Recently, a group from the Alliance Secretariat, including myself, attended a two-day conference focusing on treatment as prevention and pre-exposure prophylaxis.
Treatment as prevention (TasP) means the use of antiretroviral drugs irrespective of CD4 count by a person living with HIV to reduce the risk of passing HIV to their negative sexual partners. For more information on TasP, see the recent WHO Programmatic Update and read our Campaign Policy Briefing on TasP.
Pre-exposure prophylaxis (PrEP) is the use of antiretroviral drugs by people who are not infected with HIV to reduce the risk of HIV acquisition. For more information on PrEP, visit prepwatch.org
The conference that was held in London provided a good overview of the complexity of these two biomedical prevention interventions, opportunities they provide, challenges they pose, and difficult decisions that stakeholders face in moving forward.
The programme and presentations of the conference entitled Controlling the HIV epidemic with antiretrovirals can be found at: www.iapac.org.
The conference had participants from all over the world, though primarily from Europe and North America. Some voices from communities most affected by HIV were heard, but not many. Missing voices included communities such as sex workers, although they were mentioned as a potential ‘priority group’ for TasP.
One speaker did provide some quotes from a blog that includes personal accounts of using PrEP. This is an important read! People speak, for instance, about the stigma that can arise from using PrEP (being considered willful risk takers), or how PrEP has provided them with the option to have condomless sex to increase their sexual pleasure or try to conceive a child.
There was a lot that this conference covered. Some of the key points were:
- The use of antiretroviral drugs for prevention is a rapidly changing field. More evidence is on the way, as a huge number of trials are currently being conducted.
- Major inequities persist between the Global South and the Global North in the availability and the use of antiretroviral drugs for treatment and prevention, and in the access to HIV testing, treatment and prevention, particularly for key populations.
- Knowledge of HIV status remains insufficient, though this knowledge is a pre-condition for TasP and PrEP.
But how do we get people to test (earlier and regularly), particularly people from communities most affected by HIV? This was not much discussed. Scientists are working on making testing simpler and more accessible. For instance, home testing HIV kits are already available legally in some countries.
Strengthening community responses and health systems
However, new technologies alone will not ensure an increased uptake of services. The mobilisation of communities most affected by HIV to increase health and rights literacy and to remove structural barriers are critical to the HIV response.
But even where a large number of the population has been tested and counselled for HIV, such as in South Africa, linkage to care is often poor, resulting in low rates and late uptake of antiretroviral therapy (ART). There is also a high loss to follow up, as data presented during the conference demonstrated.
So, for TasP and PrEP to work, a lot more needs to be done to enrol and retain people in care after they have been tested and are eligible for TasP or PrEP.
Then there is the weakness of many health systems. Many will be unable to cope with an increased number of people eligible for and on ART. More needs to be invested into health systems strengthening, including community systems strengthening, to make TasP and PrEP work.
There are many other questions when it comes to TasP and PrEP. Adherence levels and support are major barriers to the success of both and we know little about the costs, feasibility, impact on drug resistance, and stakeholder acceptability.
There is the big issue of ensuring a safe and enabling environment in which people (both HIV negative and positive) are not pressurised or coerced into testing and treatment if they do not want it. They should not have to be afraid to say no to testing and treatment, of being stigmatized, discriminated against or of having their human rights abused.
Another big issue that came up at the conference was: How we will reframe ‘safer sex’ to expand beyond condoms to include PrEP and TasP? What should our messages be, for instance, to two people who want to put the pleasure back into their sexual life by choosing condomless sex and use either PrEP or TasP, even though the effectiveness of both is likely to be lower than the efficacy shown in the clinical trials?
What will the consequences of wide availability of PrEP and TasP be? For example, how will risk perceptions in communities most affected by HIV change and how will it affect relationships between sexual partners? One presenter rightly asked: what are our responsibilities to each other in a world of TasP and PrEP? One may add: how will cultural and social norms and personal fears of disclosure shape our decisions on the use of prevention technologies? How do we ensure that individuals and communities receive adequate information about PrEP and TasP to make informed decisions?
More research essential
It is clear that more social science research is needed, alongside and integrated into biomedical research. Earlier treatment and PrEP will have to be incrementally introduced in most contexts and carefully monitored for all the reasons outlined above. TasP seems, at the moment, the most feasible option of the two, but it was clear from the conference that both technologies are gaining momentum and communities need to be prepared and be engaged as equal partners in decision-making and the development of strategic and operational guidance on TasP and PrEP.
In practical terms, that means, for instance, that communities need to be adequately represented at the working groups that WHO is currently setting up to develop new consolidated ART guidelines, and in ongoing research on TasP and PREP.
We also need more innovative thinking around and ways to promote confidential HIV testing and counselling, to support people to adhere to ART and to stay in care. We should look at the lessons learnt from scaling up HIV testing and treatment and the introduction of new HIV prevention and family planning technologies over the past decades – something that was discussed very little during the conference.
Most importantly TasP and PrEP have to become integral components of a human rights-based combination prevention approach and should not be researched and implemented in isolation.