This article previously appeared on the CATIE website, here.
Une version française est disponible ici.
by Andrew Brett
Research over the past several years has opened up new possibilities for the prevention of both HIV and hepatitis C. From greater knowledge to newer technologies, we are now in a better position to prevent infections than we have ever been.
But are we making the most of these new possibilities?
That was one of the questions tackled at the CATIE Forum in October 2015. Bringing together close to 400 people working on the front lines of HIV and hepatitis C, the Forum heard speakers from across Canada and beyond sharing the lessons they have learned from both research and practice, and putting forward recommendations to improve our response.
1. Provide more options to test for HIV and hepatitis C
Early diagnosis of both HIV and hepatitis C is the first step toward treatment that results in better health, a longer life, a lower chance of transmitting the virus to another person and—in the case of hepatitis C—a cure. Yet an estimated 21% of HIV-positive Canadians don’t know they have the virus. Among Canadians with hepatitis C, an estimated 44% of people with chronic infection are undiagnosed.
McGill University’s Dr. Nitika Pant Pai says one of the main reasons for such a high percentage of undiagnosed people in Canada is that the testing process is arduous from the perspective of the patient.
Dr. Pant Pai argues that new testing technologies such as point-of-care and self-administered tests can help to “democratize” this process by providing rapid tests in clinics, communities and even homes. Dr. Pant Pai also advocates for the integration of testing for HIV, hepatitis C and other sexually transmitted infections through the same facilities, which can both make the process easier for patients and realize cost savings for health systems.
2. Focus on programs that can reach more people at risk of infection
In a context where resources for HIV prevention are limited, program planners prioritize interventions that can deliver greater results. Israel Nieves-Rivera from the San Francisco Department of Public Health explains how San Francisco rethought its HIV prevention strategy in 2009 to focus on specific programs and populations.
Departing from previous attempts to treat all populations equally, San Francisco revamped its HIV strategy in 2009 to focus on key populations where the epidemic is concentrated: men who have sex with men, people who inject drugs and trans women. By focusing limited resources in the communities at greatest risk, Nieves-Rivera says, they were able to achieve a significant reduction in new HIV infections.
In addition to prioritizing populations, they also prioritized programs. According to their research, counselling programs for people at risk of infection—while effective at an individual level—could only reach small fractions of their target populations. And yet, he says, half of their HIV prevention budget was allocated to these low-scale interventions prior to 2009. By delivering a comprehensive set of prevention programs that have a high impact and can reach a greater number of people at risk—such as needle syringe programs—they were able to have a greater impact on HIV infections at the population level.
3. Ensure that individuals have an accurate understanding of their own risk
In the last few years, more highly effective HIV prevention methods have been added to the prevention toolbox. However, Dr. Darrell Tan from St. Michael’s Hospital has found that individuals might not take advantage of these new options because they underestimate their risk of infection.
Surveying more than 400 gay and bisexual men at Toronto’s Hassle Free Clinic, Dr. Tan’s team found that half were willing to consider pre-exposure prophylaxis (PrEP) to prevent HIV infection. However, this willingness depended on whether they perceived themselves to be at risk—and their perception often did not match reality.
Although 64% of the men surveyed were determined to be at “high risk” of HIV infection based on an objective assessment tool, only 20% perceived themselves to be at risk. And those who did not perceive themselves to be at high risk were less likely to consider PrEP as a prevention option.
These findings demonstrate that campaigns about new HIV prevention methods such as PrEP will need to do more than simply raise awareness about their existence. Dr. Tan says that education must be done to “close the gap” between an individual’s actual risk and their perception of their risk.
4. See culture and identity as a prevention tool instead of as a risk factor
As Canada’s HIV and hepatitis C epidemics are concentrated in key populations, these identities are sometimes thought of as “risk factors” for transmission. Dr. Alexandra King sees things differently, pointing out that Indigenous people are not inherently at greater risk of HIV or hepatitis C infection, but social determinants such as racism and colonization make them more vulnerable.
At the same time, Dr. King says, Indigenous identity can be a source of strength and resilience. By acknowledging and employing Indigenous approaches and community connections, culture and identity can be a tool in the prevention of HIV and hepatitis C.
5. Strengthen the role of community-based organizations in prevention
Ukraine and Russia are geographically close and share similar HIV epidemics, with most transmission occurring through injection drug use. Yet Russia’s rates of infection have steadily increased, while new infections in Ukraine are stabilizing. What explains the difference?
According to Andriy Klepikov of the International HIV/AIDS Alliance in Ukraine, one of the key differences between the responses of each country has been the role of civil society. The greater freedom for community-based organizations to operate in Ukraine has allowed them to serve marginalized populations often overlooked by government and medical institutions. In practice, this has meant the development and delivery of harm reduction programs, opioid substitution therapy, and other services that help prevent the spread of HIV and hepatitis C among people who inject drugs.
What lessons can Canadian service providers draw from the Ukrainian experience? Klepikov argues that the role of community-based organizations should be strengthened within any country’s response to HIV and hepatitis C. Not only are they better positioned to reach marginalized communities, but they can also be more innovative by piloting new approaches to prevention that governments and large institutions may be slow to adopt.
To watch the full presentations from these and other speakers, visit the CATIE Forum web page.
About the author: Andrew Brett is a specialist in communications and social marketing at CATIE. He has worked in health communications since 2008, holding positions in local, national and international organizations. Andrew is currently studying public health at the London School of Hygiene and Tropical Medicine.