An international panel of nearly 50 experts in HIV prevention today warned that as access to antiretroviral treatment is expanded, a major shift in HIV prevention tactics will be needed in order to avoid a rise in HIV transmission and acceleration of the epidemic.
The Global HIV Prevention Working Group’s report, HIV prevention in the era of expanded treatment access, recommends that HIV prevention should become a routine part of primary health care in all resource-limited settings, whether antiretrovirals are being provided or not. Community and public sector HIV prevention programmes should promote HIV testing and educate people about HIV treatment at the same time, and should develop close links with antiretroviral treatment facilities and other providers of care for people with HIV.
Launching the report today, Dr Helene Gayle of the Bill and Melinda Gates Foundation said, "Now is the time to act, as treatment programmes are being launched and expanded."
The working group emphasises that HIV testing should remain voluntary, but the offer of an HIV test must be encountered in all health care settings, as should education about HIV, access to condoms and other prevention tools, and screening for sexually transmitted infections.
The report also stresses that all health care workers providing treatment and care services should receive training in HIV prevention, and services should be organised to ensure that patients are exposed to HIV prevention information at every visit, and have the opportunity to access prevention services such as condoms, sexually transmitted infections testing and clean injecting equipment.
Similarly, community-based adherence support programmes should include prevention work as a core activity. The working group highlights the contribution that adherence supporters can play, saying, “Because adherence support and HIV prevention services both seek to influence individual behaviour, adherence programmes provide an especially efficient entry point for discussion of HIV prevention.”
The effects of Medecins sans Frontieres’ treatment programme in the township of Khayelitsha are noted in the report. Community education about the successful ARV project appears to be influencing local attitudes towards HIV, with greater awareness of HIV, more positive attitudes towards HIV testing and higher rates of condom use reported by local residents.
Treatment and prevention – not an either/or choice
Increasing HIV prevention access is essential for reaching ambitious treatment goals – WHO’s 3 x 5 target and PEPFAR’s target of 2 million on treatment by the end of 2008 – but it is hoped that increasing access to treatment will also have an effect on uptake of prevention services.
“In the setting where I work, what we have noticed is that we increased voluntary counselling to a limited extent [when treatment was not available]. It’s only in the past three to four months [since it became available] that we’ve seen a steady increase in the numbers coming forward for testing. At the moment less than 10% of HIV-infected South Africans know their HIV status – treatment and voluntary counselling and testing can build each other,” said Dr Salim Abdool Karim of the University of Natal, South Africa.
“For a long time, prevention and treatment were considered to be opposing strategies – you had to choose. In fact they are mutually reinforcing,” said Dr Paolo Teixiera, formerly head of Brazil’s national AIDS programme, one of the few to have integrated treatment and prevention comprehensively.
He argued that Brazil’s success, indicated by constant rates of condom use among gay men since the introduction of ART and low rates of transmission of drug-resistant virus, was partly attributable to the strong involvement of people affected by HIV in formation of policy and implementation of services in Brazil, and he urged strong involvement of the most affected communities in the scaling-up of prevention activities.
Complacency about prevention could accompany treatment scale-up
However, the downside of heightened awareness of HIV treatment could be a relaxation in condom use, the report warns. The working group highlights declines in condom use observed among commercial sex workers in Nairobi, Kenya between 1998-90 and again in 1993-94, when the Kenyan press featured prominent reports on so-called `AIDS cures`.
The report also cites World Bank modelling of the effects of reduced condom use in India following the introduction of ART. The World Bank projects that if condom use falls by 10% following the introduction of ARVs, the net result will be a loss of 18 million life years by 2033, compared with a saving of 79.2 million life years if condom use can be increased by 20%.
The working group claims that the experiences of industrialised countries since the introduction of HAART offer a cautionary tale. The report argues that the trajectory of the epidemic in some developed nations is being influenced by a growing perception among gay men that HIV is no longer a life-threatening illness, a view disputed by some experts.
However, Dr Gayle acknowledged that a lack of emphasis on prevention since the introduction of HAART in Europe and North America has also contributed to rising rates of sexually transmitted infections and HIV diagnoses amongst high-risk groups.
Where will the money come from?
Donors should prioritise support for programmes that combine treatment and prevention activities, say the panel, and should aim to scale up funding rapidly. By 2007, the total needed to fund comprehensive prevention efforts will have reached $6.6 billion, whilst $8.5 billion will be needed for care and support (in 2002, donors provided $1.9 billion to support prevention activities, according to figures supplied to the working group by UNAIDS). Support for vaccine research should be doubled by 2007 (to $1 billion).
Approximately $4 billion in new funding for prevention activities is needed within the next two to three years, over and above any investment in treatment and care, said Dr Gayle.
Under-financing of prevention activities is severely limiting their impact, the group reports. In 2001, only 5% of women in resource-limited settings received services to prevent mother-to-child transmission, and only 19% of injecting drug users could obtain harm-reduction services such as needle exchange.
“The cost of failing to integrate prevention and treatment services will be significant, since the number of new infections will continue to grow, with a resulting need to continually expand HIV treatment services,” says the report. The working group also cautions that, unless programmes grow dramatically in scale in the next few years, any integration of prevention and treatment that does take place will have a marginal impact on the onward march of HIV into new populations.
“It’s not possible for prevention to be done on the cheap,” said Dr Gayle.
The report recommends that donors should invest significantly in support for organisations of people with HIV and AIDS to conduct prevention activities targeted at people living with HIV. “Prevention for positives” should be part of every country’s National AIDS Plan and this should be supported by strengthened efforts to reduce stigma and combat discrimination against people with HIV. This will require legal protection and political leadership as well as population-wide campaigns, the report states.