Today saw the launch of a new HIV prevention campaign in England by the Terrence Higgins Trust. The premise is bold: England “can halt HIV within a generation”.

The campaign is based on an over-arching message that is simple: test regularly, treat, use condoms (and participate in community action). The news was spotted first on the BBC website before the campaign website went up (THT press release can be found here).

There is a definitive aura of confidence and optimism surrounding this new campaign which appears to be an extension of the previous THIVK campaign focussed on testing (and which seems to have ended according to a THT Twitt).

Though not obviously stated, the rational for this new campaign is the growing body of evidence showing that HIV treatment is safe, effective and can reduce onwards transmission when taken correctly. This is the now well-known and at times controversial Test and Treat approach (aka TasP, T4P, UTT and T’n’T).

First articulated in 1996 by David Ho (“Hit hard, hit early”), TasP remained in the shadow of other often failing interventions until the seminal modelling paper by WHO Reuben Granich published in 2009 in The Lancet. The model suggested that an intensive implementation of testing followed by immediate treatment could end the epidemic within 5 years.

Since then,the HPTN052 trial (conducted in serodiscordant couples and the results of which were published in 2011) as well as a large number of studies looking at direct and indirect benefits of early HIV treatment, irrelevant of CD4 count, have provided support for TasP both as treatment and as prevention (with numerous caveats discussed on this blog and elsewhere).

The interesting aspects of the new THT campaign are its upbeat feeling, its emphasis on individual responsibility to make it happen and its focus on gay men and black minorities that overall remain the most vulnerable to HIV infection in the UK.

The stress on testing is based on a decade of data recently presented by Valerie Delpech, (Health Protection Agency, London) showing that  there was a sustained level of undiagnosed MSM in the UK responsible of a large majority of new HIV infections in that group. The data also showed that increased treatment uptake did not lead to a decrease in new infections, challenging the assumption behind the campaign.

However, the knowledge of one’s own status plays a critical role in onwards transmission. Recent data for MSM shows that 48% of new infections were acquired from undiagnosed men in primary infection, and 34% from other undiagnosed men. Overall between 60%-80% of new infections occur because the HIV infected partner does not know his HIV status.

Knowledge of one’s status can trigger behavioural change and also lead to entry into care where treatment, which lowers Viral Load, will play its prevention role.

Treatment is still recommended for individuals with CD4 count below 350/mL, but once diagnosed, the 2012 BHIVA guideline recommends that following discussion, if a patient with a CD4 cell count >350 cells/mL wishes to start treatment to reduce the risk of transmission to partners, this decision should be respected and treatment be started.

However, despite substantial progress and a “cascade of care” that looks much better in the UK than the US, there is no evidence of a reduction in the number of new infections every year in the UK.

A number of reasons have been put forward in an attempt to explain this observation: decreased condom use (few meaningful data available), high rate of undiagnosed, low testing rate, other STIs…).

Overall the campaign calls for more people to undergo regular testing so that new and in particular recent infections are diagnosed, and for people to be offered  treatment and hopefully willing to take it so that TasP delivers as a prevention approach.

Beside this, condoms are still promoted as the best barrier against HIV whilst other approaches are evasively refered to.

In 2012 The International Association of Physicians in AIDS Care (IAPAC) announced its full embrace of two new HIV prevention interventions – treatment as prevention and pre-exposure prophylaxis (PrEP),  calling for “immediate integration of these interventions into the existing HIV armamentarium as a means of significantly impacting HIV incidence worldwide.” However adding that ‘…more research into its effectiveness on the population level as well significant will, new resources, community involvement, provider support and individual commitment to provide the increased levels of HIV testing, linkage to and retention in care, access to quality treatment and adherence – all of which are critical to achieving TasP’s promise’.

It seems that THT and HIV Prevention England (HPE) the new national HIV prevention programme for England have somewhat embarked on delivering Test and Treat, though discretely (it does not show up prominently on the THT  front page, but there will be a Facebook Page!  And online gay news outlets have mostly reproduced the PR). This, whilst the PopART community randomised clinical trial aiming at answering and addressing many of the concerns raised by the IAPAC members is just about to start in Sub-Saharan Africa. This is not to say that TasP should not be implemented, but that its implementation should be very well thought through, especially in vulnerable populations.

Limiting the campaign to England, that part of the United Kingdom south of Hadrian’s Wall, may hinder its ability to deliver (but this is the results of the political agency of the kingdom) and the message, rather than over-arching may just be over-simple, remaining mostly about testing and condoms.

New prevention technologies such as PrEP but also engaging actively in advocacy for the development of other approaches such as rectal microbicides remains alien to HIV prevention in the UK. Here, prevention is still commissioned by the government, confined to and created by NGOs, rather than emerging and being crafted by the communities which are supposed to play such a crucial role in prevention as much as being its beneficiaries (“Testing is good for ALL OF US” say the website, designing campaigns should be the work of ALL OF US).

Community involvement remains minimal; they are asked to join the bandwagon now that the campaign has started. With the fast and dramatic changes affecting HIV prevention in the UK (now devolved to local councils), whether this is the best time and the best way forward to implement TasP remains open to question.

Comments from readers of Pink News are critical of the London-centric approach (though London has a much higher ratio of HIV infections than the rest of England) and its lackluster proposal; a reader noted that “the HIV prevention message [is] being warped from “condoms always” to “Test! Test! Test.”

The programme has two years to prove that it can reach those undiagnosed who are driving the epidemic and beyond that ensure that they enter care and are provided with the support needed to newly diagnosed people. Getting people to test is a major step towards controlling the epidemic, but it won’t be enough. As shown in the UK and the US, the cascade of care is still very much leaking and the number of people with a controlled viremia, which is at the heart of TasP, still remains insufficiently low for the approach to deliver.

The optimism of the campaign is appealing, though somewhat naive. It may hopefully help destigmatising HIV, testing and treatment. Its emphasis on personal responsibility is welcome but will not always appeal to those most vulnerable, and ultimately, taking control of the epidemic will need more than just test, treat and use condoms.

rjt

Updated 25 Apr 13
Revised 26 Apr 13

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Year 31 of the HIV epidemic. World AIDS day. The time of the year to publish reports and plans with a new impetus to address the HIV/AIDS epidemic. This year the theme is “Ending AIDS”. The field has never been shy of trigger words and turgid plan and 2012 is no exception with PEPFAR’s new blueprint “creating an AIDS-Free Generation” and UNAIDS’s annual report “Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths” to name only two.

To conform to the seasonal custom, here are “Five strategic orientations towards ending HIV”.

1. Learn about the epidemic, and then foster learning about it.

Many believe that education is the (ultimate) answer to end the epidemic or will play a major role ending it. Unfortunately educating people has become an end to itself and education has been reduced to providing people with accurate information with the assumption that well informed people will make the “right” decisions. The approach often overlooks the necessity for that information to be relevant, to be delivered appropriately, and to reach those who need it. Not much attention is given to people’s ability to make the right choices (or act it), and what is or could be “right” is rarely set out.

Further problems with “education only” is that it is a passive, top-down approach delivered by some assumed to know better to other assumed to know less. It is monolithic, devoid of relational dynamic in which knowledge is dumped.

The willingness of recipients to be educated is rarely considered. Many do not want to be defined by a problem that education will solve. Many do not want to know (more) about HIV than what they already know. Many think they already know enough, if not all. And what good is education when you can’t share your knowledge because of your personal circumstances (gender-based violence comes to mind) or apply it because you do not have access to material requirements to make it work?

On the other hand learning is a personal demarche coming from within the individual, a quest towards self-betterment. The will to learn expresses the desire to improve one’s knowledge with the purpose of improving one’s ability to manage better in a challenging and difficult world. Whilst education is delivered and left to the individual to use or not, learning is fostered with better chance that what has been learned will be put to use because it comes from within and when there is a will there is away.

2. Take action based on sound scientific evidences.

This should go without saying, but not without limits. The best evidences in the world will never be enough to convince those who have the power to effect change and to act on evidences, if they get the better of acting otherwise. Further, programmers and planners need to put their money where their mouth is. Funders and governments ideology often negates a world full of good intentions.

Still, evidences however logical or rational they are, should not prevail over or ignore the will and agency of people on the ground, the cultural and political context and sensitivity in which they are to be used. Forcing interventions down the throat of individuals and populations on the ground that they are based on sound evidences can only lead to rejecting these evidences and the further spread of the virus. This is true for both technological interventions but also behavioural, cultural and political changes.

3. Invest in social science research.

Learning about the epidemic is not only a matter for those at risk of infection, but first and foremost for those who aim at ending the epidemic. HIV prevention has made tremendous progresses in the last three years. New prevention technologies and approaches have arisen, sometimes surprisingly. Many were quickly branded as the solution to all our problems, and call for immediate roll out issued. But we should never forget that all these new tools are of no use if a) they are not commonly available and affordable, b) they are rejected by those who would benefit most from them. The story of the female condom still haunts the field of prevention and emphasises the need to conduct thorough social science research from an early stage in parallel to basic and clinical science, as this will be key to the successful introduction, reception and roll out of new prevention technologies and biomedical interventions.

4. Make funding work.

More money is welcome but better use of existing money would make a tremendous difference. Knowledge improves every day, even if slowly. Funding needs to be flexible to adjust to important developments but also to sudden changes. Too often funding comes with unnecessary if not damaging ties. Beside funders deciding what kind of research is worth doing or not (an issue in itself, the best science should be funded), restrictions on how, where or with whom funding can be used and protectionist procurement rules that make delivering a project insanely costly must be removed.

There is too much red tape around funding and project management. Rules, accountability, transparency, though necessary, have created a management industry that guzzles money that could be put to better use delivering interventions and projects. Unbending funding rules have led to losing opportunities to do better science. Projects with innovative potential are constrained by the strait-jacket of rules and regulations which care more for reporting and accountability to funders than for results for beneficiaries and future research. Funders, institutional and philanthropic need to empower the people and the research they have decided to support.

5. The end of AIDS starts with a political statement and ends with political action.

The span of the HIV epidemic is largely the result of a political inability to recognise the importance of the epidemic, and to act at the right time, in the right place, with the right approach. Political action means much more than improving diagnosis, delivering more drugs and counting saved lives. Political action means getting involved at the highest levels to ensure that human rights are respected, that key populations are not discriminated against, that diplomacy goes beyond economic interests to include people’s interest. Aid conditionality is a fiercely debated approach, but aid without tie will not deliver better. There is no potential trickle down effect with an epidemic the size and extent of that of HIV. We must acknowledge that behind many violations of human rights and failure to act is a thirst for power and clinging to it. Political action takes place above and beyond the epidemic.

This year World Aids Day is not so different from last year’s WAD, but we can make the next WAD different if we start with a different narrative of the epidemic and engage in different conversations. Biomedical improvements and technological innovations won’t be enough on their own. Diagnosis and treatment will not be enough on their own. Even goodwill will not be enough. To bring  the HIV epidemic to an end requires deep cultural changes and to achieve these, we need to have more than a conversation; we need to have different conversations about HIV and how to address it.

rjt.

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The day after the day HIV/AIDS is in the news. A collection of short messages sent as part of a big Tweetup to find a “Big Idea to end AIDS”.  The following messages have been organised in broad categories that often overlap.

About the “Big Idea” approach

Messages for philantropists and funders

On tackling the epidemic

To what Mapping Pathways replied:

Indeed “can also be a brief interval” would have expressed my mind better.

About HIV Activism

Some other tweets

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Morenike Ukpong

I am in Ethiopia and I sat down through a 2 days session listening to data presentation about the HIV context and situation in Africa. As usual, I was all out to hear and listen about what the data was saying about Nigeria.

One key issue was the place and role of anal sex in driving the HIV epidemic in Nigeria. This can no longer be ignored. As per statistics, yes there are Statistics from Nigeria that shows that anal sex is practiced by 12% of public secondary schools students. There was another presentation that showed that 12.1% of university students and 15.2% in-school adolescents in Northern Nigeria practice anal sex.

What does this evidence mean? Anal sex is known to be the highest risk form of sexual transmission of HIV infection with approximately 14 (10-20) times higher risk of HIV transmission when compared to penile-vagina sex. The probability of HIV infection transmission in penetrative anal sex is about 1.4% per sex act both in heterosexual and homosexual relationships. Read the rest of this entry »

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2011, the year of PrEP.

In less than 18 months 6 clinical trials investigating the potential use of HIV antiretrovirals (ARV) for the prevention of HIV acquisition have rocked the HIV prevention world. First it was the South African CAPRISA announcing in July 2010 a 39% risk reduction of HIV acquisition in women given a vaginal gel containing the anti HIV drug tenofovir. Then it was iPrEX a study conducted with Men who have Sex with Men (MSM) and transgender women announcing in November 2010 a 44% reduction in the risk of HIV acquisition for those taking the same drug but orally.

Both trials where investigating the potential of ARV to prevent HIV acquisition in HIV negative people in a new approach to HIV prevention called Pre-Exposure Prophylaxis (PrEP). Read the rest of this entry »

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