Nelly Mugo said that effective interventions need to
packaged together, provided in combination and delivered at a sufficient scale,
so that a large proportion of the population are reached (i.e. high coverage).
She gave the example of HIV testing, which is increasingly
seen as the gateway for all other services, whether the result is positive or
We need a ‘care continuum’ for those who test HIV-negative
“It’s important that testing is linked to services, and we
don't just accrue numbers of people tested,” Mugo said. “This will require
systems for effective linkages to services.”
The conference saw numerous diagrams of treatment cascades
and care continuums for people testing HIV-positive. But Wafaa El-Sadr of
Columbia University suggested that researchers and policy makers also need to
plan a ‘care continuum’ for those who test HIV-negative.
Following a negative test, people should be linked to
prevention services. Depending on the individual’s needs, these might include
counselling, social support, condom provision, pre-exposure prophylaxis (PrEP)
and male circumcision. While PrEP is the service that will most obviously
require on-going contact and monitoring, testing services should stay in
contact with all service users who will require repeat HIV testing at a later
date, she said.
Sheryl Zwerski of the National Institute of Allergy and Infectious Diseases warned that combination prevention was
not just about “throwing everything at any old population” and hoping it would
work. Research that looks at specific combinations for specific populations is
needed, she said and a number of such studies are underway.
Catherine Hankins of the Amsterdam Institute for Global
Health and Development said that choices for what is put into a combination
needed to be tailored to the local epidemiology and guided by science. But she
showed a slide showing that different African governments were giving very
different levels of support to different interventions for reasons that are not
entirely clear. For example, several countries devoted a third or more of their
budgets to prevention of mother-to-child transmission, while two spent nothing
Peter Cherutich of the Kenyan Ministry of Health said that
in the case of male circumcision, common sense suggested the interventions
which needed to be delivered alongside it. HIV testing should be provided
beforehand and the risks and partial protection of the procedure needed to be
explained to those considering it. This provided an opportunity for safer sex
counselling and condom distribution. Moreover, delivering all the
interventions together helps clients understand that no single element
provides comprehensive protection on its own.
It’s notable that this package puts together the provision
of biomedical interventions with behavioural support. Many feel that the
division between biomedical and behavioural approaches to HIV prevention is a
false one as all biomedical interventions have a behavioural component.
Dazon Dixon Diallo of SisterLove said that “the same
methodologies we learned about trying to get folks to use condoms” will be used
to help them to take pills or use microbicide gels.
In terms of demonstration projects looking at the
feasibility of offering pre-exposure prophylaxis in the US, a key question is
to establish the best place to deliver PrEP. The settings chosen – perhaps
sexually transmitted disease clinics, primary care clinics or community-based
organisations – will determine the context within which PrEP is provided and
the other services it can be put in combination with.
And questions remain about the ability of America’s
fractured and inegalitarian health system to deliver prevention interventions –
not just PrEP, but also routine HIV testing – to a sufficient proportion of the
people who need them.
Dawn K Smith of the CDC noted that many poor and
disadvantaged groups with high HIV rates are unable to access affordable
health care or do not know how to. And although Barack Obama’s healthcare reform
law will be implemented, expansion of the Medicaid programme for poor people
and its coverage of preventative services are measures that each state can opt
out of. The leaders of Florida and Texas are leading opposition to Medicaid
expansion, although HIV heavily affects both states.
“When I think about how we're going to end AIDS in the United States I look to the local level.” Chris Collins
But Chris Collins of amfAR said that when there is strong
political and public health leadership, high coverage of interventions and good
health outcomes can be achieved.
In Massachusetts, a wide expansion of health coverage for people
with HIV and the wider population over the past decade has been accompanied by
a 45% drop in new HIV diagnoses. In San Francisco, a major scale-up of HIV
testing and treatment has seen reductions in undiagnosed infection, community
viral load and HIV diagnoses. In both places, prevention had been tightly focused
on communities at greatest risk, retention in care had been prioritised, and
clinical services were ‘culturally competent’ in dealing with gay and poor
"There are success stories in this epidemic,” Collins
said. “When I think about how we're going to end AIDS in the United States I
look to the local level.”
But Moupali Das reflected on her experience in
San Francisco and warned that change will not happen overnight, especially if healthcare providers need to work together in new ways. “It takes a
long time to implement a paradigm shift,” she said.