US health surveillance director: How can we use treatment to strengthen prevention?

“Now, more than ever, it is possible to change the course of the HIV epidemic, by combining HIV prevention interventions, including antiretroviral therapy (ART) for treatment and prevention.”  These were the closing words of Dr Kevin Fenton, the Director of the US National Center for HIV, in the final plenary of the IAPAC Controlling the HIV epidemic with antiretrovirals evidence summit in London, last week.

Dr Fenton added that there were numerous barriers in the way of achieving an effective prevention response to HIV. He spoke of an ‘implementation gap’ that needed to be crossed to turn our scientific knowledge of antiretroviral therapy (ART) as prevention and of pre-exposure prophylaxis (PrEP) into the right effective, selective and economical programmes to suit specific high-risk populations. He compared the implementation research that would need to be done to put such programmes into action to building a boat while already sailing in it.

Fenton based his remarks on the position of HIV prevention in the US, though many of them apply to other prevention contexts too. In general we have a fast-changing epidemic which is tending to concentrate into population groups that are, on the one hand, taking advantage of changes in cultural norms to self-identify but on the other hand facing increasing stigma and economic and social disadvantage: examples included migrants, minority-ethnic gay men and (in many countries) those with poor healthcare access.

HIV incidence in these communities – the proportion of people infected with HIV every year – tended to be stable, said Fenton, and “stable incidence is not acceptable” as it meant a continued increase in the HIV burden in these groups. There was, therefore, a sense of urgency, yet though current prevention efforts may reduce new infections in individuals, they are unlikely to achieve sustained and widespread reduction in HIV incidence.

New interventions frequently require convincing evidence and considerable time before they are implemented: for instance, male circumcision took approximately 20 years and three randomised controlled trials (RCTs) showing consistent efficacy, yet adoption has been slow, and the prevention of mother-to-child transmission took years of basic science and field research before RCTs supported the use of antiretrovirals (ARVs) and ART to prevent transmission.

All this is happening in the context of an economic downturn, Fenton added, with the US facing “a Federal deficit of $1.3 trillion in 2011, a five-year freeze on federal discretionary spending, reductions in HIV prevention by health departments, about 45,000 state and local public health jobs lost, and many community organizations closed or struggling.”

Against this, he said, ‘combination prevention’ using a combination of biomedical, behavioural and structural methods was a huge opportunity to increase the efficacy of prevention; in addition, because ART came out of the much larger budget available for healthcare, it could be used to ‘leverage’ resources and effectiveness into the much more poorly-financed area of public health.

“However,” he warned, “We will never be able to leverage the full potential of HIV prevention or treatment if we fail to target appropriately, implement effectively, and bring to scale what we know works.” There was a big gap between what we know is scientifically efficacious and the individual tools we have for HIV prevention programmes, a gap made bigger by stigma and social norms that militate against effective programmes for certain groups.

The only way forward, he added, was not only to turn research into practice, but to get research out of practice – to mobilise demonstration projects that tested the worth of specific approaches and combinations and created the conditions for wider acceptance and adoption. He gave as an existing successful example the CDC’s Expanded Testing Initiative, which was at first regarded with suspicion by many community advocates. This has conducted 2.8 million HIV tests in its first three years, diagnosed 18,000 people with HIV of whom 70% are African-American, averted an estimated 3381 HIV infections and achieved an estimated return of $1.97 for every dollar invested.

Future demonstration projects, he said, should add ART and adherence interventions to STI screening and engagement and retention in care for people with HIV, and should “create an enabling environment for HIV prevention efforts, including PrEP”.

In the US specifically, failure to link to care is a huge problem and results in the already-estimated figure that at most 28% of the HIV-positive population of the US in on ART and virally undetectable (in contrast, Valerie Delpech of the UK Health Protection Agency had told the meeting the previous day that in the UK, which has free healthcare at the point of demand, the figure is 52%).  

The fact that there was more money in healthcare than in public health promised opportunities, said Fenton: new sources of revenue, new sources of data for decision-making, a greater emphasis on providing patient-centred holistic care that included behavioural support as a necessary component (for example to support ART or PrEP adherence) and opportunities to link clinical and community-based services for comprehensive prevention, care, and treatment.

On the other hand, the ‘new prevention’ could introduce additional fragmentation into an already fragmented system, intensify competitiveness between private, voluntary-sector and national public health care providers, and introduce an uncomfortable new focus on the achievement of prevention outcomes as part of funding requirements. In order to combat this, he said, more resources needed to be put into information and education services, the mobilisation of community/health sector partnerships, training a competent public health workforce, and better effectiveness evaluation.  

“Our future success,” he concluded, “will depend on our ability to implement and bring to scale what we know works, for those at risk; the ability to choose efficacious, synergistic combinations for specific risks, robust engagement with affected communities, strong healthcare delivery systems, and the ability to enrol, retain and maintain adherence.”

Further information

The slides for Kevin Fenton's presentation are available on the IAPAC website.