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The examinations of extremely drug resistant tuberculosis (XDR-TB) and immune control of HIV in South Africa’s KwaZulu-Natal Province was a major focus of the 2009 conference organised by the International AIDS Society in Cape Town from July 19 to 22. The conference dwelt on HIV pathogenesis, treatment and prevention in the world’s most HIV-impacted country. At Tuesday’s plenary session, the more than 5,000 researchers, clinicians and community leaders attending the conference also took a comprehensive look at research on biomedical interventions to prevent HIV infection and financing the long-term response to HIV amid growing concerns about the impact of the global recession on scale-up. 
“The XIII International AIDS Conference in Durban gave birth to the call for access to HIV treatment for rich and poor alike and the IAS has returned to South Africa as the continent stands at a threshold,” said IAS 2009 local co-chair Hoosen (Jerry) Coovadia who is chairman of Dira Sengwe and scientific director of the Doris Duke Medical Research Institute at the University of KwaZulu-Natal in Durban. “We have made real progress since 2000 but South Africa still has the worst epidemic in the world and we once again need the leadership of scientists, political leaders, international donors and community to turn the pandemic around.”
An estimated 5.7 million people in South Africa - one in every five adults - is HIV positive, and an estimated 600,000 patients had access to life-saving antiretroviral therapy (ART) by mid-2008. South Africa’s HIV/AIDS National Strategic Plan set targets to treat 80 percent of people who need ART by 2011, to give 95 percent of women access to prevention-of-mother-to-child transmission services by 2011, and to reduce new infections by 50 percent by 2011.
“In light of what is at stake, we are unwilling to accept the idea that HIV funding must fall victim to the global economy,” said IAS president Julio Montaner, who is IAS 2009 chair and director of the BC Centre for Excellence in HIV/AIDS in Vancouver, Canada. “We must always drive for an efficient response that includes rigorous evaluation, but there is nothing we can do that is more efficient in the long run than treating people early and in a sustained way.”
In his plenary presentation, Ronald Gray summarised the results of the 28 completed biomedical HIV prevention trials of STD control, microbicides, pre-exposure prophylaxis (PrEP), HIV vaccines and male circumcision. Of these trials, only four, including three of male circumcision, have reported significant efficacy. According to him, one of the conclusions to be drawn from positive and negative results is that phase III prevention trials are difficult, expensive and time-consuming. Ultimately, according to Gray, researchers would need to more carefully screen candidate interventions prior to trials and may need to conduct fewer trials, but with a greater investment in rigor and quality. Gray is Robertson Professor of Reproductive Epidemiology in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.
Bruce Walker analysed the roles of CD4 and CD8 T-cell responses in controlling HIV infection. Drawing from data collected from collaboration with South African researchers at a site in KZN, Walker focused on T-cell-driver immune responses in people infected with HIV-1 subtype C virus, the most common subtype. This ongoing work involves people of Zulu/Xhosa ethnicity who are chronically infected with subtype C virus. Walker explored several facets of how T lymphocytes fall short in fighting off HIV, including how genetics of the infected person affect HIV control, how mutations in cytotoxic (cell-killing) T lymphocytes can impair HIV’s ability to replicate, and why specific genes in the human leukocyte antigen (HLA) system affect viral control differently in people infected with different HIV-1 subtypes. Walker is Professor of Medicine at Harvard Medical School and director of the Ragon Institute of MGH, MIT and Harvard.
According to Stefano Bertozzi, the threats to HIV/AIDS funding from the global financial crisis would place a greater emphasis on getting value from investments, and require a shift in thinking from a short-term, emergency response to a more efficient, long-term approach. Bertozzi is Executive Director of the Centre for Evaluation Research and Surveys at Mexico’s National Institute of Public Health (INSP). He pointed to several tactics to improve efficiency, including strategic selection and improved targeting of HIV interventions, and better management and strategic integration of those interventions into other services. 
He also called for more balance between investing for long-term benefit and funding activities to achieve short-term results, including evaluation.
 Prashini Moodley, chief specialist and head of the Department of Infection Prevention and Control at the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, examined the emergence and spread of XDR-TB in KZN, explaining the interconnections between the local TB and HIV epidemics. Based on the experience of Tegula Ferry, site of a major XDR-TB outbreak, she discussed the roles of both nosocomial spread and the increasing numbers of immune-compromised patients in the community as factors in the spread of TB. According to Moodley these findings indicate the need for a multi-pronged approach to TB control that includes active case finding through rapid diagnostic methods, appropriate and early treatment for all patients with TB, timely initiation of antiretroviral treatment for all HIV-infected individuals and appropriate hospital infection control.