Implementation Challenges & Opportunities for HIV Treatment as Prevention (TasP) among Young Men in Vancouver, Canada

Background

Despite evidence supporting the preventative potential of HIV Treatment as Prevention (TasP), scientific experts and community stakeholders have suggested that the success of TasP at the population level will require overcoming a set of complex and population-specific implementation challenges. For example, the factors that might influence decisions to initiate ‘early’ treatment have yet to be thoroughly understood; neither have questions about the factors that enhance or impede their ability to achieve long-term adherence to ARVs or the social norms regarding various treatment regimens been examined in detail. This knowledge gap may hamper opportunities to effectively develop public health practices that are informed by the various challenges and opportunities related to TasP implementation and scale up.

Methods

Drawing on 50 in-depth, individual interviews with young men ages 18–24 in Vancouver, Canada, this study examines young men’s perspectives regarding factors that might affect their engagement with TasP.

Results

While findings from the current study indicate young men generally have a high receptiveness to TasP, our findings also identify key social and structural forces that will warrant ongoing consideration for TasP implementation. For example, participants described how an enhanced awareness regarding treatment (including awareness of the universal availability of treatment in Vancouver) would be a necessary, but not sufficient, condition to decide to endorse TasP. Their decisions about engaging in HIV care in the context of TasP (e.g., HIV testing, treatment initiation, long-term adherence) also appear to be contingent on their ability to negotiate or ‘balance’ the risks and benefits to themselves and others. The findings also offer insight into the complex and sometimes controversial narratives that continue to emerge regarding risk compensation practices in the context of TasP.

Conclusion

Based on the results of this study, we identify several areas that hold promise for informing the effective scale up of TasP, including new information regarding implementation adaptation strategies.

[sample of interview responses]

But I don’t know if that [information about HIV treatment and prognoses] makes me any less concerned about certain aspects of the disease just because I also know that it’s [treatment] expensive, and that definitely plays into me, ‘cause I know that if I needed to afford expensive medication, I just couldn’t right now. (#018)

You’re still fucked [in the event of an HIV diagnosis]. I don’t even know if it’s covered by MSP [Medical Services Plan, the provincial health care plan in the province of British Columbia]. I highly doubt it. So if you’re on welfare and you have HIV, I think you’re pretty fucking screwed. And I would not want to have to figure it out, either. (#041)

The person may feel like, ‘Well, you’re only making me undergo treatment because you just wanna protect those around me and decrease their chance of contracting the infection, as opposed to treating me and being concerned about me.’ So I can see the person viewing the measure as ‘all but me.’ (#001)

Full article at:   http://goo.gl/xmw22R

By:  Rod Knight, Will Small, Kim Thomson, Mark Gilbert, and Jean Shoveller

Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada

British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada

School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada

Ontario HIV Treatment Network, Toronto, Canada

Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

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Willingness to Act Upon Beliefs about ‘Treatment as Prevention’ among Australian Gay and Bisexual Men

HIV ‘treatment as prevention’ (TasP) is highly effective in reducing HIV transmission in serodiscordant couples. There has been little examination of gay and bisexual men’s attitudes towards TasP, particularly regarding men’s willingness to act on beliefs about TasP. 

We conducted an online cross-sectional survey of Australian men in late 2012 to investigate knowledge and beliefs about new developments in HIV prevention. 

• Amongst 839 men (mean age 39.5 years), men tended to disagree that TasP was sufficiently effective to justify reduced condom use, although HIV-positive men had more favourable attitudes. 
• Only a minority of men were aware of any evidence for TasP; and 
• one-quarter incorrectly believed that evidence for the effectiveness of TasP already existed for the homosexual population. 
• One-fifth (20.5%) of men reported that they would be willing to have condomless anal intercourse with an opposite-status sexual partner when the HIV-positive partner was taking HIV treatments. 
• Factors independently associated with such willingness were: 
• HIV-positive serostatus, 
• reporting any serodiscordant or serononconcordant condomless anal intercourse with a regular male partner in the previous six months, 
• reporting any condomless anal intercourse with a casual male partner in the previous six months, and 
• having greater beliefs in the effectiveness of TasP. 
• This indicated that the men most willing to rely on TasP to prevent transmission were already engaging in higher risk practices. 
• Biomedical HIV prevention represents a rapidly changing environment with new research as well as community and policy responses emerging at a fast pace. 

For men with serodiscordant sexual partners to successfully apply TasP to reducing transmission risk, more support and education is needed to enable better utilisation of TasP in specific relational and sexual contexts.

Below:  Individual scale items for total sample, and comparison between HIV-positive and non-HIV-positive men (bivariate)

Full article at:   http://goo.gl/wcB0dH

By:  

Benjamin R. Bavinton, Andrew E. Grulich, Iryna B. Zablotska, Garrett P. Prestage

Kirby Institute, University of NSW Australia, Sydney, Australia

Martin Holt

Centre for Social Research in Health, University of NSW Australia, Sydney, Australia

Graham Brown, Garrett P. Prestage

Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia

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Hepatitis C Virus Treatment as Prevention in People Who Inject Drugs: Testing the Evidence

PURPOSE OF REVIEW:

The majority of hepatitis C virus (HCV) infections in the United Kingdom and many developing countries were acquired through injecting. New clinical guidance suggests that HCV treatment should be offered to people with a transmission risk - such as people who inject drugs (PWID) - irrespective of severity of liver disease. We consider the strength of the evidence base and potential problems in evaluating HCV treatment as prevention among PWID.

RECENT FINDINGS:

There is good theoretical evidence from dynamic models that HCV treatment for PWID could reduce HCV chronic prevalence and incidence among PWID. Economic evaluations from high-income settings have suggested HCV treatment for PWID is cost-effective, and that in many settings HCV treatment of PWID could be more cost-effective than treating those at an equivalent stage with no ongoing transmission risk. Epidemiological studies of older interferon treatments have suggested that PWID can achieve similar treatment outcomes to other patient groups treated for chronic HCV. Impact and cost-effectiveness of HCV treatment is driven by the potential 'prevention benefit' of treating PWID. Model projections suggest that more future infections, end stage liver disease, and HCV-related deaths will be averted than lost through reinfection of PWID treated successfully for HCV. However, there is to date no empirical evidence from trials or observational studies that test the model projections and 'prevention benefit' hypothesis. In part this is because of uncertainty in the evidence base but also there is unlikely to have been a change in HCV prevalence due to HCV treatment because PWID HCV treatment rates historically in most sites have been low, and any scale-up and switch to the new direct acting antiviral has not yet occurred. There are a number of key uncertainties in the data available on PWID that need to be improved and addressed to evaluate treatment as prevention. These include estimates of the prevalence of PWID, measurements of HCV chronic prevalence and incidence among PWID, and how to interpret reinfection rates as potential outcome measures.

SUMMARY:

Eliminating HCV through scaling up treatment is a theoretical possibility. But empirical data are required to demonstrate that HCV treatment can reduce HCV transmission, which will require an improved evidence base and analytic framework for measuring PWID and HCV prevalence.

Full article at:   http://goo.gl/xyuGQF

By:   Hickman M¹, De Angelis D, Vickerman P, Hutchinson S, Martin NK.

¹aSchool of Social and Community Medicine, University of Bristol bMRC Biostatistics Unit, University of Cambridge and Public Health England cGlasgow Caledonian University and Health Protection Scotland, UK dDivision of Global Public Health, University of California San Diego, California, 

Curr Opin Infect Dis. 2015 Dec;28(6):576-82. doi: 10.1097/QCO.0000000000000216. 

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Increased Prevalence of Controlled Viremia and Decreased Rates of HIV Drug Resistance among HIV-Positive People Who Use Illicit Drugs During a Community-Wide Treatment-as-Prevention Initiative

BACKGROUND:

Although treatment-as prevention (TasP) is a new cornerstone of global human immunodeficiency virus (HIV)-AIDS strategies, its effect among HIV-positive people who use illicit drugs (PWUD) has yet to be evaluated. We sought to describe longitudinal trends in exposure to antiretroviral therapy (ART), plasma HIV-1 RNA viral load (VL) and HIV drug resistance during a community-wide TasP intervention.

METHODS:

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services study, a prospective cohort of HIV-positivePWUD linked to HIV clinical monitoring records. We estimated longitudinal changes in the proportion of individuals with VL <50 copies/mL and rates of HIV drug resistance using generalized estimating equations (GEE) and extended Cox models.

RESULTS:

Between 1 January 2006 and 30 June 2014, 819 individuals were recruited and contributed 1 or more VL observation. During that time, the proportion of individuals with nondetectable VL increased from 28% to 63% (P < .001). In a multivariable GEE model, later year of observation was independently and positively associated with greater likelihood of nondetectable VL (adjusted odds ratio = 1.20 per year; P < .001). Although the proportion of individuals on ART increased, the incidence of HIV drug resistance declined (adjusted hazard ratio = 0.78 per year; P = .011).

CONCLUSIONS:

We observed significant improvements in several measures of exposure to ART and virologic status, including declines in HIV drug resistance, in this large long-running community-recruited cohort of HIV-seropositive illicit drug users during a community-wide ART expansion intervention. Our findings support continued efforts to scale up ART coverage among HIV-positive PWUD.

Purchase full article at: http://goo.gl/58J4iB

By:   Milloy MJ1, Wood E1, Kerr T1, Hogg B2, Guillemi S3, Harrigan PR1, Montaner J1.

• 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver.
• 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.
• 3British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital. 

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Investigating Combination HIV Prevention: Isolated Interventions or Complex System

INTRODUCTION:

Treatment as prevention has mobilized new opportunities in preventing HIV transmission and has led to bold new UNAIDS targets in testing, treatment coverage and transmission reduction. These will require not only an increase in investment but also a deeper understanding of the dynamics of combining behavioural, biomedical and structural HIV prevention interventions. High-income countries are making substantial investments in combination HIV prevention, but is this investment leading to a deeper understanding of how to combine interventions? The combining of interventions involves complexity, with many strategies interacting with non-linear and multiplying rather than additive effects.

DISCUSSION:

Drawing on a recent scoping study of the published research evidence in HIV prevention in high-income countries, this paper argues that there is a gap between the evidence currently available and the evidence needed to guide the achieving of these bold targets. The emphasis of HIV prevention intervention research continues to look at one intervention at a time in isolation from its interactions with other interventions, the community and the socio-political context of their implementation. To understand and evaluate the role of a combination of interventions, we need to understand not only what works, but in what circumstances, what role the parts need to play in their relationship with each other, when the combination needs to adapt and identify emergent effects of any resulting synergies. There is little development of evidence-based indicators on how interventions in combination should achieve that strategic advantage and synergy. This commentary discusses the implications of this ongoing situation for future research and the required investment in partnership. We suggest that systems science approaches, which are being increasingly applied in other areas of public health, could provide an expanded vocabulary and analytic tools for understanding these complex interactions, relationships and emergent effects.

CONCLUSIONS:

Relying on the current linear but disconnected approaches to intervention research and evidence we will miss the potential to achieve and understand system-level synergies. Given the challenges in sustaining public health and HIV prevention investment, meeting the bold UNAIDS targets that have been set is likely to be dependent on achieving systems level synergies.

Full article at:   http://goo.gl/EBwg30

By:   Brown G1,2, Reeders D1, Dowsett GW1,3, Ellard J1,4, Carman M1, Hendry N1, Wallace J1.

• 1Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia.
• 2Centre for Social Research in Health, University of New South Wales, Sydney, Australia; Graham.brown@latrobe.edu.au.
• 3Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
• 4Kirby Institute, University of New South Wales, Sydney, Australia. 

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Modelling the Impact & Cost-Effectiveness of Combination Prevention amongst HIV Serodiscordant Couples in Nigeria

To estimate the impact and cost-effectiveness of treatment as prevention (TasP), pre-exposure prophylaxis (PrEP) and condom promotion for serodiscordant couples in Nigeria.

A deterministic model of HIV-1 transmission within a cohort of serodiscordant couples and to/from external partners was parameterized using data from Nigeria and other African settings. The impact and cost-effectiveness were estimated for condom promotion, PrEP and/or TasP, compared with a baseline where antiretroviral therapy (ART) was offered according to 2010 national guidelines (CD4 <350 cells/μl) to all HIV-positive partners. The impact was additionally compared with a baseline of current ART coverage (35% of those with CD4 <350 cells/μl). Full costs (in US $2012) of programme introduction and implementation were estimated from a provider perspective.

Substantial benefits came from scaling up ART to all HIV-positive partners according to 2010 national guidelines, with additional smaller benefits of providing TasP, PrEP or condom promotion. Compared with a baseline of offering ART to all HIV-positive partners at the 2010 national guidelines, condom promotion was the most cost-effective strategy [US $1206/disability-adjusted-life-year (DALY)], the next most cost-effective intervention was to additionally give TasP to HIV-positive partners (incremental cost-effectiveness ratio US $1607/DALY), followed by additionally giving PrEP to HIV-negative partners until their HIV-positive partners initiate ART (US $7870/DALY). When impact was measured in terms of infections averted, PrEP with condom promotion prevented double the number of infections as condom promotion alone.

The first priority intervention for serodiscordant couples in Nigeria should be scaled up ART access for HIV-positive partners. Subsequent incremental benefits are greatest with condom promotion and TasP, followed by PrEP.

Via:  http://ht.ly/S9W55 

By: Mitchell KM1, Lépine A, Terris-Prestholt F, Torpey K, Khamofu H, Folayan MO, Musa J, Anenih J, Sagay AS, Alhassan E, Idoko J, Vickerman P.

• 1aLondon School of Hygiene and Tropical Medicine, London, UK bFamily Health International, Abuja cObafemi Awolowo University and New HIV Vaccine and Microbicide Advocacy Society, Lagos dUniversity of Jos, Jos eNational Agency for the Control of AIDS, Abuja, Nigeria fUniversity of Bristol, Bristol, UK.