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‘We are creating national-level HIV cohorts’

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Dr Rajat Goyal, Country Director – India, International AIDS Vaccine Initiative (IAVI), in an exclusive interaction with Sachin Jagdale, gives details regarding recent developments in AIDS vaccine research in India

How will you describe the progress of AIDS vaccine research in India over the last three decades?

20160615ep27While scientists first began to turn their attention to an AIDS vaccine about three decades ago, in 1994, the Rockefeller Foundation convened a meeting of 24 authorities on the disease. Two major themes emerged in their discussions. First, that the institutions most capable of developing such vaccines, particularly pharmaceutical companies, lacked the financial incentive to invest sufficient resources in the task. Second, although HIV was already taking a disproportionate toll on developing countries (like India), none of the handful of vaccine candidates then under development was devised to address the epidemics and particular needs of such nations.

So, in 1996, IAVI was launched to address these problems and in 2002, IAVI began conducting vaccine and research preparedness activities in India. Since then, the focus has been on translating research activities towards the design of a safe and effective vaccine. This has covered the entire value chain from next-generation approaches in our HIV Vaccine Translational Research Laboratory (in partnership with the Translational Health Science and Technology Institute), through global linkages with other organisations and labs working on AIDS vaccine design, and through bilateral collaborations with Africa where we are working on the specific strain of the virus pertinent to India and Africa so that we can design a more region specific vaccine. These activities are intertwined with various partners such as the National AIDS Research Institute, YRGCARE, and regional scientific hubs in India to name a few.

Is India keeping pace with global AIDS vaccine research efforts? If yes, explain how. If not, where are we lagging behind?

Yes, India is playing an important role and contributing to global efforts in accelerating the discovery of an AIDS vaccine. One of the most promising breakthroughs in this regard is the identification of people who have demonstrated natural immunity to the virus in varying levels. These include people who are able to show low viral loads for an extended period of time after exposure to the virus, and people who have been exposed to the virus but not contracted an infection. Efforts are underway in India and various parts of the globe to study the unique immune responses of such individuals and isolate the broadly neutralising antibodies (bNAbs) that help them control the disease. Scientists are working to reverse engineer immunogens that will elicit similar immune responses in other people to protect them from HIV. This is something that has not been attempted in vaccine science before, and once successful, will inform vaccine discovery efforts for multiple other diseases in the future.

In addition to bNAbs, India is working to further the understanding of the HIV-1 clade-C strain which predominantly circulates in India and Africa, and comprises more than three-quarters of the global HIV burden. We are creating national-level HIV cohorts and a national bio-repository to store blood and tissue samples covering varying stages of the infection. Towards this end, we will begin collaborating with researchers in the Netherlands to share expertise and ensure adherence to global standards in research.

Additionally, the HVTR lab along with various collaborations that have been set up nationally, bilaterally and globally are producing cutting–edge scientific outputs that are catalysing efforts for a global effective vaccine.

What are specific challenges faced by Low and Middle Income Countries (LMICs) as far as AIDS vaccine research is concerned?

The biggest challenges faced by (LMICs) in innovative clinical and immunobiological research are lack of trained human resources and poor access to latest technologies and infrastructure. This slows down the pace of research and development. India is in the unique position of being a developing country, and yet having steadily and gradually developed significant capabilities in health and biotechnological research. We are harnessing these capabilities not just to fuel our own thriving and innovative biotechnological ecosystem, but are also working with various African nations to enhance their capabilities in disease research and prevention through various collaborative research projects, training and capacity building programmes, etc. At last years’ India Africa Forum Summit (IAFS – III), India committed significant resources towards development and health funds for Africa. The resulting South-South collaborations will have a significant impact on scaling research capabilities in LMICs.

Explain the limitations of drugs available in the market that AIDS vaccine will manage to get rid of?

There are a variety of prevention, treatment and care tools, including medications, currently available and all of them are part of a comprehensive response to the epidemic. In India, these tools include condoms, antiretroviral therapy (ART), public health education and behaviour change campaigns.

Male and female condoms, when used consistently and correctly, are highly effective in preventing the sexual transmission of HIV though there is still a risk of failure and women may face resistance in negotiating condom use with some men. In fact, even with female condoms, cost and access, consistency of use or incorrect use, amongst others, remain important challenges.

Access to available prevention and treatment is also a barrier to specific populations and regions in India and elsewhere. Similarly, enrolment and adherence targets for current treatment and prevention approaches have been difficult to meet in many cases.

With respect to ARTs, key challenges include the burden of expenses (including the cost of transport to often distant treatment centres, lost wages, registration fees and user fees), side-effects, waiting times at the treatment centres, inconvenient dosing frequency, dietary restrictions and fear of stigma and discrimination. As well, the emergence of drug-resistant HIV variants remains a key risk.

Finally, public health education and behaviour change campaigns face challenges in terms of cost, reaching the intended audiences, overcoming social pressures or norms, and so on.

What could be the limitations of AIDS vaccine?

As part of a comprehensive response, an effective vaccine could prevent millions of HIV infections, averting deaths, suffering and long-term treatment costs. A vaccine has many advantages including that it can be delivered before exposure to the virus, provide long-lasting protection, be distributed widely and confidentially within broader public health programmes, enhance control of vulnerable people and populations over their health and rights, and overcome challenges of behaviour change and adherence.

The limitations of any vaccine discovery project are mostly related to the uncertain time for development, prolonged lab-to-market time due to multiple phases of trials to ensure safety, and depending on the final product – efficacy and number of doses needed to yield optimal results. But given that vaccines are the most effective and cost-effective disease prevention tools known to man, they are worth the wait. The reason we have vaccines for dozens of diseases is because they all received the sustained support and investments through various phases of discovery and clinical trials that they required.

What is your take on the Indian Government’s efforts to keep check on HIV infections? Which are the improvement areas for the government?

India’s response to the HIV epidemic has been globally recognised as having been particularly effective in reducing rates of infection in the country. That said, we believe that prevention tools will continue to play an important role in reducing new infection and IAVI remains firmly focused on accelerating vaccine R&D.

How can AIDS vaccine become a tool for women empowerment?

Women are more vulnerable to HIV than men and AIDS is the number one cause of mortality among women of reproductive age. Gender inequity or violence, poverty and limited education can restrict a women’s ability to learn about HIV prevention or to negotiate safe sex. These same factors can force women into the sex trade, increasing the risk of infection and the stigma that can inhibit access to HIV prevention testing and treatment. However, an AIDS vaccine, which can be distributed as part of broader public health programmes and remains invisible to others (unlike, for example, condoms), could help women to independently protect themselves and their children from HIV infection and strengthen their power over their lives.

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