At the CROI conference earlier this year, Julie Davids asked a question that lies at the very heart of HIV prevention – “What needs to happen to ensure that PrEP doesn’t become a hard-to-get intervention?” Now, halfway through the year, we checked in with her. Below, Julie shares her thoughts on how dollars-and-cents issues have serious repercussions with regard to the HIV/AIDS situation in the US.
“While there has been much debate over the use of antiretrovirals (ARVS) for HIV prevention, the entire HIV prevention and treatment landscape overall is also in a state of flux in the US. In the era of the National HIV/AIDS Strategy, many questions have arisen. Perhaps the most important is this – what prevention/treatment methods can be brought to scale for population-level impact? There has been lots of effective work that has helped prevent HIV and save lives, but what can be scaled up to a point where it can start to reduce incidence? There are initiatives that work very well but are too expensive to bring to larger scale. People are also wondering if there are targeted ways of delivering PrEP to ensure maximum impact without incurring enormous amounts of expenditure.
The global economic crisis has only exacerbated the situation. The effects of the sustained downturn in the US are deep and hard to untangle. In some areas, the impact is specific and tangible: many organizations and initiatives that provide HIV prevention, treat and care are shutting down and others are under lot of duress. So, understandably, when it comes to using ARVs for prevention, people are saying, “We’ve been told not to expect any new money – in fact, we’ve braced ourselves for cuts in funding. If we’re talking about adding something new, where is the money going to come from? And is this the best use of the available resources?”
But the effects are also larger and more intangible, in terms of a generalized anxiety and fear. The recession is hitting the most marginalized the most severely. One of the main drivers of HIV incidence in the US is poverty – and we’re seeing a sharp increase in poverty and homelessness. People are scrambling to find housing and put food on table, to retain a sense dignity as they struggle to provide for their families. These factors create vulnerability to health challenges and in this regard HIV/AIDS is more the rule than the exception. We may sharpen and tailor HIV prevention to be more effective, but I fear this could be counterbalanced by the effects of the downturn, leading to persistently high HIV incidence.
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