CHAPTER 3: No Vaccine, No Cure |
35. Given the scale of the challenge, what can
be done in response? The International AIDS Vaccine Initiative
(IAVI) noted that,
"no other health intervention is more cost effective or has
a greater impact on public health than vaccination".
In the last century, vaccines have delivered striking successes
in the worldwide fight against diseases such as smallpox and polio.
36. The same was forecast for HIV. In 1984, the
then United States Health Secretary, Margaret Heckler, said: "We
hope to have a vaccine ready for testing in approximately two
yet another terrible disease is about to yield to
patience, persistence and outright genius".
More than 25 years later, this pledge remains unfulfilled. Nonetheless,
the development of a vaccine remains an important goal in the
fight against HIV and AIDS.
37. In 2009, the latest year for which we received
data, the main thrust of research worldwide came from the United
States, through both public and charitable channels. The US National
Institutes of Health dwarfed other funders, providing $596m, whilst
the Bill and Melinda Gates Foundation provided more than $72m.
In comparison, funders based in the United Kingdomthe Government,
the Medical Research Council (MRC) and the Wellcome Trustprovided
$23.6m between them.
38. Despite the dominant role of the United States,
the United Kingdom has been an important partner. In 2009, the
United Kingdom was Europe's largest investor in HIV vaccine research,
and the third largest funder worldwide.
Scientists based in the United Kingdom have also contributed significantly
to the development of candidate vaccines. IAVI praised "UK
leadership in the global arena".
Professor Sir Andrew McMichael, Director of the Weatherall
Institute of Molecular Medicine, noted that approximately half
the MRC spend on HIV was relevant to vaccine development.
39. We applaud the commitment and leadership
shown by successive governments in their support for the development
of a HIV vaccine. Continuing commitment to the development of
a vaccine is essential. This must continue to involve extensive
40. It is not only the public and philanthropic
sectors, though, that can play a part in vaccine development.
Pharmaceutical companies also have extensive expertise that could
drive forward promising developments.
At present, they are not prominent within the field of HIV vaccine
research. Professor Sir Andrew McMichael said that the
"huge outlay, high risk of failure and impoverished markets"
meant it was not an attractive area.
Mary Kerr, Vice-President and European Head of ViiV Healthcare,
stressed that the complexity of HIV vaccine development, combined
with a relative lack of capacity for HIV vaccine research within
pharmaceutical companies, meant it was "not surprising that
there has been a limited focus".
41. In light of these factors, the key question
is how best to encourage participation. One model suggested was
the Product Development Partnership, marrying public sector research
with private sector product development;
Mary Kerr and Lisa Bright, General Manager for UK and Ireland
of Gilead Sciences,
believed that a more streamlined approach to regulatory approval
for clinical trials could also improve the situation.
42. The truth is, however, that the development
of a vaccine is not likely in the short-term. Professor Sir Andrew
McMichael stressed that there were "huge scientific obstacles"
to overcome, and felt that a vaccine was at least a decade away.
Peter Weatherburn, Director of Sigma Research,
noted that, "a vaccine has been five to six years away for
at least 15 years ..."
43. Funding bodies, both public and private,
should continue to support HIV vaccine research as part of their
research strategies. Cooperation with international partners must
be central to this work. At the same time, the Government should
consult with the pharmaceutical sector to determine whether improvements
can be made to existing models of working and regulatory processes
to better involve them in efforts to develop a HIV vaccine.
44. Although the successful development of
a vaccine is crucial in the longer-term, the response to HIV and
AIDS in the United Kingdom must be based on the assumption that
none will exist for at least a decade.
45. Another way to combat a disease is to cure
a person affected by eradicating it from their body. This is not
yet possible for HIV. The virus can be suppressed, but not eliminated,
by existing therapies.
According to Professor Jonathan Weber, Director of Research
for the Faculty of Medicine at Imperial College London, such eradication
is "the grail" for HIV research.
Nevertheless, suppressive antiretroviral therapy has been an important
part of the response to HIV (see Chapter 7). As Professor Sir Andrew
McMichael said, "you cannot treat your way out of this pandemic,
but you can do quite a lot of good with drug treatment as a holding
46. It is essential, though, that treatment does
not cause longer-term harm. If a person fails to stick to a regime
of antiretroviral drugs, it can lead to the development of drug
resistance, as has been seen with antibiotics. Were such resistance
to become widespread, treatment efforts would be hampered in the
long-term. This is closely monitored. The United Kingdom has the
largest resistance database linked to clinical data in the world,
to ensure that any problems are quickly identified.
With no vaccine and no cure, it is important that surveillance
systems robustly monitor and contain the risk of emerging antiretroviral
resistance (see paras 227 to 228).
Putting prevention first
47. Given the lack of either a vaccine or a cure,
we must consider what else can be done to prevent the spread of
HIV. Dr John Middleton, Vice-President of the United Kingdom
Faculty of Public Health, noted that, "prevention is better
than cure when there is no cure".
48. At present, the priority given to prevention
at national and local levels is woefully inadequate. Peter Weatherburn
believed that HIV prevention was a "poor relation" within
sexual health services.
This is demonstrated by the disparity in spending between HIV
treatment and prevention. £2.9m will be spent on national
prevention programmes in 2011/12.
This spending has been static since 2009/10, and is less than
half a percent of the £762m spent on treatment and care in
England in that year.
In London, treatment costs last year were around £250m,
whilst Primary Care Trusts spent around £3m on prevention
work, which included awareness campaigns and counselling, as well
as one-to-one and group interventions.
49. This failure to invest persists despite evidence
of the savings that prevention work could yield. The Health Protection
Agency indicated that each infection prevented would save between
£280,000 and £360,000 in direct lifetime treatment costs.
This means that if the estimated 3,800 UK-acquired HIV cases diagnosed
in 2010 had been prevented, more than £32m annually, and
£1.2bn in lifetime costs, would have been avoided.
50. Such stark figures demonstrate that there
is no downside to investing in effective prevention, and no justification
for the existing imbalance in spending. There are still thousands
of new infections per year, which will increase the costs of treatment
in the long-term. Current spending priorities commit the Government
to ever-more expensive treatment costs without providing anywhere
near enough resources to break the cycle. This must be rectified.
Though we acknowledge elsewhere that diagnosing and treating those
infected with HIV can have preventive effects which support broader
prevention efforts (see para 175), more money should be devoted
to preventing new infections through a range of interventions
in addition to antiretroviral therapy.
51. We note the support for the prevention agenda
from the Government. Professor David Harper, Director General
for Health Improvement and Protection and Chief Scientist at the
Department of Health, outlined that prevention was "absolutely
at the heart of what we are saying and what we are trying to achieve."
Anne Milton MP, Minister for Public Health, stressed that
"prevention remains as important as it did 25 years ago."
Despite this, she believed that the question of resources was
more about "how effectively that money is spent ..."
52. The Government must match their words with
action. Though money must of course be spent effectively (see
para 93), the balance between money spent on the treatment of
those infected and that spent on preventing people acquiring HIV
is simply disproportionate. This must be rectified. More resources
should be allocated to HIV prevention work, going beyond controlling
the viral load of those infected. Such work should include testing
and treatment for other STIs, as well as individual and group
interventions to reduce risk behaviours amongst those who are
HIV-positive or at high risk of infection, both within and outside
53. The Government have an opportunity to give
this broader prevention work greater priority through the development
of a new sexual health policy document. This will replace the
previous (now-expired) sexual health strategy,
and the Minister indicated that the new document would have the
same status and purpose as that strategy.
This opportunity must be taken.
54. Funding for prevention should not, though,
come at the expense of HIV treatment. As Peter Weatherburn said,
"you cannot buy prevention instead of drugs";
not least because of the important preventive role such treatment
plays by suppressing levels of the virus in the body. Treatment
and prevention work together; both must be fully supported by
the Government if combating HIV and AIDS in this country is to
be taken seriously.
55. Further Government support for prevention
is required. Prevention should be at the forefront of the response
to HIV. This must be reflected in the Government's replacement
of the 2001 sexual health strategy. More resources must be provided
at national and local levels. The Government should monitor and
audit the use of resources so provided, to ensure they are used
for the purpose of preventing new HIV infections.
80 A not-for-profit public-private partnership working
to develop a vaccine for HIV. Back
HAUK 65. Back
Office of Technology Assessment 'Review of the Public Health Service's
Response to AIDS', U.S. Congress, Washington DC., February 1985,
HAUK 65 (IAVI). Back
HAUK 14. Back
Q 434 (Professor Sir Andrew McMichael). Back
HAUK 14. Back
A joint GlaxoSmithKline and Pfizer HIV pharmaceuticals venture. Back
Q 402. Back
HAUK 65 (IAVI), HAUK 71 (Professor Jonathan Weber). Back
A pharmaceutical company. Back
Both at Q 415. Back
Q 444. Back
A social research group, part of the Faculty of Public Health
and Policy at the London School of Hygiene and Tropical Medicine. Back
Q 906. Back
Q 477 (Professor Jonathan Weber). Back
Q 477. Back
Q 443. Back
QQ 446-7 (Dr Sheena McCormack). Back
Q 832. Back
Q 881. Back
HAUK 19 (Department of Health). Back
HAUK 94 (Department of Health). Back
HAUK 51 (London Specialised Commissioning Group). Back
Q 740 (Simon Williams ) HAUK 19 (Sima Chaudhury) and personal
correspondence with Mark Creelman, Inner North West London PCTs. Back
HAUK 97 (Health Protection Agency). Back
Q 167. Back
Q 1089. Back
Q 1090. Back
Department of Health, Better prevention, better services, better
sexual health-The national strategy for sexual health and HIV,
July 2001. Back
Q 1130. Back
Q 881. Back