20th International AIDS Conference - Melbourne, Australia


WEAC01 Maximizing the Preventive Benefits of Treatment: Evolving Views
  Oral Abstract Session : Track C
Venue: Plenary 3
Time: 23.07.2014, 14:30 - 16:00
Co-Chairs: Gottfried Hirnschall, WHO
Kenly Sikwese, Zambia

14:30
WEAC0101
Abstract
Powerpoint
Webcast
From efficacy to effectiveness: ART uptake and HIV seroincidence by ART status among HIV discordant couples in Zambia
K. Wall1,2, M. Inambao3, K. Simpungwe3, R. Parker2, J. Abdallah2, N. Ahmed3, W. Kilembe4, A. Tichacek2, E. Chomba5, J. Pulerwitz6, I. Thior7, S. Allen2
1Emory University, Department of Epidemiology, Atlanta, United States, 2Rwanda Zambia HIV Research Group, Emory University, Department of Pathology & Laboratory Medicine, Atlanta, United States, 3Rwanda Zambia HIV Research Group, Emory University, Department of Pathology & Laboratory Medicine, Ndola, Zambia, 4Rwanda Zambia HIV Research Group, Emory University, Department of Pathology & Laboratory Medicine, Lusaka, Zambia, 5Ministry of Community Development, Mother and Child Health, Lusaka, Zambia, 6Population Council, New York, United States, 7Program for Appropriate Technology in Health (PATH), Washington, DC, United States

14:45
WEAC0102
Abstract
Powerpoint
Webcast
Evidence of behavioural risk compensation in a cohort study of HIV treatment and transmission in homosexual male serodiscordant couples
B.R. Bavinton1, F. Jin1, G. Prestage1,2, I. Zablotska1, A. Grulich1, the Opposites Attract Study Group
1The University of New South Wales, The Kirby Institute, Sydney, Australia, 2La Trobe University, Australian Research Centre in Sex, Health and Society, Melbourne, Australia

15:00
WEAC0103
Abstract
Powerpoint
Webcast
“What is this 'Universal Test and Treat' (UTT)?” Community understandings of key concepts linked to a combination HIV prevention strategy in 21 Zambian and South African communities
V. Bond1,2, G. Hoddinott3, M. Simuyaba1, K. Abrahams3, H. Ayles4,5, N. Beyers3, P. Bock3, C. Bwalya1, L.-A. Erasmus-Claassen3, S. Fidler6, J. Hargreaves7, R. Hayes8, J. Mantantana3, M. Musheke1, R. Ndubani1, J. Seeley9,10, M. Simwinga1,2, L. Viljoen3
1Zambia AIDS-related Tuberculosis Project (ZAMBART), Social Science, Lusaka, Zambia, 2London School of Hygiene and Tropical Medicine, Department of Global Health and Development, Faculty of Public Health and Policy, London, United Kingdom, 3Desmond Tutu TB Centre, University of Stellenbosch, Department of Paediatrics and Child Health, Cape Town, South Africa, 4Zambia AIDS-related Tuberculosis Project (ZAMBART), Clinical Research, Lusaka, Zambia, 5London School of Hygiene and Tropical Medicine, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London, United Kingdom, 6Imperial College London, London, United Kingdom, 7London School of Hygiene and Tropical Medicine, Department of Social and Environmental Health Research, London, United Kingdom, 8London School of Hygiene and Tropical Medicine, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London, United Kingdom, 9University of East Anglia, School of International Development, Norwich, United Kingdom, 10MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda

15:15
WEAC0104
Abstract
Powerpoint
Webcast
Is use of antiretroviral treatment (ART) associated with decreased condom use? A meta-analysis of studies from low- and middle-income countries (LMICs)
C. Kennedy1, K. Armstrong2, V. Fonner1, M. Sweat2, K. O'Reilly2
1Johns Hopkins Bloomberg School of Public Health, International Health, Baltimore, United States, 2Medical University of South Carolina, Psychiatry and Behavioral Sciences, Charleston, United States

15:30
WEAC0105LB
Abstract
Powerpoint
Webcast
Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention in rural South Africa: results from the ANRS 12249 TasP cluster-randomised trial
C. Iwuji1, J. Orne-Gliemann2, F. Tanser1, R. Thiébaut2, J. Larmarange3, N. Okesola1, M.-L. Newell4, F. Dabis2
1Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa, 2Bordeaux University, Institut de Santé Publique, Epidemiologie et Developpement, Bordeaux, France, 3Centre Population et Développement (CEPED UMR 196 Université Paris Descartes-Ined-IRD), Paris, France, 4University of Southampton, Faculty of Medicine, Faculty of Social and Human Sciences, Southampton, United Kingdom

15:45
WEAC0106
Webcast
Moderated discussion

Powerpoints presentations
From efficacy to effectiveness: ART uptake and HIV seroincidence by ART status among HIV discordant couples in Zambia - Kristin Wall

Evidence of behavioural risk compensation in a cohort study of HIV treatment and transmission in homosexual male serodiscordant couples - Benjamin Robert Bavinton

“What is this 'Universal Test and Treat' (UTT)?” Community understandings of key concepts linked to a combination HIV prevention strategy in 21 Zambian and South African communities - Virginia Bond

Is use of antiretroviral treatment (ART) associated with decreased condom use? A meta-analysis of studies from low- and middle-income countries (LMICs) - Caitlin Kennedy

Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention in rural South Africa: results from the ANRS 12249 TasP cluster-randomised trial - Collins Iwuji



Rapporteur reports

Track D report by Carlos F. Caceres


This Abstract-Driven Session  presented five important studies about the preventive effects of treatment (and perceptions around this), in various settings and populations.

In the first presentation, From efficacy to effectiveness: ART uptake and HIV seroincidence by ART status among HIV discordant couples in Zambia”, by Kristin Wall, it was concluded that ART uptake among HIV+ individuals in discordant relationships was low. The CIDA-funded Couples VCT (CVCT) expansion led to testing of more couples over a shorter period of time relative to other regions and a significantly higher follow-up rate that allowed for seroincidence estimates. If was found that ART effectiveness in the cohort was much lower than in randomized trials likely due to access and adherence issues. Given reduced HIV transmission rates in discordant couples after CVCT irrespective of ART, CVCT with follow-up testing for discordant couples, an effective and locally affordable prevention intervention, should be provided and promoted in government clinics.

The second presentation, Evidence of behavioural risk compensation in a cohort study of HIV treatment and transmission in homosexual male serodiscordant couples”, by Ben Bavinton (Australia), among MSM in the Opposites Atract study, showed that among Australian HIV-negative men in homosexual male serodiscordant couples, perceiving the partner''s VL to be undetectable was associated with increased practice of UAI, and this association persisted over time. We have documented behavioural risk compensation but no HIV seroconversion in this cohort of homosexual male SDCs. It was suggested that studies of the efficacy of HIV treatment as prevention in homosexual male populations are a research priority.

The third presentation, What is this 'Universal Test and Treat' (UTT)?” Community understandings of key concepts linked to a combination HIV prevention strategy in 21 Zambian and South African communities, by Virginia Bond (Zambia), focused on understandings of prevention (and particularly ARV-based prevention) in 21 African community sites, found that UTT and Treatment as Prevention (TasP) were not yet familiar concepts in the 21 community sites. Most people welcomed such prevention strategies ''in principle''; but health system barriers and sustainable implementation were common reservations. Implementers of UTT and TasP must work to revisit these interchangeable concepts, building on evident community support for PMTCT.

The fourth presentation, Is use of antiretroviral treatment (ART) associated with decreased condom use? A meta-analysis of studies from low- and middle-income countries (LMICs)”, by Caitlin Kennedy, was a systematic review of condom use among people livin with HIV in relation to ARV use. This review, which found that most studies on this topic have been conducted in the past 5 years, concluded that in LMIC, PLHIV on ART are more likely to report condom use than those not on ART. The authors described this as encouraging news for continued expansion of ART programs in LMICs, which suggested that “treatment as prevention” may be true in more ways than one.

The fifth presentation, Feasibility and acceptability of an antiretroviral treatment as prevention (TasP) intervention in rural South Africa: results from the ANRS 12249 TasP cluster-randomised trial”, presented by Collins Iwuji (South Africa), reported on a study where three six-monthly rounds of home-based HIV testing were undertaken in 10 (2x5) clusters of ~1,000 adults each (03/12-03/14) in that country. Trial participants were offered rapid HIV testing and provided a dried blood spot (DBS), and HIV+ participants were referred to the cluster trial clinic. The study concluded that the home-based HIV testing strategy and TasP intervention as piloted could decrease HIV incidence at population level. Enrolment is thus expanding to an additional 2x6 clusters from May 2014; all 22 clusters will be followed until June 2016 to estimate the population impact of TasP on HIV incidence.

All studies generated questions from the public, and generally showed enthusiasm about the preventive effects of treatment. Discussion also showed that expectations about consequences of viral suppression in serodiscordant couples do not necessarily consider acceptable that some people (or couples) choose to use low viral loads as a prevention strategy. It also showed that many concepts, and also many terms, related to treatment as prevention, are controversial ad/or unstable in current discussions about HIV prevention.




Track C report by Frederick Altice


Maximizing the Preventive Benefits of Treatment: Evolving Views

The session was lively and included divergent data on the impact of TasP in HIC versus LMICs, perhaps due to the increased understanding of what TasP really is. Importantly, there was a discussion about whether the term TasP should be used to avoid any real or perceived conflict between treatment and prevention.  One side suggested that TasP was stigmatizing for PLWH by blaming them for not reducing HIV transmission, while the alternative suggested that we be accurate about defining and explaining that TasP benefits the patient, their sexual partner, the healthcare system and society through documented benefits.  What is clearly needed is better education about what TasP really is and what it does (part of a combination prevention strategy) and how to use positive message frames when describing it. 

K Wall S. presented intriguing modeling data of TasP data, including cost, from <150,000 couples in Zambia where individuals underwent couples-based VCT (CVCT), followed by TasP for the HIV+ partner within serodiscordant couples.  Though questions were raised about the parameters that were selected for HIV incidence and the lack of incorporation of non-primary partners, there was a 82% risk reduction for CVCT compared to 69% reduction for TasP followed by CVCT.  Though not discussed, the TasP arm resulted in a markedly lower HIV incidence compared to CVCT alone (0.44% vs 2.0%). The cost of averting one HIV infection using CVCT was estimated to be $392 (not sure how this relates to income and per capita health costs in Zambia).  Costs to avert HIV, however, were estimated to increase to $666 if the HIV+ partner was on ART before CVCT due to only an estimated 30% reduction in HIV incidence. One conclusion was that for couples (not individuals) that CVCT would ultimately lead to a higher reduction in incidence and at a relatively low cost than TasP where the couple is not HIV tested and counseled together (additional benefit from doing the counseling and disclosure together). 

B. Bavinton presented preliminary data from the Australian (high income country) sample of a larger study TasP of 124 serodiscordant MSM couples (Opposites Attract Cohort).  The study sought to explore whether the “perception” by the HIV- partner that the HIV+ partner was non-detectable resulted in UAI (defined as risk compensation).  The sample was primarily gay-identified, over 50% were university educated and about half had sex with men outside their primary relationship. Most HIV+ partners were taking ART (89.5%) and 72.9% has maximal viral load suppression, but 90% had a VL<400.  There was high concordance between the HIV- partner’s perception of their partner being non-detectable (ND) with laboratory findings.  About two-thirds of couples reported UAI at baseline, which did not change over time.  UAI was further categorized for the HIV- partner as insertive (58.9%), receptive + withdrawal upon ejaculation (37.9%), and receptive + ejaculation (18.6%).  Using time-dependent GEE analysis, having UAI, irrespective of being insertive or receptive partner conferred about a 2-fold association with the perception that the HIV+ partner had a ND VL.  Though there was some debate whether this should be called “risk compensation”, the findings from this study in a high income setting with highly educated MSM that individuals make decisions about sexual activities based on the perception that they are at markedly reduced risk for acquiring (or transmitting) HIV.  Not discussed was how this translated to sex outside the primary relationship and whether participants had a working framework about whether a ND (or markedly low) VL conferred a reduced risk for transmitting HIV. 

V. Bond presented data on the formative planning for HPTN 071 (PopART), which is alarge-scale 3-arm, community-randomised controlled trial of a multi-component HIV prevention intervention (including earlier access to ART) in 21 community sites in Zambia (N=12) and South Africa (N=9), which built on a Universal Test and Treat (UTT) model, underscored by TasP paradigm.  Focus groups and key informant interviews were conducted with >750 individuals at all sites to explore the local context for “what does prevention mean”?  Though there were some common themes, including PMCTC, VCT, and ABC, it was concerning that the context was profoundly different for the two countries and that a large population-based prevention trial was about to be conducted in a setting where concepts like universal test and treat and TasP were not even understood as prevention and the notion that testing should be linked to treatment was not at all understood.  It is the reminder that researchers from high income countries that ethically before they introduce interventions that are poorly understood, they must raise the bar for potential participants and truly provide “informed” decision-making in a setting where the very intervention that is proposed needs considerable explanation and understanding before study participants are enrolled.  It was not surprising that the term that researchers use (e.g., UTT, TasP, PrEP) were not part of the public vernacular because despite them being used by researchers routinely (including at this conference), there has been a failure by researchers, implementers and communities to filter down information that is understandable.  While it is seductive to speculate that we should rename some of our evidence-based practices (e.g., TasP, PrEP, etc) as something else, the more informed strategy is to educate participants and provide the appropriate message frame for it to potential consumers (e.g., TasP is a method to not only improve individual help, but to potentially improve the lives of your sexual partners, the community and society).  

C. Kennedy conducted a meta-analysis of whether patients on ART in LMICs self-reported decreased condom use.  Using data from 1990, data consistently showed that condom use was NOT decreased for patients on ART, despite partner type and gender.  PLWH were 1.8-fold more likely to report consistent condom use and 2.3-fold more likely to report condom use during last sexual encounter.  Aside from 3 studies (of 35), all were published after 2007 and an update to June 2014 found a total of 50 eligible papers.  When asked why these findings diverged from findings from Australia (see Bavinton et al), it was speculated that there was just insufficient knowledge about TasP in LMIC and the prevention messages propagated in these settings (see Bond et al) do not represent contemporary scientific thinking and mostly reflect outdated and often judgmental prevention messages.  It was further speculated that as individuals become more informed about the potential benefit of TasP, that condom use levels may change similarly to findings from high-income countries. 

C. Iwuji presented preliminary findings on the feasibility and acceptability of a TasP intervention in Kwazulu Natal in preparation for the conduct of a cluster-randomized controlled trial (ANRS 12249). Data were reported for Phase I of the trial to confirm pre-planned parameters estimated for the initial conduct of the study.  The details of the study design and intervention were delineated.  Using GPS to identify households, members underwent home-based HIV testing with HIV+s being referred immediately to HIV care and HIV-s underwent semi-annual HIV testing. HIV+s are randomized to control (ART if CD4<350) or intervention (ART for any CD4).  Of the ~13,000 registered households, 77.5% were successfully contacted, of which 82.3% were HIV tested.  Linkage to HIV care, however, was lower than expected with only 31.2% of HIV+s being linked to care.  For initial HIV-s, repeat HIV testing was 62.7% at second contact.  Most assumptions were verified with empirical data, except linkage to HIV care, which often took >6 months (which had not been planned), but justifies moving to Phase II.   




Track C report by Frederick Altice


Maximizing the Preventive Benefits of Treatment: Evolving Views

The session was lively and included divergent data on the impact of TasP in HIC versus LMICs, perhaps due to the increased understanding of what TasP really is. Importantly, there was a discussion about whether the term TasP should be used to avoid any real or perceived conflict between treatment and prevention.  One side suggested that TasP was stigmatizing for PLWH by blaming them for not reducing HIV transmission, while the alternative suggested that we be accurate about defining and explaining that TasP benefits the patient, their sexual partner, the healthcare system and society through documented benefits.  What is clearly needed is better education about what TasP really is and what it does (part of a combination prevention strategy) and how to use positive message frames when describing it. 

K Wall S. presented intriguing modeling data of TasP data, including cost, from <150,000 couples in Zambia where individuals underwent couples-based VCT (CVCT), followed by TasP for the HIV+ partner within serodiscordant couples.  Though questions were raised about the parameters that were selected for HIV incidence and the lack of incorporation of non-primary partners, there was a 82% risk reduction for CVCT compared to 69% reduction for TasP followed by CVCT.  Though not discussed, the TasP arm resulted in a markedly lower HIV incidence compared to CVCT alone (0.44% vs 2.0%). The cost of averting one HIV infection using CVCT was estimated to be $392 (not sure how this relates to income and per capita health costs in Zambia).  Costs to avert HIV, however, were estimated to increase to $666 if the HIV+ partner was on ART before CVCT due to only an estimated 30% reduction in HIV incidence. One conclusion was that for couples (not individuals) that CVCT would ultimately lead to a higher reduction in incidence and at a relatively low cost than TasP where the couple is not HIV tested and counseled together (additional benefit from doing the counseling and disclosure together). One factor that was central to the findings in Africa is that among HIV serodiscordant couples, 21% of HIV+ partners were already taking ART, often without the partner's knowledge of HIV status or ART prescription (non-disclosure issue).  This translated to the reduction in HIV incidence observed in HIV- partners was a combination of CVCT and ART in reducing the HIV+ partners ability to transmit virus.   

B. Bavinton presented preliminary data from the Australian (high income country) sample of a larger study TasP of 124 serodiscordant MSM couples (Opposites Attract Cohort).  The study sought to explore whether the “perception” by the HIV- partner that the HIV+ partner was non-detectable resulted in UAI (defined as risk compensation).  The sample was primarily gay-identified, over 50% were university educated and about half had sex with men outside their primary relationship. Most HIV+ partners were taking ART (89.5%) and 72.9% has maximal viral load suppression, but 90% had a VL<400.  There was high concordance between the HIV- partner’s perception of their partner being non-detectable (ND) with laboratory findings.  About two-thirds of couples reported UAI at baseline, which did not change over time.  UAI was further categorized for the HIV- partner as insertive (58.9%), receptive + withdrawal upon ejaculation (37.9%), and receptive + ejaculation (18.6%).  Using time-dependent GEE analysis, having UAI, irrespective of being insertive or receptive partner conferred about a 2-fold association with the perception that the HIV+ partner had a ND VL.  Though there was some debate whether this should be called “risk compensation”, the findings from this study in a high income setting with highly educated MSM that individuals make decisions about sexual activities based on the perception that they are at markedly reduced risk for acquiring (or transmitting) HIV.  Not discussed was how this translated to sex outside the primary relationship and whether participants had a working framework about whether a ND (or markedly low) VL conferred a reduced risk for transmitting HIV. 

V. Bond presented data on the formative planning for HPTN 071 (PopART), which is alarge-scale 3-arm, community-randomised controlled trial of a multi-component HIV prevention intervention (including earlier access to ART) in 21 community sites in Zambia (N=12) and South Africa (N=9), which built on a Universal Test and Treat (UTT) model, underscored by TasP paradigm.  Focus groups and key informant interviews were conducted with >750 individuals at all sites to explore the local context for “what does prevention mean”?  Though there were some common themes, including PMCTC, VCT, and ABC, it was concerning that the context was profoundly different for the two countries and that a large population-based prevention trial was about to be conducted in a setting where concepts like universal test and treat and TasP were not even understood as prevention and the notion that testing should be linked to treatment was not at all understood.  It is the reminder that researchers from high income countries that ethically before they introduce interventions that are poorly understood, they must raise the bar for potential participants and truly provide “informed” decision-making in a setting where the very intervention that is proposed needs considerable explanation and understanding before study participants are enrolled.  It was not surprising that the term that researchers use (e.g., UTT, TasP, PrEP) were not part of the public vernacular because despite them being used by researchers routinely (including at this conference), there has been a failure by researchers, implementers and communities to filter down information that is understandable.  While it is seductive to speculate that we should rename some of our evidence-based practices (e.g., TasP, PrEP, etc) as something else, the more informed strategy is to educate participants and provide the appropriate message frame for it to potential consumers (e.g., TasP is a method to not only improve individual help, but to potentially improve the lives of your sexual partners, the community and society).  

C. Kennedy conducted a meta-analysis of whether patients on ART in LMICs self-reported decreased condom use.  Using data from 1990, data consistently showed that condom use was NOT decreased for patients on ART, despite partner type and gender.  PLWH were 1.8-fold more likely to report consistent condom use and 2.3-fold more likely to report condom use during last sexual encounter.  Aside from 3 studies (of 35), all were published after 2007 and an update to June 2014 found a total of 50 eligible papers.  When asked why these findings diverged from findings from Australia (see Bavinton et al), it was speculated that there was just insufficient knowledge about TasP in LMIC and the prevention messages propagated in these settings (see Bond et al) do not represent contemporary scientific thinking and mostly reflect outdated and often judgmental prevention messages.  It was further speculated that as individuals become more informed about the potential benefit of TasP, that condom use levels may change similarly to findings from high-income countries. 

C. Iwuji presented preliminary findings on the feasibility and acceptability of a TasP intervention in Kwazulu Natal in preparation for the conduct of a cluster-randomized controlled trial (ANRS 12249). Data were reported for Phase I of the trial to confirm pre-planned parameters estimated for the initial conduct of the study.  The details of the study design and intervention were delineated.  Using GPS to identify households, members underwent home-based HIV testing with HIV+s being referred immediately to HIV care and HIV-s underwent semi-annual HIV testing. HIV+s are randomized to control (ART if CD4<350) or intervention (ART for any CD4).  Of the ~13,000 registered households, 77.5% were successfully contacted, of which 82.3% were HIV tested.  Linkage to HIV care, however, was lower than expected with only 31.2% of HIV+s being linked to care.  For initial HIV-s, repeat HIV testing was 62.7% at second contact.  Most assumptions were verified with empirical data, except linkage to HIV care, which often took >6 months (which had not been planned), but justifies moving to Phase II.   




   

    The organizers reserve the right to amend the programme.