Biomedical HIV prevention – the social complexities of achieving effectiveness

Published: July 25, 2013

Public health officials, donors, epidemiologists, researchers and clinicians need to factor in the relevance of the social and the cultural if they are to see biomedical HIV prevention strategies – including treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) – succeed in real-world settings, speakers told the 2nd International Conference for the Social Sciences and Humanities in HIV, held recently in Paris.

“TasP is a simple acronym that masks considerable complexity,” commented Professor Gary Dowsett of La Trobe University in Melbourne, Australia. 
Although modelling studies have ‘demonstrated’ that treatment as prevention (a programme of HIV testing and treatment) could eliminate HIV infections in societies such as South Africa and Vietnam, they have relied on utopian assumptions, such as 100% of people getting tested and 100% of diagnosed people taking antiretroviral treatment. 
But the gaps in the ‘treatment cascade’ suggest that the world is much more complicated than this.
Unpacking the treatment cascade
For treatment as prevention to work, large numbers of people who are at risk of HIV infection need to understand that they are personally at risk; find the idea of testing for HIV acceptable; and be able to go to trusted, convenient and affordable HIV testing services. They also need to be willing to test repeatedly, perhaps once every year (and continue to have access to the necessary health facilities).
“TasP is a simple acronym that masks considerable complexity” Gary Dowsett
Those who are diagnosed with HIV need to come to terms with the result and believe that there are benefits to engaging with health services now, even though they may not feel ill. Once again, trusted, convenient and affordable health services need to be available. 
Moreover, those diagnosed need to stay in touch with their doctors and nurses, and attend appointments regularly. Again and again, they need to overcome the same barriers which may have made it hard for them to attend a clinic in the first place – the stigma of HIV, other urgent personal priorities, difficulties getting to a health service, and so on.
When a doctor suggests that they start taking HIV treatment – which may be very soon after diagnosis – individuals need to believe that it will benefit them personally. Alternatively, they need to understand the possible advantage for a sexual partner, or for other people, and consider this a good enough reason to take the drugs. Any perceived problems with HIV treatment, such as side-effects or other people finding out about the person’s HIV status, need to feel manageable in comparison with the advantages.
An efficient healthcare system is needed to provide the drugs, in a way that is affordable for the patient, without interruptions in drug supply. In case a particular drug doesn’t work for somebody, alternative anti-HIV drugs need to be available. 
And all these things need to happen, not just for a short period of time when the conditions are favourable, but for decades.
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