Supporting community action on AIDS in developing countries
Strengthening the evidence base for treatment as prevention among key populations Maria E. Hart1, Anja Teltschik1, Gitau Mburu1, Christine Stegling1 1
International HIV/AIDS Alliance
Background Evidence from HPTN 052 suggests that immediate antiretroviral treatment of heterosexual HIV sero-discordant couples can reduce HIV transmission risk by 96%. However it is not clear how such a strategy would be implemented among populations that are at higher risk of being infected or affected by HIV (hereafter key populations), such as sex workers. We explored this area with the aim of identifying key opportunities and threats that treatment as prevention poses to key populations.
Methods We conducted a literature review, relevant to key populations’ access and uptake of HIV testing and counselling and antiretroviral therapy and conducted a SWOT analysis of treatment as prevention through the lens of key populations. We also performed an organisation-wide consultation, including with community-based organisations and networks.
Results
Conclusions and Recommendations
Treatment as prevention could reduce HIV burden, strengthen community ownership of the HIV response, and complement HIV prevention approaches and other health interventions such as sexual and reproductive health. However, the generalisability of HPTN results to key populations, who so far have largely been left out of research on treatment as prevention, is limited. In addition, it may have negative impacts, for instance on individual rights, psychosocial well-being and criminalisation of HIV transmission.
Based on our community perspective and analysis, the following needs to be in place for treatment as prevention to work for key populations:
1. Treatment as prevention needs to become an integral component of
a human rights-based combination prevention approach. Its success at the individual, community, services and policy levels depends on effective behavioural and structural interventions.
In order to make treatment as prevention work for key populations, it should be implemented through a human rights-based combination prevention approach, with a focus on behavioural and structural interventions, which are often insufficiently integrated in field trials. Community mobilisation is important in mobilising key populations to enable uptake of HIV testing and antiretroviral therapy and mitigate further medicalisation of the HIV response.
2. In order to make treatment as prevention work in real life, a range of
Community systems strengthening, as an integral component of health systems strengthening, is vital as well. Civil society interacts closely with key populations, can react quickly to their needs, advocate for quality programming and enabling policy environments, and where significant gaps exist, provide direct services (e.g. HIV testing and counselling). A strong civil society in turn leads to better designed and implemented public systems, policies and programmes.
4. Researchers should consider post-trial obligations as well as research
ethical, structural and programmatic obstacles have to be addressed, such as stigma, inequality and human rights violations.
3. Key population networks should be involved at all stages of planning,
implementing and evaluating programmes, including research, and help to develop harmonised messages around treatment as prevention. questions specific to key populations, e.g. on the most effective approaches to reach and support them; on interventions that effectively tackle barriers to structural and social access; and on the cost and cost-benefit of community engagement in treatment as prevention.
5. Treatment as prevention should strengthen the integration of communitybased interventions into the delivery of health services and contribute to increasing the evidence base on community mobilisation and engagement and community systems strengthening.
Photos (L–R): Kalahasti drop-in centre for MSM, Andhra Pradesh, India. © Jenny Matthews for the Alliance. Outreach to injecting drug users, Ukraine. © Gideon Mendel for the Alliance. Members of Tranvestites Verde Esperanza, an organisation for transgenders, Ecuador. © Marcela Nievas for the Alliance
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