a detailed report in Capetown's Mail & Globe newspaper, and here for a report from The Associated Press.

This story is a timely reminder of the ignorance, stigma and discrimination associated with HIV/AIDS, particularly in marginalized populations such as prisoners, injection drug users and sex workers. Calls here this week to make univeral access to health care a fundamental human right now seem all the more pressing.

Studies have shown that, generally, HIV isn't one of the more highly infectious viruses out there. For example, the hepatitis B and C viruses are transmitted via many of the same routes as HIV (such as sexual activity shared needles), but vary in their infectivity. If, for example, a health care worker gets stuck with a needle from an HIV+ patient, they have a very low probability of becoming infected with the virus; so low that less than 150 occupationally-acquired HIV transmissions have been positively documented in the literature. With hepatitis B virus, however, the risk is orders of magnitude greater: chance of infection following a needlestick is almost 1 in 3. The hepatitis C virus is between them, with about a 1 in 50 chance of becoming infected following such a needlestick.

The reasons for the differences in infectivity vary. Some viruses are present at higher levels in the blood or other body fluids, meaning that more particles are transmitted during each contact. Some have a lower infectious dose, meaning that it takes fewer viral particles to actually start an infection. However, host factors are also involved in transmission of pathogens, and one of these is the presence of other pathogens in the body.

No longer.

The extent of the human resource crisis--and my use of the word crisis here is well founded--was driven home to me that very afternoon. It was the statistic that the world needs 1 million health-care workers to cope with AIDS that swayed me. It was also the nurse who reminded us that it is primarily nurses who care for AIDS patients in rural areas--in Zimbabwe and elsewhere--where there are no doctors (or pain killers or IV fluids). And it was the 79-year-old Zambian doctor who's still rallying on behalf of his sick patients everyday, and who called on the experts not to overlook what his generation may still have to offer. It was the appalling fact that in Botswana between 1999 and 2005, 17 percent of health-care workers died of AIDS.

Leonard Rubenstein, director of Physicians for Human Rights, moderated the session entitled "Human Resources and HIV/AIDS: Advancing Health Workforce Capacity in Delivering Care, Treatment and Support," along with Shoji Nishimoto from UNDP. (Rubenstein noted that the bland title belied the crisis at hand.) People weren't talking about human resource shortages, even two years ago in Bangkok, according to Rubenstein. Yet, it's been on the horizon for decades, and has emerged as one of the major themes of the conference. The countries hardest hit are in Sub-Saharan Africa, the countries also carrying the highest disease burden, as well as Bangladesh, Indonesia, and India.

Some have argued that the politicians had their moment on AIDS two months ago at UNGASS (the UN General Assembly Special Meeting on HIV/AIDS) in New York, and would drown out the voices of people working on the frontline of the fight against AIDS. Others, including one of this morning's plenary speakers, Mark Heywood, demurred. "Without political leadership, it will not be possible to turn the scientific work we have heard about [this week] into public health policy," said Heywood, a prominent lawyer and activist with South Africa's Treatment Action Campaign (TAC). Wearing one of TAC's signature t-shirts that say, "HIV Positive," Heywood challenged the global community "to hold the world's leaders to account."

As if to underline his point, he called for the resignation of South Africa's minister of health, Dr. Manto Tshabalala-Msimang, who has at times undermined the country's response to HIV/AIDS. Supporters rose from the audience with signs echoing Heywood's call.

Moderated by CNN's popular medical correspondent, Dr. Sanjay Gupta, this morning's plenary was a rousing success. Heywood's message was endorsed and his passion and eloquence equaled by the other three panelists: Alexandra (Sasha) Volgina, an HIV + woman who founded FrontAIDS, the first treatment activist group in Russia; Musimbi Kanyoro, General Secretary of the World YWCA; and 21-year-old Kerrel McKay, a prominent Jamaican youth leader, whose father died of AIDS.

All four speakers had personally witnessed or felt the devestating effects of weak political will, and they asserted that the price of inaction will be death. "Political leadership can't be an ephemeral idea," concluded Heywood. "It has to be objectively measurable and objectively measured."

Earlier sessions spoke of the numbers and the risks associated with migration--whether voluntary or forced--whereas today's session focused on the challenges to those who were trying to provide information, prevention, testing and treatment. It was food for thought.

Paul Farmer, a medical anthropologist and physician at Brigham and Women's hospital in Boston, MA and the founder of Partners in Health, pointed out that the consequences of conflicts don't vanish as soon as accords are signed and troops pull out. In Rwanda, for example, a 2003 survey found that among 1,000 women who were raped during the genocide, 66 percent were HIV positive.

There are also those who are left behind and forgotten, the "invisible ones" David Mosca, an emergency surgeon in Nairobi, called them. The wives, mothers and children who don't leave or, perhaps, don't continue to the second or third country, and are left to fend for themselves. If we don't know who they are, how can we find them and provide them with the healthcare services they need? And how to make sure that a recent migrant, or one who routinely crosses borders continues to get their regular course of antiretrovirals? Difficult to do and maintain confidentiality.

A member of the audience stood up and brought attention to the situation in Darfur, where lately aid workers have been unable to provide proper care in the HIV setting. No condoms, no post-exposure prophylaxis, no therapy. As Farmer indicated: there are many consequences to Darfur, that we won't see for years.

(The photo above is when Anthony Fauci, director of the National Insitutes of Allergy and Infectious Disease at the NIH, stood to address the crowd. Protesters mobbed him, chanting: "Tony, tell George the evidence can't be ignored" and "Condoms, needles and the rest, we need more than just a test." Fauci, just stood there, and let them have their say before he began his talk.)

Midway into a long week and with the threat of fatigue setting in Richard Horton, editor-in-chief of the Lancet, took a different tact when he turned to question the panel.

"Gregg, while you were speaking, you didn't know that we were taking a poll in the audience. And even though you've moved to South Africa, we've just elected you president of the United States. You take over office tomorrow morning. What are you going to do about HIV/AIDS?"

Obviously shocked by his recent election to the White House (especially because he lives in South Africa), Gregg Gonsalves, the coordinator of the regional treatment literacy and advocacy program at the AIDS and Rights Alliance of Southern Africa, hesitated and then continued:

"Really? Look, we can first start with making needle exchange legal and federally funded. We can get rid of abstinence-only sex education programs. We know they don't work.

We can have national health care. The rest of the industrialized world has national health care. We have none of it. Now I'm living in South Africa but in the U.S., we have a country that is destroying what we set up under the New Deal and the Great Society programs and throwing the poor to the wolves. And basically, if I was president we would have national health care and we'd have evidence-based HIV prevention policies that would do a start to controlling the AIDS epidemic.

Then we have to address violence against women, epidemics of drug use, and other things I described in my talk. But that's not the way my country sees fit to deal with people living with AIDS or other people dealing with infectious and chronic diseases."

You can learn more about Adriana's work at her web site: adrianabertini.com.br (in English and Portuguese). Most of the pieces took approximately 200 hours to prepare and used more than 2,000 condoms that did not pass quality control.

Adriana plans to unveil a collection for men at the XVII International AIDS Conference in Mexico City in 2008.

Over at WebMD, they have a nice summary of many of the key points from this week's conference regarding prevention issues: 6 ways to prevent AIDS. I'll list them here briefly, but be sure to check out the article, which gives a bit more explanation:

1. Male Circumcision
2. Microbicides
3. Diaphragms and Other Cervical Barriers
4. HIV 'Prevention Pills'
5. Herpes Treatment (I'll have a post up on this tomorrow)
6. HIV Vaccines

They end by emphasizing just what Hannah mentioned:

The bottom line "is that we have to go beyond the ABCs of prevention," Ramjee says, referring to the widely used acronym for abstinence, being faithful to one sexual partner, and using condoms.

"I have described a new acronym that goes right up to I," she says.

"We have an additional C for circumcision, D for diaphragm for HIV prevention, E for exposure prophylaxis -- both pre and post, F for female-controlled microbicides, G for genital tract infection, H for HSV-2 (herpes) suppressive therapy, and I for immunization through vaccine."

While these are excellent starts, I'll note that with the exception of a vaccine, they don't address issues when HIV is transmitted via routes other than sex. In some areas, such as China, injection drug use is fueling the epidemic in a huge way, and it's important to address those behaviors as well in any comprehensive prevention strategy, as many Canadians emphasized in an earlier conference session and at the opening talks.

Image from http://www.pueblo.gsa.gov/cic_text/health/contracept/condom.gif

About 5 percent of the women, many of whom saw 10 or more clients a day, appeared to be resistant to HIV. It was an unprecedented finding and unfathomable considering the number of times in a year each sex worker was exposed to the virus.

Decades later, many of these women, who have become known as the Pumwani Sex Worker Cohort, remain resistant to HIV infection. Researchers, including the University of Manitoba's Frank Plummer, have identified several factors that appear to offer resistance to HIV infection, including a variety of gene signatures and the presence of higher levels of antibodies, cells and proteins within the genital tract.

The newest one on the list is trappin-2. For his PhD thesis Shehzad Iqbal used a proteomics approach to track down this novel secreted protein that may offer resistance to HIV. Although the work is preliminary, Iqbal has shown that women who are HIV resistant have higher levels of trappin-2, and that cell-based experiments show that physiological levels of trappin-2 can quelch HIV's ability to infect T-cells.

It's fascinating work, because trappin-2--should it continue to show promise following future experiments--could be incorporated in the a microbicide that women could use to protect themselves from HIV.

Amazing what our bodies can make, isn't it?