International AIDS Conference 2016: A Personal Perspective

My husband Trey and I had the honor of representing North Carolina as delegates to the 2016 International AIDS Conference (IAC) held recently in Durban, South Africa.

The International AIDS Conference is held annually around the world, and is sponsored by the International AIDS Society. Each year alternates between a "scientific" and "networking" focus. Both types of activities happen every year, but the primary focus alternates. This year's event was primarily a networking year: a chance for clinicians, researchers, policy-makers, activists and others from around the globe to meet each other, share knowledge, experience and expertise, as well as plans, hopes and aspirations and, hopefully, find ways to work together, share information about what has/has not worked in their experience and why, and ideally, for example, prevent an AIDS service organization (ASO) or political advocacy organization in Thailand from reinventing something that an organization in Australia has already created. Through collaboration of this kind, rather than competition, countless lives and untold amounts of time and money have been saved.

As an HIV specialist, in addition to representing North Carolina, I also represented my new and growing medical practice, Ballantyne Family Medicine (BFM), and represented several local ASOs with which BFM collaborates in providing services to HIV/AIDS patients in the Charlotte region and across North Carolina, some of which I am also pleased to serve as a member of their boards. This includes groups such as the Regional AIDS Interfaith Network (RAIN), Amity Group Foundation, CarolinasCare Partnership, Quality Home Care and NC AIDS Action Network (NCAAN). Trey was there as the acting executive director of Amity Group Foundation, the newest community-based organization (CBO) in the Charlotte region which focuses on healthcare issues, including providing HIV/AIDS services to the un- and under-insured in the Charlotte region.

Changing Times
Durban hosted the IAC in 2000 and the IAC returned this year to find a lot has changed. Sixteen years ago in Durban, the conference was a catalyst for bringing HIV medications to all countries. South Africa had one of the worst HIV programs in the world then, and today has the largest HIV treatment program.

THEN (2000)

� Zero people on treatment
� 70,000 HIV-infected babies born per year
� 330,000 avoidable HIV deaths

NOW (2016)

� 3.4 million people on treatment
� � Life expectancy increases by more than 10 percent in 5 years

Globally, in the year 2000, less than 1,000,000 people worldwide were on HIV antiretroviral medication and today 17,000,000 people are receiving HIV antiretroviral medication. That's over half of everyone living with HIV now on life saving medications worldwide! We still have a way to go but great improvement has been made.

What Did We Learn About South Africa?

No one told me about the beautiful beaches or beautiful and charming people of Durban. From before sunrise until late at night, the beach and streets were alive with activities. The rich diversity of peoples and cultures only added to our experience.

As I took my run each day, I watched young and old couples strolling, jogging and biking. There were fishermen and sand dune artists along the way. Vervet monkeys were as plentiful as seagulls and just as hungry, although signs encouraged you to not feed them.

The food was wonderful! South Africa has the largest Indian community outside of India and thus the food is heavily influenced. Indians originally came to work the vast sugarcane fields. We had curry of some sort every day! Speaking of food, there are few local items to describe. Bunny Chow - I don't know why it is called this, but it is a scoop of rich curry - usually mutton or goat, served in a hollowed-out piece of unbelievably soft white loaf bread.Think of Merita or Bunny bread loaf. Biltong and Droewors - local dried meat treats usually made from beef, bush meat and ostrich. Think Jerky and Slim Jims. Shisha Nyama or Braai - South Africans' terms for a good old fashioned grilling party. And, of course, there are koeksisters, which are syrup infused doughnuts. I had to run an extra mile or two!

The pride of Durban and South Africa shone from people of Durban. Everyone knew their city history and was delighted to share.

Muthi Market at Victoria Street Station

Victoria Street Station is a large, outdoor market selling almost anything one can dream of, from iPhones to leather and pleather bags to the fish market section. Of particular interest to me was the somewhat dark and secluded section dedicated to the traditional African, especially Zulu, and Asian Indian medicine and healing arts. The Zulu, part of the Bantu ethnic group populating Southern Africa, are the largest ethnic group in South Africa. Need ground Impala horn, tiger dung, monkey paw, hippopotamus penis or any number of other animal parts and plants? This is your market!

I found any number of AIDS "cures" that included tinctures of different tree barks and roots and animal parts. The traditional "healer's" section, called the Muthi Market, stands in stark contrast to the modern medicine and HIV testing, treatment and prevention program that has made SA a wonderful example to the rest of the world on how to take on the challenges of a modern-day plague in the face of myths and ancient cultural misunderstandings.

The visit to the market was a fascinating glimpse into very old and traditional Indian and Zulu cultures. The smell of "herb" was quite prevalent despite being illegal in South Africa, but many tour guides weren't slow to tell you which street corners might be the best options for "getting lucky!"

Nelson Mandela

We visited Ohlange High School (also known as Ohlange Institute) which was founded by John Dube and his wife Nokutela Dube n�e Mdima in 1900. It was the first school in South Africa founded by a black person.

Despite being able to vote in any location in the country, Nelson Mandela, at 75, chose Ohlange to cast his first vote as a free man on April 27, 1994 in post-apartheid South Africa. Mandela chose the area because he wanted to give the native black population the confidence to vote. He chose Ohlange High School in particular because this is where John Dube was buried and he wanted to lay a wreath. Dupe also founded and was president of the South Africa Native National Congress (SANNC), which later became the African National Congress (ANC).

After voting, Mandela stood by the grave and said "Mr. President, I have come to report to you that South Africa is free today." At the IAC, I had the honor to hang out with Mr. Mandela's grandsons Adjao and Kweku. Of course, I invited them to come visit Charlotte!

Mahatma Gandhi

We also visited Gandhi's home in South Africa where his revolutionary movement for peaceful political change began. He came to India as a lawyer at age 17 at the request of a friend, and after arriving in South Africa was thrown from the First Class section of a train because of his brown skin. This experience changed his life. During his time, he more fully developed the Seven Social Sins listed here:

� Wealth without work
� Pleasure without conscience
� Knowledge without character
� Commerce without morality
� Science without humanity
� Worship without sacrifice
� Politics without principle

Gandhi is one of my heroes. I try to live by these principles.

Tala Reserve
What would a trip to Africa be without a safari? Even a little one! We spent part of a day at the Tala Reserve, where we got to see three of the Big Five of Africa. We saw lions (way too close!), hippopotamuses, rhinoceroses, and many, many others. But no elephants or giraffes - that will be our next trip!

What Did We Learn in the Non-Scientific Sessions?

Access to HIV treatment and prevention is not equitable in a great many parts of the world. If you are not white or not male or not rich, or are LGBT or a sex worker or an IV drug user, your care is frequently not equal.

These are currently somewhat better in America, but we must make better efforts to treat all humans equally. The forgotten segment of patients is our youth. Over half of the world's new cases of HIV are occurring in the under-25 age group. HIV/AIDS has gone from a death sentence in 1985 with 18 months to live; to now, with adherence to medications and a healthy lifestyle, those living with HIV can now live as long as HIV negative patients. Technology is helping to reach more patients worldwide than we could have imagined. We have every tool we need to completely stop the epidemic: condoms, PrEP (pre-exposure prophylaxis), PEP (post-exposure prophylaxis), ART (antiretroviral therapy) awareness and education. And yet 2.1 million people, 150,000 of them children, were infected with HIV last year.

On a more upbeat note, at the 2008 IAC there were zero presentations on HIV and transgender. At IAC 2016 there were 50 presentations.

Charlize Theron delivered the opening address to IAC with these words: "The real reason we haven't beaten this epidemic boils down to one simple fact: We value some lives more than others. We value men more than women, straight love more than gay love, white skin more than black skin, the rich more than the poor, adults more than adolescents. I know this because AIDS does not discriminate on its own. It has no biological preference for black bodies, for women's bodies, for gay bodies, for youths or for the poor. It doesn't single out the vulnerable, the oppressed or the abused. We single out the vulnerable, the oppressed and the abused. We ignore them. We let them suffer and then, we let them die. HIV is not just transmitted by sex. It's transmitted by sexism, racism, poverty and homophobia. If we're going to end AIDS, we must cure the disease within our own hearts and within our own minds, first."

Nelson Mandela said: "Young people are capable, when aroused, of bringing down the towers of oppression and raising the banners of freedom." Our young people are not only our future, but the key to this epidemic. We must fully support them, effectively educate them using facts and science, and give them the confidence to speak out against bigotry and injustice.

What Did I Learn in the Scientific Sessions?

The PARTNER study which studies HIV positive patients who keep their viral load undetectable, is now several years old with more than 58,000 episodes of sex without a single new HIV seroconversion to positive. These are HIV positive patients whose HIV negative partners are not on PrEP. Undetectable is truly the new negative. PrEP is 99.99 percent effective when taken every day. On demand use indicated ~95 percent protection.

For sero-discordant couples, (one HIV positive and one HIV negative) PrEP is not needed if the HIV positive partner is undetectable (see PARTNER Study), but if you are the type to wear suspenders and a belt to keep your pants up, then both PrEP and your partner maintaining undetectable is the right path for you. Over 80,000 Americans are now on PrEP with less than 1 percent considered to be high risk flyers (See "Truvada Whores?"). Atripla and Sustiva again correlated with suicide - get patients off Atripla and Sustiva now! No vaccine anytime soon. We currently do not have the technology to create a mutating vaccine that would keep up with the rate at which HIV mutates. Current literature suggests that we are more than 10 years away from a cure.

What Did Trey and I Bring Away from This Adventure?

The conference brought together scientists, advocates, people living with HIV, implementers and many others. The conference gave everyone much to work with as we continue efforts to bring an end to AIDS. And the take-home message? We are stronger when we work together.