Whereas in previous years, delegates at the CHAPS conference of gay men’s health promoters have demonstrated a certain scepticism with respect to ‘treatment as prevention’, the topic took centre stage in Bristol this week.
At a panel discussion on the impact the approach will have in the UK, Cary James of the Terrence Higgins Trust and other speakers argued that treatment as prevention will be part of a combination prevention approach that will still promote condom use, other forms of safer sex and regular testing. Moreover treatment as prevention will amplify the benefits of the other interventions.
However earlier in the day, Ford Hickson from Sigma Research had noted that while there are multiple ways in which individuals can reduce their risk of being involved in HIV transmission there has long been a tendency for people to strongly advocate the universal use of one method, to the exclusion of all others.
While homophobes would like gay men to simply avoid having anal sex and various groups urge men to have fewer sexual partners, a great number of people see condoms as the sole answer. More recently, treatment as prevention and other biomedical interventions have sometimes been presented as magic bullets.
Matthew Hodson of GMFA noted difficulties with condoms, including failure rates and the fact that many men find that they reduce intimacy, spontaneity and sensation. “Any alternative to condom use which doesn’t have those drawbacks and which has a similar or better impact on reducing the risk of transmission has got to be welcomed,” he said.
But he warned of difficulties in communicating new HIV prevention messages. “Condoms have never been the sole HIV prevention activity but have become synonymous with ‘safer sex’,” he said. “Community attachment to the ‘use a condom every time’ message is immense and any agency which suggests alternatives or publicly questions whether condoms remain the best method for HIV prevention is going to face a truckload of criticism and accusations of betrayal.
“A lot of the adjustments we have made to our HIV prevention messages over the years have been ignored, condemned, misrepresented or gone unnoticed,” he continued. “Any change in the message that we put out will take a long time to filter through to people who aren’t already engaged with information about HIV.”
Cary James commented: “I’m not quite sure whether ‘treatment as prevention’ is the message or whether it’s just an added benefit that reinforces the work that we are already doing.”
The social researcher Peter Keogh noted the distance that needs to be travelled between the compelling evidence of effectiveness and the routine use of treatment as prevention in the UK. Research on how it can be implemented in clinical settings is needed, he suggested, and clinicians may need resources to help them be most effective when engaging with their patients about their social and sexual lives.
Cary James noted that treatment as prevention is bringing clinicians and community prevention groups together, and amplifies the role that sexual health clinics can play in HIV prevention. Matthew Hodson argued that communication around treatment as prevention will be more effective if those involved can come to a consensus on the core messages about the benefits of treatment, its impact on infectiousness and the role that condoms will continue to play.
Ian Williams, a clinician and the chair of the group preparing the new BHIVA treatment guidelines, outlined the recommendations in the draft guidelines. The advice in the guidelines is not that clinicians advise their patients to start treatment for prevention purposes, but that the clinician has a discussion with all HIV-positive patients about the potential of HIV treatment to protect sexual partners.
If a patient wishes to take treatment for this reason (even if he has no need for treatment himself), that decision should be respected. Ian Williams stressed that the choice to start treatment must be that of the person with HIV and not anyone else – not the clinician, not a sexual partner.
While the evidence does come from heterosexual couples, he said there is no clear rationale for thinking that the data would not be relevant to gay men. “It would be unethical and against biological plausibility to say in the guidelines that this this is just aimed at heterosexual serodiscordant couples,” he argued.
However he noted that while there is compelling evidence for the effectiveness of treatment as prevention on an individual level, its impact on a population level (the effectiveness of a universal test-and-treat model) is as yet unproven.