This article by Tim Rogers first appeared on the CATIE website here.
Une version française est disponible ici.
In 2014, UNAIDS proposed an ambitious set of targets for the global scale-up of HIV treatment.1 This approach to the HIV response is based on research showing that early, life-long HIV treatment can dramatically improve the health of people living with HIV and can also dramatically reduce HIV transmission. The new UNAIDS strategy emphasizes that the tremendous potential of HIV treatment is not being realized, not even in developed countries like Canada. This must change to bring the HIV epidemic under control.
In this article we will explore the crucial role HIV prevention work can play in the UNAIDS call for a “new narrative on HIV treatment.”
What are the benefits of HIV treatment?
HIV treatment can dramatically improve the health and extend the life of people living with HIV. With the development of better-tolerated HIV treatments, research is showing that starting treatment early, before the virus has a chance to cause damage to the immune system, is important for achieving the best health outcomes.2
HIV treatment works by suppressing the amount of virus in the blood to low or undetectable levels and this can also significantly reduce the risk of HIV transmission. In 2011, a landmark study known as HPTN 052 demonstrated for the first time that early treatment can significantly reduce the risk of sexual HIV transmission under certain conditions in heterosexual serodiscordant couples (where one partner is HIV positive and the other is HIV negative).3 In March 2014, a preliminary analysis of the PARTNER study reported the first direct evidence that effective antiretroviral therapy (ART) can also significantly reduce HIV risk for gay men and other men who have sex with men (MSM).4
As HIV treatment and prevention have converged, attention has turned to how well we are engaging people living with HIV in the continuum of services, including testing, care and, ultimately, effective treatment. The concept of an HIV treatment cascade has emerged as a way to identify the gaps in the continuum that are preventing people from realizing the full treatment and prevention benefits of ART.
What is the UNAIDS strategy and how is it new?
In a strategic discussion paper1 launched at the 2014 World AIDS Conference, UNAIDS proposed that by 2020:
• 90% of all people living with HIV will know their status;
• 90% of all people with diagnosed HIV infection will receive sustained ART;
• 90% of all people receiving ART will have viral suppression (undetectable viral load).
If these targets are achieved, 81% of all people living with HIV will be on treatment and 73% will have an undetectable viral load – the key indicator of ongoing successful treatment – and, therefore, be significantly less likely to transmit the virus to others. Dubbed “90-90-90,” modelling studies show that achieving these targets would result in the end of the epidemic spread of HIV by 2030.1
Previous global HIV treatment targets tended to focus on a single outcome – usually the proportion of people eligible for treatment who access treatment. The new approach by UNAIDS builds on the treatment cascade and looks at the sequence of outcomes that are required to achieve maximum benefits from treatment. This includes HIV diagnosis; engagement in care and treatment; and suppression of the viral load. This new approach means that we need to move beyond a traditional narrow focus on increased access to HIV treatment and consider a broader HIV response that includes outreach; testing and diagnosis; engagement; and retention in care, treatment and support.
Not surprisingly, UNAIDS also calls for urgent efforts to scale-up core prevention efforts for the key populations that are disproportionately impacted by HIV. Key populations identified by UNAIDS include people who inject drugs, MSM, female sex workers, and transgender people. However, in addition to this scale-up, achieving the UNAIDS targets will require a coordinated effort to ensure that people living with and at risk for HIV are informed, engaged and linked between different services within the HIV response, including prevention services. HIV prevention workers have an important role to play in developing such a coordinated response.
How can we use the UNAIDS targets to improve our efforts?
Measuring the outcomes that form the basis for the UNAIDS targets is relatively new. Globally, only a few countries or regions have developed estimates. For Canada, there are no national estimates, although British Columbia and Ontario have developed provincial ones. The table below compares different regions where estimates are available.
According to the table, Australia and the United Kingdom are closest to achieving the UNAIDS targets. France is also doing comparatively well. British Columbia, which has been a global leader in developing new and enhanced programming to improve outcomes for the treatment cascade, was still significantly below the targets in 2011. Although caution is needed in making comparisons because different methods (and data from different years) may have been used to calculate the estimates in each region, these numbers suggest that there is substantial room for improvement in most regions.
For any given region, the targets can be used to identify where programming is strongest and where it could be strengthened. This information can help people who plan and develop programs to make strategic decisions. For example, the estimates suggest that the United States is very strong with diagnosis but not as strong with treatment outcomes. In September 2014, the U.S. Centers for Disease Control and Prevention (CDC) launched a national treatment campaign to encourage people with HIV to access care and stay on treatment. Additionally, information about the treatment cascade in other countries or regions can help people identify good programming that might be adapted to their local context. For example, Sub-Saharan Africa appears to be very strong with treatment outcomes once people are diagnosed. Other regions may be able to learn from successful treatment programs that have been developed in Africa.
The UNAIDS targets can be applied to different communities at the local or organizational level to better understand the gaps in engagement with the treatment cascade and improve access and linkage to relevant services.
What role can prevention play in meeting the UNAIDS targets?
While it may appear that the UNAIDS targets are primarily concerned with treatment programs, in fact prevention programs and services have a very important role to play. That’s because treatment programs and services that passively wait for people who suspect they have an HIV infection to present for testing and care are not adequate to reach all those who need these services. Achieving the UNAIDS targets requires pro-active approaches to reach those people who are not engaged in the treatment cascade. Community-based strategies of outreach and engagement – which were pioneered in HIV prevention work – are needed to reach out to people who are undiagnosed and support them to get tested, get into early care and treatment, and remain engaged in care.
Communities need to know about the health and prevention benefits of early HIV treatment and be empowered to act on this knowledge. These messages need to be communicated not just to people diagnosed with HIV but also to people at risk for HIV. Currently these messages are not well communicated. For example, according to a recent international community consensus statement,12 many people living with HIV are unaware of the prevention benefits of HIV treatment. The prevention benefits of treatment are even less well known among people who are at risk for HIV. HIV prevention workers have an important role to play in providing individuals and communities with accurate information about the importance of early HIV diagnosis, care and treatment to optimize long-term health (similar to messages about cancer prevention) and about the effect of HIV treatment in reducing the risk of transmission. Moreover, prevention efforts should support individuals to improve their ability to prevent transmission in a way that works for them and to feel empowered to take responsibility for their own and their partners’ sexual health.12
Individuals also need to be supported to become linked and engaged to a range of services depending on their needs.13 HIV prevention services are often a first point of contact with health care for people at risk of HIV and those with undiagnosed HIV. Such prevention services may provide an ideal opportunity for engagement and linkage of clients to other services, including testing, counselling, primary care, or clinic-based prevention options such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). Prevention workers have an important role to play in identifying people who may benefit from the full spectrum of additional health services and supporting them to engage with those services.
The HIV treatment cascade – patching the leaks to improve HIV prevention has examples of Canadian programs that target the different stages of the treatment cascade.
Engaging in a new narrative about HIV treatment
The discovery that HIV treatment can dramatically reduce the transmission of HIV is a game changer that has implications for everyone working in HIV. Beyond the changes to specific prevention information and services discussed above, there is a need for people working in prevention to engage in systems-level thinking about how prevention, diagnosis, care, treatment and support services are organized and delivered to different populations and communities.14 It is crucial to consider how core prevention services fit within and support the continuum of HIV services. New directions in programming should not supplant or weaken existing prevention approaches. There is a need to develop balanced prevention and treatment programming that recognizes HIV prevention is a shared responsibility and that most onward HIV transmissions occur among people who are undiagnosed. Recently the World Health Organization has launched new Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations, which provide a framework for an integrated, systems-level approach to HIV.15
Additionally, there may be an opportunity to work together towards societal or “structural” changes that could enhance prevention efforts. A new understanding of HIV transmission risks may help to reduce stigma and fear of people living with HIV, particularly in populations who are disproportionately impacted by HIV. (For example, in a recent national survey of MSM, almost half of those who were HIV-negative said they would not have sex with an HIV-positive man and more than two thirds of HIV-positive men worry about rejection in the gay community because of their HIV status.)16
Criminalization of HIV non-disclosure is another structural factor that needs to be addressed if we are to achieve full engagement in testing and treatment.17 Coordinated strategies could also help to reduce health inequities experienced by some populations, such as newcomers to Canada.
Campaigns for change
Around the world, many new campaigns have been launched that seek to engage communities and individuals to think about HIV differently and to start new discussions about prevention and treatment based on the advances we have made in our knowledge of HIV. The time has come for everyone to join in the discussion.
British Columbia, STOP HIV/AIDS Project
Change HIV History – a campaign to expand HIV testing, treatment, and support services across BC
US Centers for Disease Control and Prevention (CDC)
HIV Treatment Works – this campaign shows how people living with HIV have overcome barriers to get in care and stay on treatment. The website has information on HIV treatment and prevention, as well as how to live well with HIV.
AIDS Council of New South Wales (ACON), Australia
ENDING HIV – a campaign for gay men with information on testing, starting treatment early and prevention strategies.
Undetectable: The New Face of HIV – a campaign to establish “Undetectable” as a health status distinct from either HIV positive or HIV negative, and in so doing eradicate stigma and promote best practices around research, treatment, and prevention.
Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014
1. a. b. c. d. UNAIDS. 90-90-90: An Ambitious Treatment Target To Help End the AIDS Epidemic. UNAIDS, 2014. Available at: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf [Accessed November 12, 2014].
2. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at: http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf [Accessed November 12, 2014].
3. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505.
4. Rodger A et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: PARTNER study. In: Program and abstracts of the 21st Conference on Retroviruses and Opportunistic Infections, March 3 to 6th, 2014, Boston, U.S., abstract 153LB.
5. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report 2014 HIV Supplement. 2014. Available at: http://kirby.unsw.edu.au/sites/default/files/hiv/resources/HIVASRsuppl2014_online.pdf [Accessed December 10, 2014].
6. Public Health England. HIV in the United Kingdom: 2014 Report. Public Health England, November 2014. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf [Accessed: January 5, 2015].
7. Katlama C. Country-based initiatives update: The French guidelines in 2014. Presented at The 2014 International Treatment as Prevention Workshop, Vancouver, April 1–4, 2014. Available at: https://www.youtube.com/watch?v=5qwCHeAXYZs&feature=player_embedded#t=304 [Accessed: November 12, 2014]
8. Nosyk B, Montaner JSG, Colley G et al. The cascade of HIV care in British Columbia, Canada, 1996-2011: a population-based retrospective cohort study. Lancet Infectious Diseases. 2014 Jan;14(1):40–9
9. AIDS Progam, Ontario Ministry of Health and Long Term Care, 2014 [private communication]
10. Mesquita P. First steps of TASP in Brazil. Presented at 2014 International Treatment as Prevention Workshop, Vancouver, April 1-4, 2014. Available at: http://www.youtube.com/watch?feature=player_embedded&v=GPfWMjJuOlE [Accessed: November 12, 2014].
11. United States Centers for Disease Control and Prevention. HIV in the United States: The stages of care. CDC Fact Sheet, July 2012. Available at: http://www.cdc.gov/hiv/pdf/research_mmp_stagesofcare.pdf [Accessed November 12, 2014].
12. a. b. Community consensus statement on the use of antiretroviral therapy in preventing HIV transmission. NAM AIDSmap and European AIDS Treatment Action Group, February 27, 2014. Available at: http://www.hivt4p.org/ [Accessed: November 12, 2014].
13. CATIE. Integrated approaches to HIV Prevention and Treatment. In: HIV in Canada: A primer for service providers. CATIE, 2014. Available at: http://www.catie.ca/en/hiv-canada/8/8-2 [Accessed November 12, 2014].
14. CATIE. National Deliberative Dialogue on Integrated Approaches to HIV Treatment and Prevention: Meeting Report. CATIE, March 2013. Available at: http://www.catie.ca/sites/default/files/National-Deliberative-Dialogue-on-Integrated-Approaches-to-HIV-Treatment-and-Prevention_05312012.pdf [Accessed November 12, 2014].
15. World Health Organization. Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. July 2014. Available at: http://www.who.int/hiv/pub/guidelines/keypopulations/en/ [Accessed November 12, 2014].
16. Male Call Canada Technical Report. Draft April 13, 2013.Available at: http://www.malecall.ca/technical-report/ [Accessed November 12, 2014].
17. Loufty M, Tyndall M, Baril J-G, et al. Canadian consensus statement on HIV and its transmission in the context of criminal law. Canadian Journal of Infectious Diseases and Medical Microbiology. 2014 May/June; 25(4):135–40.
About the author: Tim Rogers is the Director of Knowledge Exchange at CATIE. He has been involved with CATIE for more than 15 years, first as a volunteer and then a staff member.