Embarrassment of riches in HIV prevention response?

Dr Mitchell Warren, AVAC
"There are risks and costs to action. But they are far less than the long-range risks of comfortable inaction" - insightful words of former US President JF Kennedy come in mind while listening to respected HIV prevention research advocate, Dr Mitchell Warren, who is the Executive Director of AVAC - Global Advocacy for HIV Prevention. Considerable improvements have happened in HIV responses but a lot remains undone. With research taking place in HIV science, lot of credible evidence is stacking up on not just basic sciences, but also socio-behavioural and operational aspects of rolling out what we know works. Despite loads of evidence, some policies and practices are not evidence-based and impede HIV responses on the ground.

"One of our biggest challenges right now is almost the embarrassment of riches in terms of ideas. We have all of these ideas for developing new products, as well as, fruits of research to deliver! We have lot of ideas bubbling up for product development to product introduction. This is all happening at one of the most critical moments in AIDS response. Financially we are going to struggle to pay for all of our great ideas. Challenge one is, if we can resource all of these ideas" said Dr Warren who is also a distinguished member of the Programme Organizing Committee of the first HIV Research for Prevention (HIVR4P) conference in Cape Town, South Africa.

He added: "Globally we do have the growing sense that we can end this epidemic. And it is real. But it immediately pivots people to thinking how we can scale up treatment, which we must. We should be doing that but we need to ensure that prevention does not get left behind. When we think of targets for treatment, particularly UNAIDS’ target of 90:90:90, that is a prevention and treatment target as well, because if have 73% of people are virally suppressed that is prevention too. But it is not enough. Second issue is that how to we make sure that we do not just do 90:90:90 but we also build out a more comprehensive view while setting these targets to end AIDS."

Recently UNAIDS had announced its  90:90:90 by 2020 targets which aims to increasing to 90% the proportion of people living with HIV who know their diagnosis, increasing to 90% the proportion of people living with HIV (PLHIV) receiving antiretroviral treatment and increasing to 90% the proportion of people on HIV treatment who have an undetectable viral load by 2020.

"Two exciting opportunities are on different ends of the spectrum. We talk at this conference of research to roll-out. It is incredibly exciting moment where we are not just talking about basic science and product development but we are also talking about delivering products and interventions. We need to think over the next 3-5 years of our ability to do research and implement the successes of our research. On one end of the spectrum, we are going to be challenged on designing a clinical trial in future in light of the current evidence for HIV prevention. When we were talking about microbicides and vaccine trials a decade back, the HIV prevention package offered to every study participant included voluntary counselling and testing, condoms, clean needles (if people who inject drugs were in the trials), and other evidence-based methods in HIV prevention cascade. In Africa we have added voluntary medical male circumcision (VMMC) as part of the HIV prevention package offered to the study participants. We should be adding oral Pre-Exposure Prophylaxis (PrEP), and soon if studies show safety and efficacy then we should be adding tenofovir gel and dapivirine ring too. Also in future, we may have to go for possibly larger and longer trials which will be more expensive too. We still need other antiretroviral (ARV) and non-ARV based prevention options. We still need a vaccine and cure. But conducting a trial may get more complex and exciting too. We must embrace these options and not run from them as part of our trials" shared Dr Warren.

How to scale up what we know works!
"At the other end of spectrum is what do we do with things that work. As advocates so long our focus has been on various phases of a clinical trial (phase I, II and III safety and efficacy studies). Now we are talking about rolling it out. There are lot of gaps in our knowledge I think. Most experience with oral PrEP highlights that smaller demonstration projects can help us answer little questions, but we do not have the large scale implementation science that we need. Sessions at HIVR4P presented data from large scale treatment as prevention studies from several countries and thousands of participants, and rolling out treatment as prevention at a huge scale. We need that same thing for prevention. We need experiments in huge settings to really see if adding PrEP, and if evidence comes forth then, tenofovir gel and dapivirine ring, helps and how do we introduce these options into health systems" said Dr Warren.

He reiterated that "We need to ensure that prevention and treatment both get reflected in the targets we set to end AIDS. We need to make sure that we design and conduct really important combination prevention studies and are able to more effectively roll things out as soon as they work. Every day we wait after a clinical trial result that has efficacy - to roll it out - we must remember that delay is not counted in days, weeks or months, it is counted in new infections."
Not relabeling but reorienting our actions will help
"We call people who are at disproportionate risk of HIV and have low access to services as Key Populations in 2014. In 2011 we used to call them Most At Risk Populations (MARPs). But the reality is people who are at greater risk of HIV are not 'key populations' in 2014 because something had changed, those are the same populations who were getting infected at disproportionate rate 20 years ago too. We have a new name for them but the reality has not changed much - that this is an epidemic that disproportionately affects people who are at greater risk, people who are marginalized, people who are stigmatized, and people who are criminalized. That is true in 2014 because they are key populations, it was true in 2011 when they were MARPs, it was true in 1993 when we called them 'high risk populations'. What needs to change more rapidly is not our language to describe them but our actions to support them. That is where we have gaps from words to actions. I do hope that in our new language of key populations we stop trying to redescribe them but trying to reorient our actions to really deliver the services for not just HIV prevention and treatment but to deal with overall health disparities and to deal with overall human rights abuses as well. Our response hopefully will get better for communities. For me success is not in relabeling but reorienting our activities" said Dr Warren.

Bobby Ramakant, Citizen News Service - CNS
30 October 2014