Treatment as prevention by International HIV/AIDS Alliance

POLICY BRIEFING

Supporting community action on AIDS in developing countries

TREATMENT AS PREVENTION Making it work for communities most affected by HIV

©Alliance

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Treatment as prevention is another highly efficacious technology to add to the existing HIV prevention toolkit.

There are rapid developments in the field of HIV prevention. Treatment as prevention (TAP) is one emerging issue that is causing great debate. The International HIV/AIDS Alliance has conducted a partnership-wide consultation on the topic in order to inform its own programming and advocacy messages. This briefing draws on the results of that consultation and on an extensive desk review of the available literature. This briefing paper highlights some of the key questions that communities most affected by HIV and the organisations that support them are currently discussing, and outlines our eight points to remember to make TAP work. Read more about the International HIV/AIDS Alliance approach to HIV prevention at www.aidsalliance.org

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context In 2009, the International HIV/AIDS Alliance (‘the Alliance’) issued a Technical Update on communitybased HIV testing and treatment as prevention. Since then the world has seen major new developments in the field of prevention. In May 2011, preliminary results of the HPTN 052 research trial were published to great acclaim. The trial was designed to evaluate the impact of treatment as prevention (TAP), i.e. whether immediate versus delayed initiation of antiretroviral therapy (ART) by individuals living with HIV would reduce the risk of sexual transmission of HIV to their HIV-uninfected heterosexual partners and potentially benefit the health of the individual living with HIV as well. The trial showed a 96% reduction in risk of sexual HIV transmission. Since 2011, the Alliance - along with other civil society organisations and networks of people living with HIV - have welcomed the developments around TAP as another highly efficacious technology to add to the existing HIV prevention toolkit. Along with others, the Alliance is keen to engage with researchers, policy makers and other key stakeholders on the topic. However, we are concerned about current levels of community and civil society involvement in decision-making processes around TAP. We also question to what extent contextual issues such as the promotion and protection of human rights are being adequately considered.

Community groups and civil society are eager to find answers to other questions around HPTN 052, such as: • What is the optimal time to initiate ART? • What are the health benefits for the person living with HIV? • What are TAP’s benefits in relation to unprotected anal sex and unsafe injecting of drugs? • Will TAP work in real life situations and what will be its costs and impact? What are the optimal TAP communication and implementation strategies and service delivery models? • How can potential risks to communities most affected by HIV be minimised? For instance, concern that public health considerations might override personal rights and choices, or that TAP may lead to increased mandatory HIV testing, or to increased violence against people living with HIV who refuse to take up ART, or to criminalisation of HIV transmission? • How will TAP change individual and community understandings of HIV risk? Will it result in risk compensation or people living with HIV being pressurised by sexual partners or others to give up condoms and other prevention methods and rely solely on TAP as a protection measure? • How can community and health systems be strengthened to cope with the additional demands that a roll-out of TAP would present? • How will communities benefit from TAP in light of signs that funding for HIV could be further shrinking, and given that many countries are not meeting universal access targets for HIV treatment? All these questions are important given that the results of the HPTN 052 trial appear to have triggered a turning point in global prevention efforts and there may be a paradigm shift in how HIV policies and programmes will be developed, prioritised, funded and implemented in the future.1

Barr, D. et al. (2011) Articulating A Rights-Based Approach to HIV Treatment and Prevention Interventions, Current HIV Research, 2011, 9, 396-404.

At the same time communities most affected by HIV and those supporting them want to seize the opportunities that TAP offers, such as: • putting HIV prevention higher up on the agenda of policymakers, researchers and implementing organisations; • changing the way that people living with HIV think of themselves and their sexual relationships, and its potential to reduce stigma; • increasing the range of HIV prevention methods; • reinforcing existing efforts to increase universal access to high-quality HIV testing and ART, and provide a further push to tackle structural issues (e.g. human rights violations) that hamper effective HIV responses; • strengthening community ownership of HIV responses, i.e. integrating community-based interventions in the delivery of HIV prevention and treatment services, building on lessons learnt over the past decade.

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What we need to be really clear is that...[TAP should]...in no way... be misinterpreted and misconstrued as...[placing]...the...[onus]...of prevention on people living with HIV...’Shared responsibility’ is about recognising that all individuals, HIV positive or negative, need to take responsibility for protecting both their own health and that of their sexual partners. Failing to adopt a shared responsibility approach can result in an over-simplified and medicalised HIV prevention programming that ignores the full spectrum of challenges shaping the prevention needs, abilities and incentives of...[communities most affected by HIV]. Alliance Regional Technical Support Hub for South East Asia and the Pacific (based in Cambodia)

what are we calling for? The Alliance has a responsibility to engage in efforts that will help ensure that TAP research studies and combination prevention programmes are carried out in ways that protect and promote the human rights and meet the needs of people living with and vulnerable to HIV, their partners and families, including key populations.

The recent Alliance consultation highlighted two key principles to consider as we plan to advance TAP:

The primary purpose of ART for someone who is living with HIV is to benefit their own health and any preventative and public health benefits are important, but secondary, considerations.

Provision of HIV prevention, treatment, care and support should strengthen equity, and optimise the benefits of TAP by focussing on populations at higher risk of HIV, and whose exclusion could potentially undermine the benefits of TAP and continue to drive the HIV epidemic.

Eight points to remember ABOUT TREATMENT AS PREVENTION 1

Treatment as prevention (TAP) is an exciting new prevention technology and needs to become an integral component of combination prevention. However, it is not a ‘magic bullet’ and policy makers and programme implementers must not prioritise TAP to the detriment of other interventions, as its success at the individual and community levels depends on effective behavioural and structural interventions.

Taking up HIV testing and treatment is and has to remain a personal choice. The decision to initiate ART should primarily be based on what is best for the individual patient, rather than for their sexual partner(s), though patients may choose to initiate ART to protect their sexual partner(s). Informed decisions require access to all available information, in a format and language that the person can readily understand. Support systems, including peer support, must be put in place and funded.

To enable informed decisions more evidence is required on whether immediate use of ART after diagnosis regardless of CD4 count can be beneficial for the patient in prolonging life and improving the quality of life.

Treatment as prevention should strengthen the integration of community-based interventions into the delivery of health services, in tandem with all other efforts already underway to reach universal access.

Communities should be involved as equal partners at all stages of decision-making around TAP, in harmonising TAP-related messages, in the development of guidance and in the design, implementation, monitoring and evaluation of combination prevention research and programmes.

In order to ensure TAP works in the ‘real world’, a range of issues have to be addressed (ethical, structural and programmatic). Most of those relate to the same factors that have hampered effective HIV responses in many countries over the past decade, such as stigma, gender inequality, weak health systems and human rights violations. Thus, the renewed interest in treatment as prevention could support advocacy efforts (if rightly targeted) aimed at overcoming barriers to effective HIV responses.

In countries where universal access to ART is not achieved treatment for people who need ART for their own immediate health benefit should be prioritised over people receiving treatment as prevention.

TAP programming should always include a human rights monitoring element.

Read more about the Alliance’s campaign What’s preventing prevention? www.whatspreventingprevention.org For more information, contact: Anja Teltschik, Senior Advisor on Prevention ateltschik@aidsalliance.org © International HIV/AIDS Alliance (International Secretariat), published June 2012. Preece House, 91-101 Davigdor Road, Hove, BN3 1RE, UK www.aidsalliance.org