“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
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
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