Global AIDS Experts Call For Major Shift in Approach to HIV Prevention as Treatment Access Expands

The Global HIV Prevention Working Group today issued the first major report to examine global HIV prevention needs in a time of expanding treatment access. The report, HIV Prevention in the Era of Expanded Treatment Access, cites an unprecedented opportunity to forge a comprehensive response to the global AIDS epidemic by integrating HIV prevention interventions into expanding treatment programs.

"This is the best chance the world has had to build a comprehensive response to the global epidemic. More widespread access to treatment is likely to bring millions of people into health care settings, providing new opportunities for health care workers to deliver and reinforce HIV prevention messages," said Helene D. Gayle, MD, MPH, co-chair of the Working Group, and director of HIV, TB and Reproductive Health at the Bill & Melinda Gates Foundation. "Now is the time to act, as treatment programs are being launched an expanded."

New Challenge:  Potential for Increased Risk Behavior

In the report, the Working Group, an international panel of nearly 50 AIDS experts, voices concern that HIV treatment availability could shift attitudes about the threat of HIV/AIDS in the developing world, potentially resulting in increased risk behavior and the continued expansion of the global AIDS epidemic. The report recommends that HIV prevention strategies and messages be adapted to stress the importance of continued risk reduction in the context of expanded treatment access.

"Treatment access in the developing world will improve the lives of millions, but also presents new challenges to HIV prevention," said David Serwadda, MBChB, MPH, of the Institute of Public Health at Makerere University in Kampala, Uganda, and co-chair of the Working Group. "In Uganda, we have seen how HIV prevention can work, and we are now undertaking a major effort to incorporate prevention counseling into treatment programs. The goal is to ensure that treatment does not have the unintended consequence of increasing risk behavior."

The report summarizes experience in industrialized countries, where treatment access expanded without an accompanying shift in prevention strategies, and risk behavior and new infections increased. The report also cites projections which suggest that even a modest increase in risk behavior in the developing world as a result of treatment access (e.g., a decrease in condom use of 10%) could substantially accelerate the global epidemic.

Early Success in Integrating Prevention and Treatment

The report documents early successes in developing countries that embarked on coordinated prevention and treatment programs, such as Brazil, Botswana, Haiti, and South Africa. For example, Brazil implemented aggressive prevention and treatment programs early in the epidemic, and saw HIV testing rates and ART use increase substantially, while reducing rates of risk behavior. A project by Médecins Sans Frontières in the Khayelitsha township in South Africa couples prevention counseling with ART provision, resulting in increased rates of condom use in the community.

Need to Increase HIV Testing Rates

Because increased HIV testing rates are critical to both treatment and prevention efforts, the report also calls for HIV testing to be universally offered in all health care settings in areas where ART is available with the option to opt out for those who don’t want to be tested. Experts estimate that today only 10 percent of HIV-positive people in developing countries are aware of their infection.

Limited Access to Proven HIV Prevention Interventions

As the Working Group reported last year, globally, fewer than one in five people at high risk of HIV infection have access to proven prevention interventions like condoms, voluntary HIV counseling and testing, behavior change programs, drugs to prevent mother-to-child transmission, and harm reduction programs for injection drug users.

"Our latest survey shows that the majority of Americans now believe that spending more money on prevention in Africa and developing nations will lead to meaningful progress," said Drew Altman, PhD, President and CEO of the Henry J. Kaiser Family Foundation, and co-convener of the Working Group. "The challenge now is to make scaling up our number one priority in the fight against HIV, and to scale up prevention and treatment in tandem."

The report argues that unless the incidence of HIV infection is sharply reduced, treatment will not be able to keep pace with all those who will need therapy. For example, while WHO and UNAIDS have established the goal of having 3 million people on anti-retroviral therapy by 2005, 5 million new infections occur every year.

The Working Group calls for annual funding for HIV prevention and care to increase from $4.7 billion in 2003 to $10.5 billion in 2005 and $15 billion in 2007, as recommended by UNAIDS.

Recommendations

The Working Group report lays out a four-point plan of action:

1. Integrate HIV Prevention and Treatment

• Provide HIV Prevention in ART & Other Health Care Settings: All health care settings, including HIV treatment sites, should deliver HIV prevention counseling, condoms and other interventions. In addition to free-standing voluntary counseling and testing sites, HIV prevention counseling and testing should be offered in STD and TB clinics, hospitals, family planning and reproductive health centers, substance abuse clinics, and prenatal clinics, among others.
  
• Expand Access to HIV Testing & Universally Offer Testing Where ART Access Exists: Testing programs should be significantly expanded and aggressively promoted. Where ART access exists, HIV testing and counseling should be universally offered in all health care settings with the option to opt out for people who don’t want to be tested.

2. Develop Prevention Strategies for HIV-Positive People

• "Prevention for Positives": New prevention programs tailored to the needs of people living with HIV should be developed and implemented. Such programs would include counseling regarding disclosure of HIV status to partners, education about the ability of people to transmit HIV even while on ART, and counseling to address obstacles to safer behavior.
  
• Involve People Living with HIV: Donors and governments should provide financial support to organizations of people living with HIV, who should be actively engaged in the delivery of HIV prevention services to HIV-positive people.
  
• Fight Stigma: Enforceable laws must be in place to protect people with HIV from discrimination, and community-based initiatives to empower people with HIV should be implemented.

3. Adapt Prevention for HIV-Negative People

• New Messages: New strategies must emphasize the continued importance of risk reduction. "Treatment literacy" programs should emphasize that ART is not a cure, and that people on ART can still spread the virus to their partners.
  
• Monitoring Impact: Surveillance systems should closely monitor the behavioral impact of ART.

4. Fund a Comprehensive Response

• Simultaneous Scale-Up of Prevention and Treatment: HIV/AIDS spending from all sources should increase from $4.7 billion in 2003 to $10.5 billion in 2005 and to $15 billion in 2007, as recommended by UNAIDS.
  
• Research: Funding for research into a broad array of potential prevention technologies must increase. By 2007, annual research funding should roughly double to $1 billion for HIV vaccines and to $300 million for microbicides.

About the Working Group
The Global HIV Prevention Working Group is a panel of nearly 50 leading public health experts, clinicians, biomedical and behavioral researchers, and people affected by HIV/AIDS, convened by the Bill & Melinda Gates Foundation and the Henry J. Kaiser Family Foundation. The Working Group seeks to inform global policy-making, program planning, and donor decisions on HIV prevention, and to advocate for a comprehensive response to HIV/AIDS that integrates prevention and care. In July 2002, the Working Group issued its first report, Global Mobilization for HIV Prevention: A Blueprint for Action. In May 2003 it released Access to HIV Prevention:Closing the Gap. Both are available at www.gatesfoundation.org and www.kaisernetwork.org.