9 Steps to an HIV Prevention Revolution in Resource-Limited Settings

9 Steps: HIV Prevention Revolution in Resource-Limited Settings

It’s 3 decades into the war with HIV/AIDS and so far 78 million have been infected and 39 million people have died, most in an untimely way (1). Yet an important battle has been won: antiretroviral therapy (ART) brought life-saving treatment to those infected, in both the developed and the developing world, and the number of AIDS-related deaths has fallen by 42% since their peak in 2004 (2). ART is even now beginning to win a second victory, this time as prevention rather than treatment; whereby endorsement of immediate initiation on ART following diagnosis allows for more rapid viral suppression, which significantly reduces the chance of transmission.

Figure 1: From a presentation at the HIV Glasgow Conference depicting global progress towards the UNAIDS 90-90-90 goals, as shown in the UNAIDS 2016 Prevention Gap Report (3).

However, in 2015 alone more than 5000 new infections are occurring every day, 40% of those living with HIV/AIDS do not know it and 62% of HIV-positive people are not virally suppressed (3). ART has been our hammer, but AIDS is not dead yet and it is time to access what else we have in the toolbox. We need a revolution, and it needs to be a primary prevention revolution!
Nowhere is this more evident than in resource-limited settings, where multiple and location-unique obstacles challenge the traditional approach of test and treat and create the need for primary prevention implementation. Unfortunately, but importantly, developing countries where the burden of HIV is high, face significant economic constraints that often force a choice to be made between HIV prevention and HIV treatment. To overcome this, any prevention scheme implemented needs to be bespoke: tailored to the country-specific key populations and layered with dual biomedical and structural interventions where the force of infection is high. In order to kick off this revolution, we need to identify the areas that ART is leaving exposed, and then we need to cover them with primary prevention.
Prevention Gap 1:

Figure 2: From a presentation at the HIV Glasgow Conference showing how different locations have different key populations (KP). This advocates for a location-population approach to treatment. Graphs taken from the UNAIDS 2016 Prevention Gap Report. (3)

“Few countries have consistently applied a comprehensive prevention approach that provides specific packages of services tailored to priority populations within specific local contexts”
The need to recognize and identify key populations is an old hat concept. Groups such as female sex workers (4% of new infections globally), people who inject drugs (PWID, 7%), men who have sex with men (MSM, 8%), transgender people (0.4%) have been prioritised worldwide for treatment and prevention (2). In areas such as Vancouver, Canada where HIV incidence among PWID is high, or San Francisco, U.S. where the MSM population carries the weight of the HIV burden, focusing all the resources towards such key population is high effective.
However, it needs to be acknowledged that key populations differ significantly between countries and do not always align with global classifications. This is particularly evident in Eastern and Southern Africa, where all the key populations combined contribute only 21% to new infections, while adolescent girls and young women alone contribute 20% (3). In such circumstances, a high focus on the key populations, while also necessary, would not lead to huge gains in eradication of the epidemic. Therefore, it is imperative that each country adopts a location-population specific approach that identifies their unique populations in crisis and responds accordingly. It is only by correct identification of the population that the correct prevention tools can be selected and applied.
Prevention Gap 2:
“43% of countries with injecting populations do not have needles and syringe exchange programs, and only 12 countries provide the requisite 200 clean needles per person injecting per year”
For PWID a significant reduction in HIV transmission can be achieved by reducing injecting risk, through primary prevention interventions such as needle and syringe exchange programs and access to opioid-substitution therapy. Vancouver, Canada saw a 76% decrease in HIV-transmission between 1996 and 2007 in the PWID population as a direct result of implementation of such programs. The introduction of universal ART (immediate initiation after treatment) in 2010 for treatment as prevention (TasP) further accelerated the transmission decline; illustrating the success TasP can achieve while working in tandem with primary prevention (4,5). If all countries with injecting populations at high risk of contracting HIV could, with sufficient resources and political will, implement both TasP and primary prevention as part of a tailored prevention package, HIV incidence in this population could be equally swiftly turned around.
Prevention Gap 3:
“Laws and policies that undermine public health need to be actively reviewed and repealed”
Legal structures, stigmatisation and discrimination are significant barriers to certain populations, limiting the prevention programs that can be provided and decreasing engagement with health services due to fear of discrimination or incarceration. MSM provides a good example of this, as globally there are still 76 countries where same-sex relationships are illegal and HIV prevention services to this group are restricted. In Malawi, where MSM face incarceration if discovered, a study found that only 9.6% of HIV-infected individuals were aware of their status and the majority of participants were first-time testers (7). In stark comparison, MSM in San Francisco, who constituted the epicentre of the AIDS epidemic in 1980s, are the largest population currently on PrEP (pre-exposure prophylaxis) and have already reached their first two 90-90-90 goals (6). This is a result of concentrated effort and political will, as well as a legal environment conducive to provision of primary prevention.
Prevention Gap 4:
“Community empowerment and other programs that have been proven to reduce stigma, discrimination and marginalization, particularly in health clinics, have not been brought to scale”
Social discrimination towards populations already vulnerable to HIV-infection increases their risk profile, especially when this stigma is carried into the clinic by health-work professionals. While social attitudes are only likely to be changed over long time periods, much can be achieved when there is community participation, empowerment, and strong community leadership. For example, in India, despite the continued illegality of brothels, 82.8% of sex workers were reached by HIV prevention programmes that offer STI treatment and free condom distribution, but which also implement structural interventions and community mobilisation to decrease stigma and remove barriers to accessing entitlement (8, 9). This combination of biomedical and structural primary prevention has successfully resulted in a steady decline in HIV-incidence in this population (9).

Figure 3: From a presentation at the HIV Glasgow Conference illustrating the “Vicious HIV Cycle” as it would appear in the world of the Simpsons. The most vulnerable group here are young girls, who become HIV-infected typically when they enter into relationships with older men or when they are exposed to high levels of gender-based violence. This figure was adapted from de Oliveira, 2016 (9).

Prevention Gap 5:
“2/3 Young people do not have correct and comprehensive information about HIV”
Sub-Saharan Africa has been particularly hard hit by the HIV epidemic, with 24.7 million people still living with HIV (UNAIDS Gap Report 2014). Key populations feature less here and a cycle of infection instead perpetrates through the general population. For instance, in South Africa young women (<25 years) sit at high risk and typically acquire HIV due to age-disparate relationships or as a result of sexual and gender-based violence (10). As these women grow up they enter relationships with HIV-uninfected men of their own age, and the virus spreads. Men, who show significant less engagement with healthcare such that they are less likely to be tested and less likely to adhere to ART, often enter relationships with younger girls and begin the infection cycle again (10).
Multiple steps need to be taken here, with particular focus on the implementation of separate adolescent-friendly and male-friendly healthcare services. An effective way of doing is through mobile clinics, which move away from crowded health facilities and into hard to reach areas, at times that are convenient both for youth and for men who work. This allows for increased access STI testing and condoms (and hopefully soon PrEP!), as well as provides a platform to promote HIV education and awareness.
Prevention Gap 6:
“PrEP coverage is < 5% of the 2020 target of 3 million people on PrEP”
Pre-exposure prophylaxis could be a prevention revolution in itself, providing protection in circumstances where condoms, ARV’s and behaviour leave large gaps. Most importantly it has the potential to allow the vulnerable to protect themselves, as for women in areas with high gender-based violence or adolescents undergoing their sexual debut, it can be difficult to negotiate the terms of safe sex. Access to PrEP during high risk periods would allow these populations to engage with primary prevention without requiring the knowledge or consent of their prospective partners. Another scenario to consider, is people in serodiscordent partnerships who require a safety bridge before viral suppression can be achieved through ART. The ADAPT HTVN 067 study with South African women showed that the majority of women would take oral PrEP daily with good adherence, if it were to be available. PrEP rollout is still in its infancy, however, if availability and access can be accelerated, it could be the primary prevention tool needed to make eradiation of this epidemic a reality.

Figure 4: A graph from a presentation at the HIV Glasgow Conference to illustrate the positive impact of cash and cash+care on HIV-risk behaviour among adolescents in South Africa. This was taken from Cluver et al., 2015 (14).

Prevention Gap 7:
“Structural drivers need to be included in the response”
In resource-restricted settings, HIV risk is often strongly associated with structural constraints, such as economic deprivation and dropping out of school. For instance, it has been shown that for every extra year of secondary school a girl obtains, her chances of contracting HIV drop by 50%. An effective way of overcoming such structural barriers is through conditional or unconditional transfers, such as paying for school uniforms and providing cash incentives for negative STI testing scores. This has been shown to reduce sexual debut, pregnancy, age-disparate sec and translational sex (12-14). Furthermore, greater reductions in HIV-risk behaviour was observed when cash transfers were combined with care initiatives, such as increasing parental, community and educational support (15). These are all examples of social prevention interventions and, particularly with adolescents, it is important that protection is seen as additive with HIV primary prevention.
Prevention Gap 8:
“Condom provision in SSA covers less than half the required numbers, and condom use is much too low across all population groups at high risk”
Condoms remain one of the most effective means of preventing horizontal HIV transmission, yet condom fatigue and low usage across all populations restricts the protection they have the potential to provide. In an attempt to make condom use sexier for the youth, Minister of Health of South Africa, Aaron Motsoaledi, this year announced that the state had “procured new coloured and scented condoms to increase condom use among young people. They provide the four maximums: Maximum pleasure, Maximum protection, Maximum quality, and Maximum number of young people making use of them.”
Prevention Gap 9:
“The number of medical male circumcisions needs to almost double in order to meet the 2020 targets”
Men living in countries where HIV-prevalence is high in the general population present a unique challenge, as they are tend to shy away from health services, harbour fears of stigma, job loss and lack of confidentially, and are less likely to be diagnosed, receive treatment, or live a long-life once infected (16,17). Therefore, ensuring primary prevention in this group is vital as once infected this population is incredibly difficult to reach and relies on specialised male-friendly services such as community based adherence clubs and incentivized mobile testing (17,18). Primary prevention is most effectively administered through voluntary medical male circumcision (MMC), which reduces HIV-acquisition by 55-65%. Modelling studies show that to achieve HIV/AIDS eradication in the next 50 years, MMC will need to be scaled up to the maximum as it provides prevention coverage on par with universal ART access (TasP) (19).
Ultimately, the AIDS epidemic is only going to conquered if primary prevention is bought up to scale. This battle can’t be won with ART alone. Viva la primary prevention revolution!
Linda-Gail Bekker
An adaption from a keynote lecture presented at the HIV Glasgow Conference 2016, entitled “The HIV Prevention Revolution in Low- to Middle-Income Countries”.
Watch it here: https://www.youtube.com/watch?v=TfiRgYE_asU&feature=youtube
Twitter: @LindaGailBekker
References:

1. AIDS by Numbers. 2015 [cited 23 October 2016]. Available from: http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf
2. Prevention Gap Report 2014.
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14. Cluver LS, Boyws M, Orkin M, Pantelic M, Molwena T, Sherr L. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. Lancet Glob Health. 2013; 1: e362-370.
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16. Nglazi MD, van Schaik N, Kranzer K, Lawn SD, Wood R, Bekker LG. An ncentivized HIV counselling and testing program targeting hard-to-reach unemployed men in Cape Town, South Africa. J Acquie Immune Defic Syndr. 2012; 1, 59(3): e28-34.
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18. Grimsrud A, Sharp K, Kalombo C, Bekker LG, Myer L. Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa. J Int AIDS Soc. 2015; 18, 1: 19984.
19. Smith JA, Anderson SJ, Harris KL, McGillen JB, Lee E, Garnett GP, Hallet TB. Maximising HIV Prevention by balancing the opportunities of today with the promises of tomorrow: a modelling study. Lancet HIV. 2016; 3)7): e289-e296.

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