As I gaze across the quiet waters on the shores of Lake Victoria, watching the sun dip below the horizon, a boat approaches carrying a group of young African scientists. Their faces express a quiet confidence, even in the gloom of the approaching nightfall. They have embarked on a journey to rewrite the HIV narrative with a glimmer of hope that young African women will be at front and centre of efforts aimed at bringing the HIV epidemic to an end.
The scientists have designed and implemented the multi-site study for Adolescent Girls and Young Women (Magy) to explore the role of young women in Uganda, Zambia, and South Africa in the development of a vaccine against HIV.
Vaccines are like training sessions for your immune system. They introduce a weak or inactive part of a germ (like a virus or bacteria) into your body and prepare your immune system to recognise and quickly fight off potential invaders without making you sick.
Why focus on an HIV vaccine for young women? The alphabet soup of HIV prevention: Abstain, Be faithful, Condom use, and Drugs including anti-retroviral based daily oral pills, monthly injectables, and vaginal rings will prevent most HIV infections. But, alas, the number of new HIV infections especially among AGYW in sub-Saharan Africa remains unacceptably high compared to men and boys that are the same age. As a medical doctor, epidemiologist and mother, I believe we need to look at the ABCDs with honest eyes.
Let’s face it, adolescence marks the start of sexual activity for many girls, and every sexual encounter has the risk of developing into HIV/Aids. This risk increases with unprotected sex, among people with a high number of partnerships, having sexually transmitted infections, and engaging in harmful use of alcohol and drugs.
Young African women must surmount greater hurdles to access, initiate, and adhere to HIV prevention and treatment services complicated by a host of structural barriers from socioeconomic hardships to laws, social norms, and cultural expectations.
Each factor makes it harder for young women to use the ABC and D HIV prevention tools consistently. Even worse, despite their high risk of infection, many do not see themselves as vulnerable. This disconnects between perceived and actual risk underscores a gap in our collective approach to HIV prevention—a gap we can bridge by putting young women at the forefront of the research that seeks to protect their future.
The solution is an HIV vaccine, right? One that is safe, affordable, and blocks the virus quickly and permanently. This is the mission of IAVI. Almost 40 years since the identification of HIV, vaccine development is one of the greatest challenges scientists have ever faced.
This is partly because, unlike other viruses, HIV has unusual characteristics including rapid replication, furious mutation, immune system evasion, and the creation of viral reservoirs. The HIV virus is like a complex jigsaw puzzle with many constantly changing and sometimes hiding pieces, in a bid to evade the body’s immune system.
Developing an HIV vaccine is like an enormous task of finding the right pieces that fit together to create a picture of prolonged protection against a broad array of HIV viruses. Despite these challenges, scientists are dedicated to solving this puzzle by exploring innovations. One such innovation is to train the immune system to launch the production of the desired broadly neutralising antibodies (bnAbs) by stimulating the right antibody-producing cells: one way to do this is called germline targeting.
Welcome to the world of germline targeting, a stepwise approach that mimics the natural process of producing antibodies that can protect against a wide range of HIV subtypes. Antibodies are like specialized soldiers created by the immune system to recognise, attack, and destroy specific germs after the training received from previous infection with the same germ or a vaccine. Not all human beings are born equal a few are destined to be global leaders who impact global issues. Many are just regular folks who impact local and regional issues, and some are neither.
Similarly, as far as HIV is concerned, not all people are created equal in their ability to produce antibodies. A few individuals infected with HIV have superstar potential. They naturally produce antibodies that can fight diverse strains of HIV (also called broadly neutralising antibodies). This logical process can inform the development of an HIV vaccine that could protect HIV-negative people from acquiring HIV.
However, many individuals produce antibodies to fight a few strains of HIV and some produce antibodies that target relatively unimportant parts of the HIV virus.
At Iavi, scientists and their collaborators are designing a vaccine that could help all HIV-negative people produce broadly neutralising antibodies that can provide prolonged protection against a wide range of HIV strains with few side effects.
Science for and by young women
Researchers in the HIV field, like the Magy team agree that new HIV vaccine candidates will need to be tested in clinical trials in different regions of the world to ensure they work safely and effectively for all people, young and old. However, it is important that the vaccines are developed from the onset with young women in mind.
Historically, their voices have been peripheral in shaping the tools designed to protect them. Our research boundaries must extend further to include adolescent girls and young women, early on in research processes. And not just as participants but also as leaders, understanding and adapting to their unique needs and perspectives. Science, when it is inclusive, becomes a powerful tool for change. Gender-sensitive research and innovation are not mere buzzwords — they are critical to the creation of HIV prevention methodologies that are both effective and acceptable to AGYW.
This leads us back to the enthusiasm of the young African scientists, in the heart of Eastern and Southern Africa who have designed the Magy study. As a research group, we join the rest of the world to commemorate World Aids Day. We must turn a keen eye to one of the most crucial yet overlooked areas in the battle against HIV/Aids: The direct involvement of adolescent girls and young women in HIV vaccine research, especially within the hard-hit communities of Sub-Saharan Africa.
The aim of the Magy study is to develop the evidence base for best practices for including adolescents and young women in future clinical trials for HIV vaccines. A key question is how do we ensure protected engagement of our young people in biomedical research, and at the same time ensure future protection by a vaccine?
Critically, the views of adolescent girls and young women and their parents and communities are at the centre of the Magy study. This involves community visits, running adolescent and youth-friendly clinics, and collaborating with young people to design tools, collect data, and disseminate information to ensure that young people are seen and heard.
The Magy study is a collaboration between Iavi, CFHRZ in Zambia, the UVRI-Iavi HIV Vaccine Program in Uganda; Kavi Institute of Clinical Research, Kenya; the Aurum Institute in Rustenburg, South Africa; the Population Council; and the University of Manitoba. The study is funded through the Accelerate the Development of Vaccines and New Technologies to Combat the Aids Epidemic (Advance) programme, a 10-year collaborative agreement between Iavi and USAid through the US President’s Emergency Plan for Aids Relief. The goal of Advance is to ensure safe and globally effective HIV vaccine and biomedical prevention products are developed by African and Indian leaders.
The Magy project is in its infancy, and there is a long way to go before inviting young women to receive an HIV vaccine to protect them against HIV for life. However, the team of dedicated scientists crisscrossing Eastern and Southern Africa are committed to focusing their efforts on the most vulnerable demographic to HIV.
I look outside again at the break of dawn as the sun gently kisses the waters of Lake Victoria. A beautiful girl’s smile warms my heart as she grabs my hand and leads me outside to the landing where the Magy team is sharing their stories with attentive young women and their parents.
The resolute words of the team leader echo across the water, “We’ll leave no girl or woman behind in the HIV response.”
The wind carries these words, now infused with the collective resolve of young people and their community determined to shape their own destiny—to make HIV a thing of the past.
Monica Kuteesa Okello, MD, Ph., is a director of epidemiology at Iavi. She is also the co-chief investigator for the Magy study.