No vaccine, no cure: HIV and AIDS in the United Kingdom - Select Committee on HIV and AIDs in the United Kingdom Contents

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)[80] noted that, "no other health intervention is more cost effective or has a greater impact on public health than vaccination".[81] 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 years … yet another terrible disease is about to yield to patience, persistence and outright genius".[82] 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.

No vaccine

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.[83] In comparison, funders based in the United Kingdom—the Government, the Medical Research Council (MRC) and the Wellcome Trust—provided $23.6m between them.[84]

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.[85] Scientists based in the United Kingdom have also contributed significantly to the development of candidate vaccines. IAVI praised "UK leadership in the global arena".[86] 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.[87]

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 international cooperation.

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.[88] 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.[89] Mary Kerr, Vice-President and European Head of ViiV Healthcare[90], 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".[91]

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[92]; Mary Kerr and Lisa Bright, General Manager for UK and Ireland of Gilead Sciences[93], believed that a more streamlined approach to regulatory approval for clinical trials could also improve the situation.[94]

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.[95] Peter Weatherburn, Director of Sigma Research[96], noted that, "a vaccine has been five to six years away for at least 15 years ..."[97]

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.

No cure

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.[98] 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.[99] 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 measure".[100]

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.[101] 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".[102]

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.[103] 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.[104] 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.[105] In London, treatment costs last year were around £250m[106], 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.[107]

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.[108] 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.[109]

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."[110] Anne Milton MP, Minister for Public Health, stressed that "prevention remains as important as it did 25 years ago."[111] Despite this, she believed that the question of resources was more about "how effectively that money is spent ..."[112]

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 clinical settings.

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[113], and the Minister indicated that the new document would have the same status and purpose as that strategy.[114] 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"[115]; 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

81   HAUK 65. Back

82   Office of Technology Assessment 'Review of the Public Health Service's Response to AIDS', U.S. Congress, Washington DC., February 1985, p29. Back

83   HAUK 65 (IAVI). Back

84   ibid. Back

85   ibid. Back

86   ibid. Back

87   HAUK 14. Back

88   Q 434 (Professor Sir Andrew McMichael). Back

89   HAUK 14. Back

90   A joint GlaxoSmithKline and Pfizer HIV pharmaceuticals venture. Back

91   Q 402. Back

92   HAUK 65 (IAVI), HAUK 71 (Professor Jonathan Weber). Back

93   A pharmaceutical company. Back

94   Both at Q 415. Back

95   Q 444. Back

96   A social research group, part of the Faculty of Public Health and Policy at the London School of Hygiene and Tropical Medicine. Back

97   Q 906. Back

98   Q 477 (Professor Jonathan Weber). Back

99   Q 477. Back

100   Q 443. Back

101   QQ 446-7 (Dr Sheena McCormack). Back

102   Q 832. Back

103   Q 881. Back

104   HAUK 19 (Department of Health). Back

105   HAUK 94 (Department of Health). Back

106   HAUK 51 (London Specialised Commissioning Group). Back

107   Q 740 (Simon Williams ) HAUK 19 (Sima Chaudhury) and personal correspondence with Mark Creelman, Inner North West London PCTs. Back

108   HAUK 97 (Health Protection Agency). Back

109   ibid. Back

110   Q 167. Back

111   Q 1089. Back

112   Q 1090. Back

113   Department of Health, Better prevention, better services, better sexual health-The national strategy for sexual health and HIV, July 2001. Back

114   Q 1130. Back

115   Q 881. Back

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