In this guest blog post, CATIE’s James Wilton explores the challenges and opportunities in moving research around new HIV prevention technologies into practice, highlighting the important role of community based organizations in implementing new approaches to HIV prevention and in doing community-based research to evaluate new models of intervention.
Moving research on new “biomedical” HIV prevention technologies into practice
By James Wilton
Recent research findings have improved our understanding of HIV transmission and prevention and could change the landscape of our response to the HIV epidemic. In the past few years, several new HIV prevention approaches, such as post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and the use of antiretroviral treatment as prevention, have been found to reduce the risk of HIV transmission. These new strategies are often referred to as new “biomedical” HIV prevention technologies, or NPTs.
If moved into practice in an appropriate way, these new approaches could have a dramatic impact on the HIV epidemic in Canada and other parts of the world. However, translating this research into a reduction in new HIV infections within the communities we work with will be challenging. Community-based organizations (CBOs) – through programming and research – will have an important role to play in understanding these challenges, overcoming them, and effectively implementing these approaches.
Engaging people and communities in new HIV prevention approaches
At the most basic level, we know that the more people in a population who use a specific strategy, the more HIV transmissions they can potentially prevent. The number of people who use a strategy, often referred to as uptake or adoption, will depend on a number of factors, such as awareness (do people know about it?), acceptability (do people want to use it?) and availability (can people access and afford the technology if they want to use it?).
The impact of these strategies will also depend on “who” in a population uses them. More HIV transmissions will be prevented if the strategies are adopted by individuals who are at highest risk of HIV transmission, such as those who don’t use condoms consistently or share injection drug use equipment.
Focusing uptake among those at highest risk may be important for another reason. There is a concern that some people using these new approaches may feel a false sense of security and increase their risk behaviour, such as using fewer condoms or having sex with more partners (a concept known as risk compensation or behavioural disinhibition). Since none of these new strategies are 100% protective, this could potentially offset some of the benefit of NPTs and limit the number of HIV infections they prevent. However, the potential impact of risk compensation will be lower when used by people who are already at higher risk of HIV transmission.
Community-based organizations will play a key role in engaging individuals and communities and facilitating the appropriate uptake of these technologies. This will involve:
- Community mobilization to build readiness for new approaches and address barriers that may affect their acceptability, such as stigma and social, cultural, and political norms.
- Outreach and educational campaigns to improve awareness of these strategies, including information on who they are appropriate for and where they can be accessed, particularly among those at highest risk for HIV transmission.
- Accurate risk assessments for those who are interested in using these approaches and, if appropriate, referral to locations where they can be accessed.
- Community planning to ensure NPTs are provided in a way that respects human rights and supports informed decision making by the people using them.
- Advocacy to ensure the technologies are available and affordable.
Community-based research (CBR) will be essential to gain a better understanding of the acceptability, awareness and availability of these technologies in the community, the barriers to adopting them, and the characteristics of those who are using them.
Packaging new approaches with other strategies and supports
Among those who do use these strategies, what will influence the effectiveness of NPTs at reducing HIV incidence?
How consistently and correctly these strategies are used will be important. Research shows that these new approaches – such as post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and the use of antiretroviral treatment as prevention – are much less protective if not used consistently. Correct use means different things for different strategies. However, as none of these new approaches are 100% protective, correct use generally means that these new approaches are combined with, instead of replace, existing HIV prevention strategies.
Furthermore, the presence of certain biological factors that are known to increase HIV risk, such as sexually transmitted infections (STIs), may reduce the effectiveness of these new approaches. Therefore, correct use of these strategies also means combining them with STI prevention, testing, and treatment services.
In research studies and clinical trials, these NPTs have been credited with dramatic reductions in HIV incidence and this has generated a lot of excitement. For example, the HPTN 052 study found that antiretroviral treatment reduced HIV incidence among heterosexual serodiscordant couples by 96%.
However, we may not see the same large reductions in incidence in populations using these strategies in the “real world,” outside of a clinical trial. In clinical trial settings, participants are provided with ongoing prevention and support services including free condoms, HIV testing, STI testing and treatment, and intensive adherence and risk-reduction counselling. All of these services help to create “ideal” conditions that can maximize the impact of an HIV prevention strategy on HIV incidence. These new approaches may be less effective outside of a clinical trial if they are not provided in combination with these additional support services.
Community-based organizations will play an important role in packaging new prevention approaches with additional strategies and supports. This will include:
- Adherence support to help people integrate these strategies into their daily lives and use them consistently.
- Education on how to use the strategies correctly, including information on their advantages and disadvantages compared to existing approaches and the factors that may reduce their effectiveness.
- HIV prevention and risk-reduction counselling to help people understand their HIV transmission risk while they are using a prevention technology and to help them adopt additional HIV and STI prevention strategies. This will also need to include linkages and referrals to other services needed by people at risk of HIV infection and transmission.
Again, community-based research can play an important role in providing insight into how people are using these strategies in the “real world” and the barriers to using these strategies consistently and correctly.
The role of CBOs and CBR in the changing HIV prevention landscape
The HIV prevention landscape is changing and CBOs have an important role to play in ensuring NPTs are used by the “right” people, at the “right” time, in the “right” context, and in the “right” way.
However, there is an increasing concern that the introduction of these technologies, particularly those based on antiretrovirals, will “medicalize” HIV prevention and reduce the role of CBOs in the response to the HIV epidemic. This is because most “biomedical” NPTs can only be obtained from a healthcare provider and need to be combined with ongoing medical services, such as laboratory and clinical monitoring, HIV testing (in the case of PEP and PrEP), and STI testing and treatment. Therefore, the worry is that these new “biomedical” approaches will shift the setting of HIV prevention from the community to the clinic.
In reality, it’s clear that these new prevention approaches are not exclusively “biomedical” and need to be packaged with several non-clinical services in order to prevent risk compensation, promote their appropriate uptake and sustained use, and ensure they are effective outside of a clinical trial setting. These are services that many healthcare providers do not have the time, knowledge, or expertise to provide effectively and, therefore, represent a gap that CBOs need to fill.
Dr. Kevin Fenton of the Centers for Disease Control and Prevention (CDC) in the United States gave a presentation at the 2012 International AIDS Conference in Washington where he discussed the implications of this new research for CBOs. He called upon CBOs to adapt to the changing HIV prevention landscape by:
- Learning new skills (improving their science base and understanding of clinical trial results).
- Developing new clinical alliances (improving their ties with organizations and institutions where these prevention technologies can be obtained).
- Providing new clinical and prevention services (offering HIV and STI testing, adherence support, and risk-reduction support).
- Promoting the uptake and correct use of these technologies (developing accurate, tailored, context-specific information; ensuring messages reach their target populations through a variety of different mechanisms, such as peer–peer outreach).