20th International AIDS Conference - Melbourne, Australia


WESY04 ARV-based HIV Prevention in Practice: Social and Behavioural Aspects
  Symposia Session
Venue: Clarendon Auditorium
Time: 23.07.2014, 14:30 - 16:00
Co-Chairs: Veronica Noseda, France
Albert Liu, United States

There is now proof of concept from robust random clinical trials for the potential of Antiretroviral(ARV)-based HIV prevention approaches to reduce the likelihood of HIV transmission and acquisition. This has generated much excitement and debate regarding the potential population prevention impact of early treatment initiation and the use of ARVs as chemoprophylaxis. However, it is now recognized that efficacy of ARV-based prevention approaches as established in controlled studies does not necessarily equate to effectiveness in real life settings and that impact will critically depend on how they are implemented. This session will address issues that shape the potential success of ARV-based prevention and discuss research-based evidence of the critical role of social and behavioural factors in the effectiveness of ARV-based prevention. At the completion of the session, participants will understand evolving guidelines and will be knowledgeable about factors that affect uptake, approaches to support adherence and strategies to engage health care providers.
14:30
WESY0401
Webcast
Introduction

14:33
WESY0402
Powerpoint
Webcast
An overview of the potential and challenges of ARV-based prevention
S. Abdool Karim, South Africa

14:48
WESY0403
Powerpoint
Webcast
User perspectives on ARV-based HIV prevention
S. Chariyalertsak, Thailand

15:03
WESY0404
Powerpoint
Webcast
Promoting adherence and retention in ARV-based prevention
S. Sahay, India

15:18
WESY0405
Powerpoint
Webcast
Identifying and addressing risk compensation in ARV-based HIV prevention
K. Underhill, United States

15:33
WESY0406
Powerpoint
Webcast
Engaging health care providers in ARV-based prevention
E. Wright, Australia

15:48
WESY0407
Webcast
Questions and answers

15:58
WESY0408
Webcast
Closing remarks

Powerpoints presentations
An overview of the potential and challenges of ARV-based prevention - Salim Abdool Karim

User perspectives on ARV-based HIV prevention - Suwat Chariyalertsak

Promoting adherence and retention in ARV-based prevention - Seema Sahay

Identifying and addressing risk compensation in ARV-based HIV prevention - Kristen Underhill
Identifying and addressing risk compensation in ARV-based HIV prevention - Kristen Underhill

Engaging health care providers in ARV-based prevention - Edwina J Wright



Rapporteur reports

Track D report by Martin Holt


This symposium session about antiretroviral or ARV-based prevention was designed to identify the issues that will shape the potential success of ARV-based prevention and discuss the social and behavioural aspects of these new prevention strategies.

Salim Abdool Karim (University of KwaZulu-Natal), discussed the potential and challenges of ARV-based prevention. Karim noted that despite compelling evidence of the benefit of ARVs in preventing transmission, the rollout of ARV-based prevention has been slow. He discussed barriers to ARV-based prevention, such as beliefs that treatment rollout should be prioritised over the preventative use of ARVs, that ARVs are not safe for HIV-negative people, that HIV-negative people cannot adhere to ARVs, that treatment as prevention will not have a community benefit, that pre-exposure prophylaxis (PrEP) use will create drug resistance and that we do not know enough to implement PrEP successfully. He argued that all of these beliefs are myths and that ARV-based prevention needs to be fast tracked for key affected populations.

Suwat Chariyalertsak (Chiang Mai University) gave a presentation on the importance of understanding user perspectives on ARV-based HIV prevention. He observed that what people do in ‘real life’ is often very different to what happens in clinical trials, and this may undermine the effectiveness of ARV-based prevention. Motivations to take ARVs may be quite different for HIV-positive and HIV-negative people, and the costs and benefits also vary.

Seema Sahay (National AIDS Research Institute, India) discussed the difficulties associated with promoting adherence and retention in ARV-based prevention. Sahay noted that adherence to a drug regime requires a user to incorporate drug treatment into the routine of daily life sufficiently well to achieve a beneficial effect. Adherence is affected by a range of factors including the ease of taking the drug, beliefs about the drug, perceived need for the drug and the level of support from partners, peers, service providers and the community.

Kristen Underhill (Yale) discussed the issue of risk compensation in ARV-based HIV prevention (the idea that the benefits of a strategy will be outweighed by increased rates of risk-taking as a result of lower perceived risks). Underhill noted that fears about risk compensation continue to drive fierce debates in HIV prevention. She described how risk compensation is most likely to occur when people can see significant benefits from taking increased risks e.g. greater intimacy, pleasure, freedom or fertility. Underhill suggested that it is very difficult to assess risk compensation properly in prevention trials.

Edwina Wright (Alfred Hospital, Melbourne) spoke about the role of clinicians in advocating for ARV-based prevention. She noted the tricky balancing act for clinicians in prioritising the health care needs of patients while also being mindful of the public health benefits of ARV-based prevention. She highlighted the stigma attached to new prevention strategies, which she believed would affect treatment decisions and make it difficult for patients to discuss their needs for treatment or ARV-based prevention.

Questions from the floor noted that ‘risk compensation’ is a relatively pejorative term, and that neutral or more positive alternatives might be warranted. Bob Grant (of the iPrEx trial) noted that human behaviour was rarely rational and wondered why we still use 'rational decision maker' models to understand ARV-based prevention. There was also discussion about the apparent desire of some within the HIV field to circumvent the vagaries of human behaviour with prevention technology, rather than designing prevention strategies that accommodate the diverse needs of people at risk of HIV.

Overall, while there was recognition of many issues associated with the implementation of ARV-based prevention from a provider or researcher perspective, there was a notable lack of discussion about the views of potential users within affected communities. This suggests a lack of detailed social science research on the ways in which ARV-based strategies are perceived and will be used by the people they are designed to protect.




Track E report by Bridget Haire


ARV-based HIV Prevention in Practice: Social and Behavioural Aspects

Summary: This session focused on the relationship between the clinical trial evidence on the efficacy of new biomedical HIV prevention methods and how these may or may not translate into real world effectiveness.

Slim Abdool Karim of South Africa presented an overview of the clinical trial evidence, and showed a summary slide that demonstrated the very clear relationship between adherence and efficacy across the range of trials using ARV-based prevention. He discussed the notion of combination prevention – the need for structural and behavioural interventions along with biomedical approaches. Professor Karim made a compelling argument for the immediate roll out of biomedical prevention interventions including pre-exposure prophylaxis (PrEP). He addressed a series of myths about ARV-based prophylaxis. He pointed out that it is neither necessary nor ethical to wait until every person with who requires ARV for treatment, as he said the drugs now are the cheapest part of supplying ARV – it is the health system challenges that impede access. It is safe to give ARV to healthy HIV uninfected people, shown in a range of studies, effectiveness is high, adherence support can be achieved, and task-shifting the prescription of ARV can improve sustainability of access, he said. Finally, Professor Karim argued against the focus on ‘demonstration projects’ for PrEP, as he said there is no need for further provision within limited artificial environments – wide scale implementation should begin in key populations, with appropriate studies to monitor and improve implementation in a continuous quality improvement cycle.

Suwat Chariyalertsak of Thailand spoke on issues in making new technologies available. He advocated for the collection of user perspectives on ARV-based HIV prevention experience, as he said clinical trials are different to real world applications.  Dr Chariyalertsak also said that while HPTN052 showed that early access to ARV was shown to be good for the HIV positive people in that trial, life long therapy is arduous, people may experience side effects, taking treatment may expose people to stigma, and poor adherence can lead to drug resistance. A major advantage of PrEP according to, Dr Chariyalertsak, is the fact that it is utilised by HIV negative people and need not be life long.

Seema Sahay of India spoke on promoting adherence and retention in ARV-based prevention. She said that prevention is difficult  long term and there needs to be multidimensional approach to adherence to prevention. Dr Sahay discussed the relationships between the individual, the product, the provider and the community, and argues for further social research on adherence and on stigma and how it impacts on people’s prevention practices.

Kristen Underhill from the United States spoke on identifying and addressing risk compensation in ARV-based HIV prevention. She explained that risk compensation has the potential to undermine use of new technologies under particular conditions, such as where there is only a small margin of protection, where risk/benefits miscalculated, and where ancillary risks (such as other STIs) are not calculated. Dr Underhill said that for risk compensation to occur, the protective intervention has to be visible, has to be believed in, and the user has to have control over behavioural reasons to take risks. She also pointed out that people have reasons for engaging in risk behaviour, as it has benefits that people value, such as intimacy, pleasure, relationship, fertility.

Edwina Wright of Australia spoke on engaging health care providers in ARV-based prevention. Dr Wright argued that clinicians already take active roles in HIV prevention, and she warned of the potential for coercion of patients into early treatment in some circumstances. She argued that the primary responsibility of a clinician is to the person in front of her, and pointed out that the strength of evidence for clinical benefit of ARV treatment is at lower CD4 levels, not at the very highest. While she supported the prescription of early treatment for people wanting to reduce infectivity, she argued for the importance of waiting for the release of results of forthcoming ‘when to start ARV?’ studies before making blanket recommendations about the clinical benefit of very early treatment. Dr Wright also said that clinicians need to be activists and to become engaged in changing laws that criminalise and stigmatise patients.

Recommendations: Roll out PrEP and other biomedical HIV prevention intervention now in key populations; develop appropriate monitoring and evaluation of PrEP implementation; invest in the development of new technologies that are easier for users, such as injectable PrEP; facilitate the communication between clinicians and affected communities through professional societies; advocate for reform of laws that criminalise and stigmatise people with HIV.

 




Track E report by Bridget Haire


ARV-based HIV Prevention in Practice: Social and Behavioural Aspects

Summary: This session focused on the relationship between the clinical trial evidence on the efficacy of new biomedical HIV prevention methods and how these may or may not translate into real world effectiveness.

Slim Abdool Karim of South Africa presented an overview of the clinical trial evidence, and showed a summary slide that demonstrated the very clear relationship between adherence and efficacy across the range of trials using ARV-based prevention. He discussed the notion of combination prevention – the need for structural and behavioural interventions along with biomedical approaches. Professor Karim made a compelling argument for the immediate roll out of biomedical prevention interventions including pre-exposure prophylaxis (PrEP). He addressed a series of myths about ARV-based prophylaxis. He pointed out that it is neither necessary nor ethical to wait until every person with who requires ARV for treatment, as he said the drugs now are the cheapest part of supplying ARV – it is the health system challenges that impede access. It is safe to give ARV to healthy HIV uninfected people, shown in a range of studies, effectiveness is high, adherence support can be achieved, and task-shifting the prescription of ARV can improve sustainability of access, he said. Finally, Professor Karim argued against the focus on ‘demonstration projects’ for PrEP, as he said there is no need for further provision within limited artificial environments – wide scale implementation should begin in key populations, with appropriate studies to monitor and improve implementation in a continuous quality improvement cycle.

Suwat Chariyalertsak of Thailand spoke on issues in making new technologies available. He advocated for the collection of user perspectives on ARV-based HIV prevention experience, as he said clinical trials are different to real world applications.  Dr Chariyalertsak also said that while HPTN052 showed that early access to ARV was shown to be good for the HIV positive people in that trial, life long therapy is arduous, people may experience side effects, taking treatment may expose people to stigma, and poor adherence can lead to drug resistance. A major advantage of PrEP according to, Dr Chariyalertsak, is the fact that it is utilised by HIV negative people and need not be life long.

Seema Sahay of India spoke on promoting adherence and retention in ARV-based prevention. She said that prevention is difficult  long term and there needs to be multidimensional approach to adherence to prevention. Dr Sahay discussed the relationships between the individual, the product, the provider and the community, and argues for further social research on adherence and on stigma and how it impacts on people’s prevention practices.

Kristen Underhill from the United States spoke on identifying and addressing risk compensation in ARV-based HIV prevention. She explained that risk compensation has the potential to undermine use of new technologies under particular conditions, such as where there is only a small margin of protection, where risk/benefits miscalculated, and where ancillary risks (such as other STIs) are not calculated. Dr Underhill said that for risk compensation to occur, the protective intervention has to be visible, has to be believed in, and the user has to have control over behavioural reasons to take risks. She also pointed out that people have reasons for engaging in risk behaviour, as it has benefits that people value, such as intimacy, pleasure, relationship, fertility.

Edwina Wright of Australia spoke on engaging health care providers in ARV-based prevention. Dr Wright argued that clinicians already take active roles in HIV prevention, and she warned of the potential for coercion of patients into early treatment in some circumstances. She argued that the primary responsibility of a clinician is to the person in front of her, and pointed out that the strength of evidence for clinical benefit of ARV treatment is at lower CD4 levels, not at the very highest. While she supported the prescription of early treatment for people wanting to reduce infectivity, she argued for the importance of waiting for the release of results of forthcoming ‘when to start ARV?’ studies before making blanket recommendations about the clinical benefit of very early treatment. Dr Wright also said that clinicians need to be activists and to become engaged in changing laws that criminalise and stigmatise patients.

Recommendations: Roll out PrEP and other biomedical HIV prevention intervention now in key populations; develop appropriate monitoring and evaluation of PrEP implementation; invest in the development of new technologies that are easier for users, such as injectable PrEP; facilitate the communication between clinicians and affected communities through professional societies; advocate for reform of laws that criminalise and stigmatise people with HIV.

 




Track E report by Bridget Haire


ARV-based HIV Prevention in Practice: Social and Behavioural Aspects

Summary: This session focused on the relationship between the clinical trial evidence on the efficacy of new biomedical HIV prevention methods and how these may or may not translate into real world effectiveness.

Slim Abdool Karim of South Africa presented an overview of the clinical trial evidence, and showed a summary slide that demonstrated the very clear relationship between adherence and efficacy across the range of trials using ARV-based prevention. He discussed the notion of combination prevention – the need for structural and behavioural interventions along with biomedical approaches. Professor Karim made a compelling argument for the immediate roll out of biomedical prevention interventions including pre-exposure prophylaxis (PrEP). He addressed series of myths about ARV-based prophylaxis. He pointed out that it is neither necessary nor ethical to wait until every person with who requires ARV for treatment, as he said the drugs now are the cheapest part of supplying ARV – it is the health system challenges that impede access. It is safe to give ARV to healthy HIV uninfected people, shown in a range of studies, effectiveness is high, adherence support can be achieved, and task-shifting the prescription of ARV can improve sustainability of access, he said. Finally, Professor Karim argued against the focus on ‘demonstration projects’ for PrEP, as he said there is no need for further provision within limited artificial environments – wide scale implementation should begin in key populations, with appropriate studies to monitor and improve implementation in a continuous quality improvement cycle.

Suwat Chariyalertsak of Thailand spoke on issues in making new technologies available. He advocated for the collection of user perspectives on ARV-based HIV prevention experience, as he said – clinical trials are different to real world applications.  Dr Chariyalertsak also said that while HPTN052 showed that early access to ARV was shown to be good for the HIV positive people in that trial, life long therapy is arduous, people may experience side effects, taking treatment may expose people to stigma, and poor adherence can lead to drug resistance. A major advantage of PrEP according to, Dr Chariyalertsak, is the fact that it is utilised by HIV negative people and need not be life long.

Seema Sahay of India spoke on promoting adherence and retention in ARV-based prevention. She said that prevention is difficult, long term and there need to be multidimensional approach to adherence to prevention. Dr Sahay discussed the relationships between the individual, the product, the provider and the community, and argues for further social research on adherence and on stigma and how it impacts on people’s prevention practices.

Kristen Underhill from the United States spoke on identifying and addressing risk compensation in ARV-based HIV prevention. She explained that risk compensation has the potential to undermine use of new technologies under particular conditions, such as where there is only a small margin of protection, where risk/benefits miscalculated, and where ancillary risks (such as other STIs) are not calculated. Dr Underhill said that for risk compensation to occur, the protective intervention has to be visible, has to be believed in, and the user has to have control over behavioural reasons to take risks. She also pointed out that people have reasons for engaging in risk behaviour, as it has benefits that people value, such as intimacy, pleasure, relationship, fertility.

Edwina Wright of Australia spoke on engaging health care providers in ARV-based prevention. Dr Wright argued that clinicians already take active roles in HIV prevention, and she warned of the potential for coercion of patients into early treatment in some circumstances. She argued that the primary responsibility of a clinician is to the person in front of her, and pointed out that the strength of evidence for clinical benefit of ARV treatment is at lower CD4 levels, not at the very highest. While she supported the prescription of early treatment for people wanting to reduce infectivity, she argued for the importance of waiting for the release of results of forthcoming ‘when to start ARV?’ studies before making blanket recommendations about the clinical benefit of early treatment. Dr Wright also said that clinicians need to be activists and to become engaged in changing laws that criminalise and stigmatise patients.

Recommendations: Roll out PrEP and other biomedical HIV prevention intervention now in key populations; develop appropriate monitoring and evaluation of PrEP implementation; invest in the development of new technologies that are easier for users, such as injectable PrEP; facilitate the communication between clinicians and affected communities through professional societies; advocate for reform of laws that criminalise and stigmatise people with HIV.

 




   

    The organizers reserve the right to amend the programme.