The purpose of the semi-annual Newsletter is to provide information about our program activities and to offer a forum for our teams in the field, while also keeping up with the most recent therapeutic advances and showcasing well-known figures in the field of HIV ... The letters are published at the same time as World AIDS Day (December) and our General Assembly (June).

To make sure that updated information about Solthis is available to a maximum number of readers, all Newsletters exist in English and French versions since December 2007. To subscribe, click on the "About" button on the right.  For more information - and/or if you have suggestions for articles - please contact Pénélope Autret: penelope.autret@solthis.org.

SOLTHIS

Initiative : means beginning activities where  there was nothing available, providing training where there is so much still to do, and organising where things are in their earliest stages. But our initiative should also include innovation, now and even more in the future, inventing ways to gain better access to patients, especially patients who abandon treatment and follow-up, patients who we too easily categorise as “lost to follow up”, hiding behind a pat epidemiological term. We must understand and find solutions to the terrible fatality of a 10% or even 20% mortality rate in Mali in men and women who have only just begun to imagine living and surviving. Why do certain people give up even when treatment is available? Discrimination, the difficulty of day-to-day living with a disease that is not really like others, the impossibility of regular follow-up, not wanting other people to know. Certain people hide their illness, live in denial, in depression – patients and caretakers, both…

Probably the most difficult thing to understand is what it means to live with a chronic disease when you do not die. Chronicity which is obviously necessary when treatment is effective and well tolerated and when the patient has accepted the virus that they will live a long life with. This is definitely an unprecedented challenge and all the national and international institutions from the developing and the developed countries, organisations, healthcare professionals and associations will never be enough if we do not imagine new ways to gain access to and communicate with the populations in the different countries, to free them from the most backwards type of discrimination, to provide them with regular access to treatment and to effectively share and delegate these different tasks. These are the new challenges facing SOLTHIS.

Five years already in the life of Solthis ! In the past five years, advocacy for access to antiretroviral treatments has transformed into universal principle. Yet much remains to be done to ensure high-quality care, which is today the ultimate indicator of HIV-positive patients’ situation. Biological and particularly virological testing is necessary to guarantee the best possible therapeutic prescription and follow-up. Tomorrow, we will measure our success not in the number of ARV treatments dispensed, but in the number of patients with undetectable viral loads. But such a vision can only triumph if we come together as stakeholders from both the North and South. Further, we must work with virologists and researchers to develop techniques for tomorrow, so that measuring viral load becomes as simple as rapid HIV tests – an unthinkable achievement only a few years ago.
The 15th International Conference on AIDS and Sexually transmitted infections in Africa (ICASA) this December in Dakar will be the occasion to report on various initiatives in the fight against HIV/AIDS in Africa. As Profs. Papa Salif Sow and Robert Murphy say in this Letter, it is only by working together that African treatment teams will be able to effectively fight the disease. Now is also an important moment for Francophone countries, which are provided the increasingly rare opportunity to express themselves at an international conference. The French-speaking community finds its voice when permitted to articulate an alternative and complementary point of view, contributing to the collective welfare of African patients.
This conference is also the chance for Solthis to present on an international stage its quotidian work in the field – in direct support of local teams and national health policies. Our teams have done remarkable work. First, Solthis will present results from its study “Patients lost to follow up in Segou, Mali,” notably on the importance of various forms of patient accompaniment. The study was produced thanks to a multidisciplinary partnership between local treatment teams, patient associations, epidemiologists from the Institut Pasteur, and economists from the Sciences-Po school in Paris. Then, Niger will give a presentation on its successful implementation of a patient information system, an initiative supported by Solthis. A final presentation covers virological results issuing from the partnership between Prof. Christine Rouzioux’s team at Necker Hospital and the National Reference Laboratory in Antananarivo, Madagascar.
Turning a concept into reality – yesterday, we worked toward treatment access; today, we seek earlier access to treatment for people living with HIV and virological oversight of treatment. These are our two biggest priorities for the years to come.
Rendez-vous in five years!

Solthis is sharing in one the most important advances in the medical management of HIV in the developing countries: remarkable progress is being made in this domain in almost all of these countries! The inequalities persist, but it is now clear that medical management is possible. By training medical teams, informing patients and managing drug supplies, more and more patients can be treated and their immune deficiencies corrected every day. The ups and downs continue; viral resistance to treatment, the development of adverse effects, life-long treatment and the management of chronic disease are important problems both in the developing and developed countries, but a dynamic has been created: treatment is possible and effective in the developing countries. Besides these advances, significant progress has also been made with new antiviral treatments that prevent the virus from entering into or integrating the cell, which we hope will soon be available in the developing countries.

Still, the fight against the disease is not over. Effective prevention would be an easier, less expensive and less painful solution. What progress has been made in this field? Some advances have been fantastically positive, others terribly negative. The most effective prevention today is circumcision, seemingly a traditional form of hygiene and protection against sexually transmitted diseases. All studies confirm that circumcision could prevent 50% of cases - and the map of the distribution of circumcision is the mirror image of that of the prevalence of HIV. Women obtain secondary benefits from the lower prevalence of infection in all countries where circumcision is widely practiced.

Unfortunately, there is bad news alongside these success stories: the continued failure of vaccines. Indeed, a therapeutic immunisation trial performed by our group supported by the Fondation Bettencourt-Schueller with a candidate recombinant vaccine - the canarypox which expresses HIV genes, administered to patients who were already infected and being treated - resulted in increased anti-HIV immunity. However, when treatment was stopped after the immunization period, there was greater viral replication in vaccinated patients than in those receiving a placebo...

Another preventive vaccination trial (STEP) performed in at-risk volunteers used what was considered the most serious candidate vaccine: a non-pathogenic modified adenovirus expressing certain HIV genes. This trial was stopped half way through, because of a higher frequency of HIV infections in vaccinated patients than in those receiving a placebo! However, this effect was not found in volunteers who already had a natural immunity against the adenovirus and who were not circumcised (once again confirming the efficacy of this practice). The conclusion of the bad news: by activating anti-vaccine or anti- HIV CD4 lymphocytes, the vaccination makes them more receptive to HIV itself, and favours infection! Should these results be generalized to include all "candidate" anti-HIV vaccines?

It's too early to say, and other studies must be performed before drawing definitive conclusions. One conclusion is sure: the road will be long, very long, before an effective anti-HIV vaccine is marketed... With this in mind, Solthis' activities have never been more important!

We hope that this letter gives you a feeling for the spirit that motivates the teams at Solthis: making high quality treatment available to the greatest number of patients. The articles in this issue take up the themes treated during our Scientific Workshop on June 27, 2008, which was dedicated to medical news about patient management in Africa. In particular, we present the debate around the article by Andrew Philips about virological follow up that was published last April in The Lancet.  

Scientific debate, which is essential if we are to further our knowledge and become more efficient, will be the central theme at the Solthis Day this year.

There are more reasons than ever for hope. True, we cannot declare victory yet, far from it. And the most recent figures from UNAIDS show that we cannot relax our efforts, on the contrary, we must be twice as committed: more than 33 million people are living with HIV worldwide, there were more than 2.5 million new cases this year and more than 2 million deaths including 330 000 children... A situation that is still disastrous, especially in Africa, where two thirds of the new cases, and three quarters of the deaths occurred.

A virus that continues to progress, especially in Asia, the Caribbean and Eastern Europe. Although the numbers are decreasing, this is only because there has been a change in the way they are calculated, not because of a reversal in the tendency of the HIV/AIDS epidemic.

So, what are the reasons for hope in the face of these terrible statistics?

First, active mobilisation on an international scale, in particular to obtain the necessary means to treat patients.  Michel Kazatchkine, General Manager of the Global Fund testifies to this in our Letter: more than 1.4 million patients now have access to ARVs (anti-retrovirals). The "country driven" strategy of this fund means that the different countries are responsible for their policy in the fight against AIDS, which is essential if the programs are to last and if there is to be effective mobilization in the field. This is Solthis' strategy too.

We must also mention the strong mobilization in France to increase funding with the creation of UNITAID one year ago. In this issue, Philippe Duneton presents us with encouraging end-of-the-year results: 27 countries have promised to contribute funds mainly by placing a tax on airplane tickets, a financing mechanism which should continue to grow as more and more passengers use electronic tickets and make a voluntary, personal choice to contribute to the fight against AIDS.

Today these funds are principally used to fight HIV in children, in the prevention of mother-to-child transmission and to make paediatric ARV accessible: enormous needs and undeniable priorities.

But the road will be long, very long, because there is no miraculous solution. Since the hope of a vaccine in the near future is fading, it is absolutely essential to provide access and guarantee proper long term administration of antiretrovirals.

To reach our goal we have the amazing solidarity of all of those involved. This is perhaps the real answer to the battle against all those diseases and the inequalities in healthcare for which HIV and AIDS are the most dramatic, inexcusable examples... the battle against a disease that destroys a person's health, but that also means that s/he is excluded, and that his/her family may be ostracized....

The fight against AIDS is still a fight to respect the rights and dignity of infected individuals.

The fight against AIDS, more than any other disease, is the source of coordination and new actions between the developing and the developed countries. The 4^th Francophone conference, held in Paris last March is a sign of this dynamic relationship. Organized by C. Katlama, President of Solthis and JF Delfraissy, Director of the ANRS, 1600 people from 60 countries participated in this conference to exchange their experiences and share their difficulties....

On December 1, 2006, World AIDS Day will be dedicated to the sad 25th anniversary of this disease and announce the most recent statistics about the pandemic. Unfortunately the 25 years of the disease have not been associated with a regression of the development of HIV, which was identified in 1981 and which is today an omnipresent medical reality that still affects Africa more than any other place in the world. 

The most recent figures in 2006 from UNOAIDS show the extreme severity of the situation of HIV /AIDS in the developing countries. Nearly 40 million people live with HIV, including 2.3 million children...