Laura Waters

IAS 2019 kicked off with an impressive & wide-ranging opening plenary session by three compelling speakers, including: (1) the challenges of ART scale-up resource-constrained settings, (2)stem cell & genome editing for HIV cure & (3) implementation of HIV pre-exposure prophylaxis (PrEP) in transgender people.

Gloria Maimela utilised storytelling to highlight barriers to 3rd 90 achievment. Large global gaps won’t be bridged without redesigned health care delivery. We must learn from successes of community ART in Namibia & data from South Africa supporting less frequent drug refills – “only clinicians think it is fun to attend clinic”. Paula Cannon delivered a comprehensive, accessible review of stem cell & genome editing, summarising three main roles for this technology: PROTECT (gene engineering to render HIV-uninfected cells resistant), ATTACK (enhance anti-HIV immune responses) & PURGE: remove the reservoir! Asa Radix acknowledged the importance of issues for trans people making a major conference plenary for the first time. This talk highlighted importance of language, lower PrEP adherence for trans women in iPrEX, lack of impact of PrEP on hormones, small decline in tenofovir concentrations with oestrogen (higher PrEP adherence may be necessary) & need for accessible, gender affirming services

For service delivery we must ask ourselves: Are people hard to reach or are we (clinicians) hard to find? Why ask relatively well people to attend overstretched facilities, ill equipped to attend their diverse needs? The glittering promise of gene editing must be considered alongside potential limitations including cost, acceptability & safety – is this complex therapy warranted for a treatable condition? Finally, when we get home, we must all ensure our services ask the recommended, two-step gender question so we are not creating barriers to trans people at the first point of contact.

Fabio Romerio

Monday’s Plenary Session was chaired by Drs. Alessandra Ramos from the Instituto Transformar (Brazil) and Horacio Solomon from the University of Buenos Aires (Argentina). It featured presentations that focused on challenges of treatment in resource-constrained settings, HIV cure strategies through genome editing, and implementation of PrEP in the transgender community.

The session was opened by Dr. Gloria Maimela who described the challenges of accessing and delivering therapy in resource-constrained settings through the example of a working family. She emphasized the need to reconfigure the health systems toward community-based models that are more accessible to the needs of patients, to scale strategies that increase patient convenience, and to tackle stigmas and discrimination that limit access. Dr. Paula Cannon described HIV cure efforts based on genome editing strategies: CRISPR/Cas9 and ZNF nucleases. These technologies allow to precisely target and disable the CCR5 gene in hematopoietic stem cells, which upon reintroduction into the host give rise to HIV resistant cells. They can also be utilized to introduce genes expressing neutralizing antibodies. Dr. Asa Radix discussed the difficulties associated with the implementation of PrEP in the transgender community. These include existing barriers in the PrEP care continuum: eligibility, linkage, initiation, retention, adherence.

This session touched upon many critical themes. Dr. Maimela identified strategies to remove barriers that still prevent the achievement of the 90-90-90 goal. Dr. Cannon’s approach to HIV cure through genome editing may face challenges such as its implementation of such strategy in resource-constrained settings, its public acceptance due to the recent report of the “CRISPR babies” in China, and its potential impact on life expectancy. Dr. Radix highlighted the social and health challenges that transgender people face every day such as bullying, rejection, poverty, homelessness, discrimination, suicide, which leads member of this community to avoid medical care.