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Over the last 35 years, the International AIDS Conferences under the auspices of the International AIDS Society, have united a global community spanning people living with HIV, politicians, scientists and celebrities for the better exchange of information, challenges, solutions to HIV and AIDS, and reasons for hope. Due to COVID-19, the 23rd International AIDS Conference relocated from San Francisco to cyberspace, offering 24-hour access to breaking science like never before. We spoke with Professor Sharon Lewin, Director of the Doherty Institute, as this year’s conference drew to a close to learn more about the gains being made in treatment, how HIV informs and intersects with COVID-19, and how the pandemic threatens to derail the progress made in HIV and AIDS worldwide.

Q: One of the strengths of the International AIDS Conference is that it brings together people from all corners of the globe, including scientists, journalists, activists, patients, doctors and health workers. How did that translate into a virtual space?

A: It was very different to what we normally have for the AIDS conferences, however I found that I could engage with the issues, even if fully remote. Being able to immerse myself in the content of the conference (even if only in my lounge room) made for a very rewarding experience. I heard some inspiring talks from people living with HIV, such as Billy Porter, who highlighted the endemic issues of discrimination in his life as a gay, Black man living with HIV. You can watch this on YouTube here. There were some excellent discussions with a range of speakers, including Tony Fauci (yes he actually has a full time job as a researcher outside of being the sensible voice of the US on COVID19), my ex PhD student Associate Professor Reena Rajasuriar who presented a plenary talk on ageing with HIV and Elton John and his passion for philanthropy! It was quite a diverse line up! The conference also featured access to the Global Village, a free space that had a multitude of performances, including music and theatre. These spaces could be widely accessed by anyone, anywhere in the world. I really enjoyed seeing performances from colleagues of mine from University of California San Francisco (UCSF) Peter Hunt, Satish Pillai and Devi Sangupta. Not only are each of my colleague’s superb HIV scientists but very talented musicians too!

Q: UNAIDS released their latest report on the first day of the conference that presented the latest statistics - 38 million people are currently living with HIV, including 25 million people taking antiretroviral drugs. How might they be uniquely impacted by COVID-19?

The real global impact of COVID-19 hit me strongly during this conference. The Global Fund and UNAIDS released a report on the impact of COVID-19 on HIV programs, estimating that there may be an additional 500,000 deaths from AIDS if disruptions to HIV services continue for the next 6 months.

In many parts of the world, a huge number of people live with HIV – in some areas in countries such as South Africa, it’s up to a third of the population. When you have a widespread lockdown and people are stuck in their homes and cannot access their treatment, or they cannot get to the doctor to get tested, or the hospital is not functioning, there is a real impact with that.

The Global Fund released similar data for the impact of COVID-19 on tuberculosis and malaria. I think we’ll see the impact of the pandemic on these big killers globally in the next six months. This conference was a strong reminder for me of the real impact of COVID-19 on global health.

Q: There was quite a bit of attention on the ‘São Paulo patient’ and Dr. Ricardo Diaz's “kick and kill” method. Can you tell me more about this and whether you think it’s the promising cure that the press was reporting it to be?

The ‘São Paulo patient’ was a very interesting case report. He was part of a clinical trial with four other people who received regular antiviral therapy, as well as two additional antiviral drugs and a medication called nicotinamide (a form of Vitamin B) for 12 months. He then continued regular antiviral treatment for three years and then stopped his medications. When he stopped his antivirals, no virus could be measured in his blood for now 60 weeks.

This is very unusual as in most cases, when people stop their antivirals, virus rebounds I blood in two-to-three weeks. But we know from other studies, that in people who start antiviral treatment within six months of infection, about 10% of people can have a prolonged time to viral rebounds when they stop their antivirals. This is called post-treatment control. It’s rare, but certainly described. In this case, it is unclear if this man was a post-treatment controller, or if the additional interventions made a difference.

The interesting thing about this man was that his HIV antibody levels were decreasing when he was off antiviral treatment. When you have HIV, you make antibodies to the virus. Those antibodies hang around in almost everyone, even when you go on treatment. In a few cases, however, we have seen the antibodies can slowly decrease. That's what happened with Timothy Brown, the man that was cured of HIV. In this man in Brazil, his antibodies were also decreasing once he stopped treatment. That's a very interesting observation, but much more detailed work needs to be done to understand what was happening to his antibodies to produce this outcome.

We need a large randomised clinical trial to really understand if this additional treatment made a difference in inducing control of HIV and if it did, how it actually worked.

Q: Tell us about the ‘London patient’ who was also interviewed at AIDS 2020?

A: The London ‘patient’ is a man called Adam Castillejo. Adam’s the second person cured of HIV through a bone marrow transplant, which was used to treat his blood cancer. He received the bone marrow transplant from a donor who was naturally resistant to HIV. He then stopped his antiviral drugs and his virus remained at undetectable levels, now for three years. His case was first reported and published in 2019 and then a follow up more detailed analysis was published in 2020. During that time, his doctors looked high and low to see if they could find the virus anywhere in him. They looked in his gastrointestinal tract, his lymph nodes and his blood, and they could find pieces of the virus but not the whole, intact virus. This supports the claim that he is in fact cured.

Adam Castillejo went public with his identity in February of this year; however, he hasn't been interviewed or spoken publicly with HIV researchers or community yet. So, we were really excited to have him be interviewed at the pre-conference on cure. We asked his doctor, Ravi Gupta from Cambridge, to be interviewed alongside him. It was very inspiring. Adam was asked a lot of questions from people about what they should be feeling in the pandemic, and he had some really nice ways of inspiring people. He had a message: "Never give up hope”. He never thought for a minute that he could be cured of his cancer, let alone cured of both his cancer and HIV. Incredible things are possible.

Q: Were there other highlights that you’re taking away with you from this year’s conference?

A: There was a particularly interesting study on an injectable pre-exposure prophylaxis (PrEP) treatment. Currently, we have an oral PrEP drug called Truvada that’s available in Australia. It works extremely well at preventing HIV infection. This study investigated an injectable PrEP, cabotegravir, which required an injection every two months. This actually worked better than the oral tablets. If cabotegravir becomes widely accessible and cheap it would be very exciting.

Q: The end of this year marks another milestone, known as 90:90:90, which aims to see 90% of people with HIV globally being diagnosed, 90% of those diagnosed receiving treatment, and 90% of those receiving treatment to have viral suppression, along with under 500,000 deaths annually. We’re not quite there yet, as we’re at 81%, 82% and 88% respectively. Do you see this as a sign of hope that we’re moving in the right direction?

A: Yes, we are not far off. We have done well to increase access to treatment and there’s been real progress there. That's good. Once people are diagnosed, they’re receiving treatment and once they’re on treatment, they do well.

But we aren't meeting the goal to reduce deaths. In 2019, there were 1.7 million new infections and 690,000 deaths. The number of people with HIV and AIDS is growing, and 90:90:90 doesn't address the issue of new infections. Treatment alone will not address the issue of new infections. We need other approaches, such as PrEP, education, and additional public health measures.

What’s more, in 2020 we can also add the impact of COVID-19 to these markers. We cannot pretend that the pandemic is going to come and go without having a major impact on the progress that has been made in HIV and AIDS.

By 2030, the target was 95:95:95, with less than 500,000 new infections and zero deaths from AIDS. I’m actually not feeling enthusiastic that we're really going to meet these targets as planned. I think that our progress could be derailed by COVID-19. I actually came away from the conference feeling a lot more concerned, having underestimated the bigger impact of COVID-19 is not going to just make economically on the world but on advances that have been made in global health – not just in HIV, but in many other infectious diseases.

To get a feel for the global impact of COVID-19, I encourage everyone to tune into the AIDS2020-COVID19 conference. There were some brilliant talks there – including presentations from Bill Gates, Jane Goodall, Peter Piot and the highlight was Mary Robinson (previous Prime Minister or Ireland). See: https://covid19.aids2020.org/