It's raining good news
There was tons of good news coming out of the Conference on Retroviruses and Opportunistic Infections (CROI) last month. And it really pissed me off!
True, there was some bad news, but in general it was really good news. PositiveLite.com covered a lot of it including news about just how powerful ARVs can be for both treatment and prevention. There was news about the benefits of early treatment for the health of people living with HIV (Temprano), about treatment-as-prevention (Opposites Attract), about PrEP (PROUD; Ipergay), and about the combined use of treatment-as-prevention and PrEP (Partners Demonstration Project; modelling in San Francisco). Among others.
And this was really good news mind you. Not just “it kind of works”, but multiple messages about “no HIV transmissions”, “virtually eliminates HIV infections”, “reducing risk of serious illness and death”…
So as you can well imagine, I am really angry!
"All the studies showed just how powerful these interventions can be. Meanwhile, there is so little happening to leverage that power."
What made me angry about the good news from CROI was not the good news itself obviously, but how it pointed out the inertia (at best) that still prevails, along with the outright resistance and hostility (at worse) to the idea of implementing some of these new interventions. All the studies I mentioned above showed just how powerful these interventions can be. Meanwhile, there is so little happening to leverage that power.
Anyone who has read my articles about PROUD and Ipergay will guess that the incidence rates in those studies also made me angry. Very angry. You’re telling me that after 30+ years of developing the best prevention interventions we can — risk reduction counselling, adherence counselling, condoms, STI testing and treatment, PEP, HIV counselling and testing, HAV/HBV vaccination — we’re still seeing annual incidence rates between 6.6% and 8.9%?! Among middle-aged, educated, employed, self-efficacious white gay men in high-income settings who have privileged access to information, programs and services?!? Let alone in other populations! And some people think we’re actually in a position to suggest that we SHOULDN’T offer more options?
According to those studies, adding PrEP to the mix (just to use that as one example) could reduce the incidence by 86% and we’re still poopoo-ing and foot-dragging on this idea becaaaauuuussszzzzz…..??????
Let me be clear. This is not a recommendation to replace condoms, STI screening and treatment, risk reduction counseling, other behavioural interventions or structural interventions with treatment-as-prevention or PrEP or anything else.
· First because that would be just silly.
· Second because none of these interventions was ever meant to be a stand-alone, however often critics will use the phrase “magic bullet” to disparage advocates pushing for a broader range of options. Ensuring access to and use of male or female condoms, PrEP or treatment-as-prevention (just as examples) REQUIRES a combination of structural, behavioural and biomedical approaches. When someone uses a condom, that’s a behaviour. It’s a biomedical tool. And it’s happening because there have been a host of structural interventions (addressing health disparities, homophobia, sexism, racism, transphobia, income, housing, human rights, programmatic, policy and financial barriers…) that have led to using (behaviour) this biomedical tool.
· Third because the multiple findings at CROI eloquently and unequivocally demonstrate that it is the COMBINATION of multiple interventions that have the greatest impact. There’s no denying the power of the classic intervention package (male and female condoms, STI screening and treatment, HIV testing, HAV/HBV vaccination, PEP, risk reduction and adherence counseling). Good god, what would incidence rates be without it? Well, we have a good idea what those rates would be because too many people still don’t have access to the classic prevention package. However, the CROI results showed us the tremendous impact of combining this package with powerful new biomedical interventions. The impact is not due to PrEP/ART alone, but to the combination of elements within the package. However, it’s clear that adding PrEP and/or ART to this package has a considerable impact, to say the least. Likewise, the San Francisco study presented at CROI is interesting because it showed how PrEP could enhance the impact that ART and other classic interventions are already having.
It’s worth pointing out that both PROUD and the Partners Demonstration Project found reductions in risk even better than previous trials, and both are “real life” implementation studies. They were designed to offer PrEP and ART in the way that they would be outside of a study—through the same clinics that would normally offer these services. And it worked. According to the proud PROUD Principal Investigator, “The sexual health clinics that took part in the PROUD study were able to adapt their routine practice to include PrEP.” Both studies show that:
- We can identify high-risk populations.
- They are interested in these interventions.
- We can deliver these interventions.
- People will adhere to these interventions AND they will do so WITHOUT increasing their risk behaviours or rates of other STIs.
- These interventions will reduce HIV risk, and very substantially so. In fact, they seem to virtually eliminate risk.
So what are we going to do about this? There is some movement in Canada, but not enough.
Of course BC has been a huge proponent of treatment as-prevention. (Understatement of the year). But support for this approach has not been as strong elsewhere in the country, perhaps in part due to the slightly bombastic discourse emanating from BC. But there is room for improvement all around. A recent article shows that BC and Ontario (and presumably the rest of Canada) still have much to do to improve access to treatment to all who need it. I don’t think we need to expound on the benefits of treatment for the health of people living with HIV. And of course we know the impact treatment has on prevention.
Yet a paper published the day before CROI estimated that 61.3% of new infections in the U.S. were from people who were aware of their status but not retained in care and therefore not receiving treatment. Not being retained in care is not good for the health of the HIV-positive person, just to state the obvious. Nor is it helpful from a prevention perspective. So we must to better at ensuring access to treatment and linkage to care for all people living with HIV who need it and want it. There are considerable gaps in the infamous cascade in Canada.
Consensus statements, calls to action, and more
NAM and the European AIDS Treatment Group (EATG) have an exemplary Community Consensus Statement on the Use of Antiretroviral Therapy in Preventing HIV Transmission and it seems like Canada may soon have one of its own. Toronto PWA Foundation has had a position paper for years.
Last Fall when it was announced that PROUD and Ipergay had found PrEP to be effective, the Coalition des organismes communautaires québécois de lutte contre le sida (COCQ-sida) sent a letter to the provincial government, calling for the development of implementation guidance. (Quebec is currently the only province to have even an interim notice on PrEP). The moment the PROUD and Ipergay results were announced at CROI, at least 2 groups immediately issued calls for greater PrEP implementation. Warning (a prevention activist group in France, Montreal and Brussels) issued a call to make PrEP available, including the development of implementation guidance and efforts by community organisations to support interested PrEP users. EATG and the French NGO AIDES issued a manifesto calling for PrEP access, endorsed by a coalition of over 80 European groups.
"I’m left unimpressed by Canada’s response so far."
I’m left unimpressed by Canada’s response so far. We’re not doing particularly well in terms of ensuring access to healthcare and treatment to all who need it and want it. And it terms of PrEP, it’s a pretty sad state of affairs. To be sure, having Truvada approved for PrEP use by Health Canada would help. But why is Quebec the only province to have said anything about PrEP? Why is Toronto the only place to have a demonstration project? Where is the PrEP implementation guidance from the Public Health Agency of Canada? From the provinces? In the US the CDC has full implementation guidelines. There are many awareness campaigns, PrEP resources developed by many community groups and public health authorities, widespread financial coverage from public and private insurance plans, a national hotline for clinicians, community navigators in San Francisco… they are moving and shaking!
Yes, we should develop consensus statements and position papers. They elicit much needed dialogue on these issues. And they can serve as a basis for further action. In fact it could serve as a basis for the development of a Joint Advocacy Strategy on the use of ARVs for both Treatment and Prevention (JASATAP—meant to be accompanied with vigorous jazz hands), which would bring together treatment activists, prevention advocates, and networks of people living with HIV to work together on issues of common interest, such as:
- Setting targets and developing strategies to ensure that everyone who wants and needs treatment and healthcare has access
- Ensuring a rights-based approach, meaning both recognizing the right to health and therefore the right to access for those who want the interventions, but also ensuring the voluntary, non-coercive offer of treatment/ARVs
- Confronting the patchwork of drug access and coverage in Canada
- Addressing barriers in the prevention, care and treatment cascades—whether it’s to access treatment, PEP or PrEP, many communities face similar systemic, policy and programmatic barriers
- Advocating for legislative reform to address drug laws, laws on sex work, and criminalisation of non-disclosure
- Advocating for implementation guidance
- Advocating for demonstration and implementation programs
- Challenging the ridiculous price of ARVs
- Tackling the stigma and sex-shaming surrounding HIV-positivity, detectability and PrEP use
The list could go on. But instead of list-making, let’s get busy!