Mapping Pathways is a multi-national project to develop and nurture a research-driven, community-led global understanding of the emerging evidence base around the adoption of antiretroviral-based prevention strategies to end the HIV/AIDS epidemic. The evidence base is more than results from clinical trials - it must include stakeholder and community perspectives as well.

30 November 2011

Mapping Pathways South Africa: What we’re hearing so far

Original content from our Mapping Pathways blogs team

An important part of the Mapping Pathways project is to learn what people think and feel about ARV-based prevention strategies (such as PrEP), not just through academic streams and studies but also through everyday experience and wisdom. What do the people who work daily with treatment and prevention and/or have first-hand experience of living with HIV think? What are their concerns? What information do they need about PrEP, TLC+ (testing, linkage to care, plus treatment), and microbicides? Do they think these prevention tools can be useful for their community or country? Would they use them or prescribe them?

The Mapping Pathways online survey and in-depth stakeholder interviews are important ways for us to gain knowledge on these questions. Both processes took place over the year, and we’re starting to unpack a number of some interesting observations and ideas now that the interviews have finished and the survey is closed. Of course, this data is still preliminary but we thought we’d share some snapshots of what we’re hearing from South African doctors, policymakers, and activists on the ground.

Thoughts on the Mapping Pathways project
Although each person we spoke with had very different views on ARV-based strategies and HIV prevention within the South African context, most agreed that Mapping Pathways was an excellent and timely initiative. People thought the project was “inclusive”, “collaborative”, “captures everything that’s going on at the moment”, “well thought through”, “urgently needed”, “spot on”, and “a project worth doing”. One South African researcher felt it “hits the nail on the head about what needs to be done in the field”, and a South African policymaker said research like this is “the only way forward”. Concerns included the fact that only three countries are participating and that the field may be moving too fast to document everything effectively.

Thoughts on TLC+
Nearly everyone we spoke with agreed that TLC+ was scientifically valid – that is, to expand treatment access for people living with HIV as a way to reduce onward infections to others. “The prevention benefits of treatment are absolute,” said one South African clinician. However, some felt that it was tough to implement TLC+ in a resource-limited setting like South Africa, and there were concerns about infrastructure, cost, staffing, and sustainability. One South African pathologist said it was “a quantum leap”, a policymaker mentioned it was “operationally far away”, and an activist said that “financial sustainability in this context is unlikely”.

Others thought it could be done. “The programme will pay for itself,” stated a South African pathologist. Another added, “Keeping patients well is always a good thing financially.”Many people felt more research still needed to be conducted on such as side-effects, resistance, drug delivery, and adherence/acceptability. One South African epidemiologist pointed out the importance of operational research: “We do know enough to start finding out how we can do it.”

Thoughts on oral PrEP
There was a fair amount of concern about how oral PrEP could work within the South African context, especially given the country’s limited resources and high incidence rate. People were also confused by the seemingly conflicting results from various trials. (Read Daniella Mark’s thought-provoking interview on this here and here.) One South African researcher said, “The iPrEx and FEM-PrEP results have left us wondering.” Some people felt rolling out oral PrEP to high-risk populations was the right step; however, there were concerns expressed on how these populations would be defined and traced, e.g., adolescent girls, sex workers, and truckers.

Thoughts on microbicides
Microbicides evoked interesting and varied reactions from the people we spoke with. Most agreed that there still needs to be more evidence on their efficacy. “We’re not there yet,” said one South African epidemiologist. Some people felt a microbicide might be easier to implement than oral PrEP. One South African activist felt microbicides have the potential for much greater use. “If they’re like condoms and can be handed out freely to everyone, it would be easier,” said a South African policymaker.

Others thought differently, saying that a microbicide might be more difficult to implement than oral PrEP since it is a new modality and people are not used to topical prevention. “It might be difficult to know if you’ve put on enough,” said one South African pathologist. There were also concerns about acceptability and adherence. Read more about this here and here. What was also interesting was the view that a vaginal microbicide is female-controlled. “We’ve been seeking a female-controlled prevention methodology for a long time,” said a South African activist. “It is some small degree of female empowerment,” added a South African policymaker.

[Editors note: the VOICE trial announced November 25 the closure of its study arm testing tenofovir gel. The decision was made due to futility – while tenofovir gel was found to be safe, the trial was not able to prove the gel worked to prevent HIV. See the statement from the Microbicide Trials Network for more information. The Truvada tablet arm in the trial is continuing.]

Thoughts on HIV prevention funding allocation
The consensus on funding seemed to be that there was no “silver bullet” and South Africa should focus on multiple, concurrent strategies. “A one-size-fits-all approach won’t work,” said one South African researcher. There was also a general feeling that funds should go into proven, effective strategies. “Funders should think about where they will get the ‘biggest bang for their buck,’” said a South African policymaker. One South African activist remarked that the country doesn’t yet have a proper prevention strategy or prevention targets, which “leads to a scattergun approach and we miss people”. Some people strongly felt that the focus should be on treatment first. Others felt that funds should go to strategies that are female-controlled.

For more analysis on South African reactions towards ARV-based prevention  and HIV prevention in general, read our two-part interview with Daniella Mark from the Desmond Tutu HIV Foundation, a Mapping Pathways partner organisation: In Conversation with Daniella Mark: It’s a question of “how” in South Africa and In Conversation with Daniella Mark – Part 2: Climbing “Mount Everest”.

Mapping Pathways is presenting two posters at the ICASA 2011 conference showcasing some of the data collected. Stay tuned to this blog to see the actual posters – next week.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

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