The divide between ARV for Treatment and for Prevention. It’s all about perceptions?

October 8, 2011 by Roger | ARV-based Intervention


New HIV Prevention Technologies (NPTs) were presented and discussed during a seminar on the “Social Aspects of HIV prevention technologies: Translating research into policy & practice” organised by The African Health Policy Network, with the aim to address key research questions affecting African communities in the UK.

As part of the Treatment for Prevention (Test and Treat) discussion group I was interested to hear the concerns raised by members – men and women, HIV-positives and HIV-negatives, of the African community living in London. Unsurprisingly, issues of safety, level of protection but also trust in the HIV-positive partner to take his/her medication were raised as well as the more salient issue of potential pressure from the HIV negative partner (particularly if male) to ask for unsafe sex since NPTs are thought to prevent HIV infections (the focus is more often on disinhibition of the HIV-positive).

A key concern was how to communicate the results of the recent NPTs trials and what they meant for one’s everyday sex life. There were also great confusion about NPTs pushing aside 30 years of HIV prevention messages focused on ABC; people were finding it difficult to understand and surprising that from now on, the condoms message was no longer on top of the list.

Remarkably, concerns raised about using ARV for the prevention of HIV infection apply to using ARV for treatment. Somehow, a dichotomy has been created between having to take treatment because a treatment guideline recommends doing so, and starting treatment because a prevention guideline recommends doing so. Compliance, adherence, side-effects and many of the concerns raised by the audience are valid whatever the reason one is on treatment for. Somehow by placing the emphasis on treatment AS prevention changes perceptions about using ARV for prevention rather than for treatment.

A great rift is dividing HIV-positive people according to their CD4 count, putting them in the treatment box with its constraints or in the prevention box with what appears to be a different set or exacerbated set of constraints. This is of course an artificial and immaterial distinction. Though being on treatment for a longer period of time have a systemic impact on health (lest we forget balanced by treatment bringing one’s life back!), it is important to keep in mind that the preventive property of treatment works whatever people’s CD4 count is (caveat: as long as the viral load is controlled) and that currently, because of late HIV infection diagnosis, a majority of those diagnosed need to start treatment within a very short period of time, adding only a small number of months to a life-long treatment.

When used for HIV-positive people, the CD4 count creates a divide between ARV for prevention (CD4>350, left side) or for treatment (CD4<350, right side). But that criteria is changing and guidelines are just what they are. Despite getting narrower, this Great Rift still divides public health experts, the medical and clinical comunity, activists, patients and most affected communities.

Since the availability of HAART, the guideline for treatment based on CD4 count has changed a number of times and is evolving towards a closure of the rift between prevention and treatment: treatment will be prevention, not all of it but a good part of it.

The treatment messages and the prevention messages, already very similar, will have to evolve as maintaining a distinction between the two will soon become unwarranted and counterproductive. The difficulty will be to refrain framing treatment as either for prevention of for treatment but to mesh the prevention messages into the treatment messages and to deliver it to those starting treatment, irrelevant of their CD4 count.

For the African communities in the UK this is one more challenge to add to low level of HIV testing, difficulty to access prevention services and treatment, immigration laws that threaten African living with HIV, and changing perceptions but there was a reassuring feeling that people were willing to get involved, to find out more and mobilise their community so that NPTs becomes part of HIV prevention.


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