A World Without AIDS, Still Worlds Away

via the New York Times, by Lawrence K. Altman

WASHINGTON — Is the world on the verge of ending the AIDS epidemic and creating an AIDS-free generation, even though a cure and a vaccine are still distant hopes?

Yes, roared enthusiasts among the nearly 24,000 participants at the 19th International AIDS Conference here last week. Their hopes are based on the extraordinary scientific gains made since the conference was last held in the United States, 22 years ago, when an AIDS diagnosis was a sure death sentence.

Among those gains: antiretroviral drug combinations for women to prevent infection of their newborns; drugs to treat and prevent infection with H.I.V., the virus that causes AIDS, among adults; and evidence that voluntary male circumcision can reduce the risk of female-to-male transmission by 50 to 60 percent.

Today, H.I.V. has become a chronic disease that, if treated appropriately, can be held at bay in a newly infected young adult for decades — if the patient adheres to the rigid daily drug regimen.

Michel Sidibé, the executive director of the United Nations AIDS agency, said that the opportunity to end AIDS will “evaporate” if governments do not show greater political will and increase investments to make gains available to millions more people.

“All that can stop us now is indecision and lack of courage,” he said.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

PrEP debate is reminiscent of the past

via Global Post, by Emily Judem

WASHINGTON, DC—During the 1996 International AIDS Conference in Vancouver, Dr. David Ho announced that HIV could be suppressed to undetectable levels if patients took a “cocktail” of anti-retroviral drugs.

Time Magazine named him “man of the year,” and according to Rolling Stone, he became the most famous AIDS scientist in the world.

But in the years that followed, ARV distribution was also met with criticism, said Mitchell Warren, director of AVAC, a non-profit that advocates for HIV prevention programs.

“People said we can’t do treatment,” Warren said. “Too expensive. Not feasible. No one’s going to take their pill. What about drug resistance?”

For those who have attended sessions about pre-exposure prophylaxis (PrEP) this week at the 2012 International AIDS conference, this might sound familiar.

When the FDA approved Truvada as a preventative drug against HIV on July 16 this year, leaders of the AIDS fight and news outlets alike began posing questions. How will it be decided who takes the drug? How will the drug be distributed? How will we lower the price tag? Should we be concerned that those taking Truvada will stop using condoms and protecting themselves in other ways?

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

The ExpertLens– Building bricks of evidence

Original content from the Mapping Pathways blog team

Caroline Viola Fry

The ongoing International AIDS Conference (AIDS 2012) in Washington D.C. is an opportunity for Mapping Pathways team members to disseminate information and findings on the project. 

In the second of this two-part post, Ohid Yaqub and Caroline Viola Fry from RAND Europe discuss the work involved for the ExpertLens, a cornerstone of the Mapping Pathways project. Read part one here.

Ohid Yaqub

MP: How did you narrow down on the stakeholders or participants in the ExpertLens?

OY: We chose the participants from the U.S., South Africa and India, the three focus countries of the Mapping Pathways project. We aimed to assemble an expert panel across multiple stakeholder groups in each country. So we were looking for policy makers, academic researchers, clinical researchers and people from industry.

One more thing to note is that we weren’t targeting extremely top-level policy makers who may not necessarily be familiar with the details of the situation on the ground and the context in which the proposed care strategy might be deployed. We were looking for people with the appropriate knowledge and the time to think very carefully about their answers, think about them yet again in relation to the group, justify their answers to the group, discuss them and maybe refine their answers afterwards over the course of three weeks in an online forum. Our participants needed to be very engaged with the topic.

CVF: We wanted our participants to have some background knowledge and expertise in their area but not necessarily be experts in everything there is to know about the HIV landscape. The benchmark on which we were trying to look for people to engage with was if they knew about the HPTN052 trial or about Truvada.

MP: How much time and effort went into drafting the questions for the ExpertLens?

OY: We drafted the questions very carefully and lot of work went into giving questions the right tone so that we could generate useful discussions in the online forum. There were more than 20 versions of the question set. 

We were very aware when thinking about the questions that the situation many decision-makers might face is not one where they can say yes to everything but one where they may have to make choices from a limited pot of resources. There may be a situation where they have to choose one over the other and so that’s why some of those questions were ranking questions.

CVF: The questions ended up drawing out some of the more nuanced views on issues, which highlighted the fact that they were not straightforward questions and that policy decisions are not black and white.

MP: What, in your view, were some of the most palpable benefits of using the ExpertLens?

OY: Our initial impression was that we’d get quick-fire, reactionary opinions being thrown around on this topic. The ExpertLens forced people to be little more reflective, and take on board what other people were saying.

One thing everyone does agree on is that HIV is a very interdisciplinary problem where concerns of policymakers, researchers and clinicians need to taken into account since they are all stakeholders. Being able to get different stakeholder groups to be able to talk to each other is very important since some forms of media and discussion forums don’t allow that. A prime example is journals, where disciplines and professions talk to each other in very considered, robust ways. But the issue there is that they talk to their own disciplines and tend to talk to people who read the same journals. So the ExpertLens is a great way to have a different kind of conversation.

CVF: One of the useful aspects of it being online on forums rather than being a conversation in person is that one can track these discussions and analyse what contributed to someone changing mind if they did. We also looked at what may not have had an effect and left people where they were. We went through comments very carefully and stepped into some of these conversations as moderators to prompt some of the discussions and ask relevant questions.

MP: Is the ExpertLens an ongoing process? Is there a key finding that you could share?

OY: The iterations have all been done and the ExpertLens has been closed. It ran for roughly about a week for each round. We then analysed the data and are in the process of writing up the findings, which will be published in an upcoming RAND book on the Mapping Pathways project (forthcoming on www.randeurope.org).

CVF: The findings are so complex that it’s impossible to sum up here. The key finding is that there’s very little information out there and very little consensus. It’s not a bad thing because it’s still interesting to ask where the points of divergence are and why do people disagree.

OY: Phase two plans to build on what we’ve assembled here in phase one. ExpertLens is one of the bricks of evidence we’re pulling together. We’ll be synthesising evidence from literature reviews, surveys, interviews and this ExpertLens to make up series of assumptions that can feed into better starting conditions on a model and we can then try and model for behavior. 

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

AIDS 2012 Poster Presentations from Mapping Pathways - Check Them Out!

Original content from the Mapping Pathways blog team

[Pictured discussing the implications of the findings from the posters  are Georgina Caswell from GNP+ and Jessica Terlikowski and Molly Morgan Jones from the Mapping Pathways team.]

The Mapping Pathways project presented two posters at the AIDS 2012 conference on Monday, July 23. One was "Developing the evidence base for biomedical prevention strategies" and the other "Synthesising the empirical evidence to map pathways for HIV prevention planning."

Check out both posters below.

Developing the evidence base for biomedical prevention strategies 

Synthesising the empirical evidence to map pathways for HIV prevention planning 

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

AIDS 2012 Slide Presentation: Exploring Strategies and Perspectives to Map Pathways for the Use of ARVs as Prevention

Original content from the Mapping Pathways blog team

Molly Morgan Jones from RAND Europe - a Mapping Pathways partner - presented project findings specific to PrEP in the United States context at an AIDS 2012 satellite session this past Sunday, July 22. The satellite was called "From Revolution to Reality: How Will New Science Impact the U.S National HIV Aids Strategy?"

Please check out Molly's slides below.

Exploring Strategies and Perspectives to Map Pathways for the Use of ARVs as Prevention

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

The ExpertLens– Exploring different pathways for different contexts

Original content from the Mapping Pathways blog team

Caroline Viola Fry

The ongoing International AIDS Conference (AIDS 2012) in Washington D.C. is an opportunity for Mapping Pathways team members to disseminate information and findings on the project. 

In this two-part series, we take an in-depth look at the ExpertLens, one of the cornerstones of the Mapping Pathways project, with colleagues Ohid Yaqub and Caroline Viola Fry from RAND Europe.

Ohid Yaqub

MP: Please introduce yourselves and tell us a bit about what you do. 

CVF: I work as an associate analyst at RAND Europe, a non-profit organisation that works to improve public policy and decision-making through objective research and analysis. I come with a global health background and work in the Innovation and Technology policy team, which explores the way governments or institutions support translation of research into new ideas or technologies that society can make use of.

OY: I’m an analyst with RAND Europe and work in the same team with Caroline. My motivation and interest in this project came through my Ph.D. in vaccine innovation. One of the cases I looked at was the vaccine development effort for HIV. The Mapping Pathways project interested me hugely because ARV drugs, which were previously thought of only as therapeutic options, were starting to take on properties and policy issues very similar to vaccines i.e. as preventatives.

MP: Please explain what ExpertLens is.

OY: ExpertLens is particular software, developed by RAND, which is a derivative on a technique that was actually developed back in the 1950’s, called the Delphi method.

While the Delphi method requires participants to be present in person, the ExpertLens is an online method of gathering qualitative information in a structured way.

                                   

You gather a set of experts into a panel and ask them a set of questions in round one. In round two, participants are presented back not only their own answers but also details about how the group answered, such as the median answer, the first quartile answer and last quartile answer.

In round two, participants take the results and discuss them in an online forum. Participants can view how their answers match with the group median. If their answer is well above the group median, they may stick with that answer and justify their high score or, after participating in discussions, may revise their answer in the next round.

In round three, participants get the opportunity to refine their answers by changing them to either move closer or further away from the group median or not changing them at all.

This three-round iteration process helps us get insight into what the members of the expert panel agree on, disagree on and even what they agree to disagree on.

MP: How is the ExpertLens different from a survey?

OY: The key difference from a survey is that the ExpertLens happens over multiple rounds, allowing respondents to refine their answers. This means that the questions need to be designed in a way that allows us to analyse and report back the answers to the group. For example, questions have to be tailored so respondents rank options into their preferred order or they rate a particular option from one to 10.

Responses to these types of questions allow us to return to the participants with information on how far their answer was from the group average and gives them food for thought for the next round. But a question like “what do you think about this?” will not return answers in a way that can be reported back to the group.

CVF: The key thing about the Delphi method is that it’s a consensus-seeking process. Where consensus is not achieved, the ExpertLens helps illuminate the reasons behind the lack of consensus. So it has in a lot more depth than surveys.

MP: How did the ExpertLens fit from a Mapping Pathways perspective?

OY: For the Expertlens from a Mapping Pathways perspective, we looked at a number of scenarios in which ARV drugs can be used. The strategies that we looked at were oral PrEP, topical PrEP, TLC+ and PEP.

For example, we’d ask a question like “Rank the following four care strategy in order of how cost effective you feel they are for your country.” In a hypothetical scenario, if the median for PEP were 2, we’d ask in the discussion forum whether it correlated with the score different participants gave for it. Participants might then discuss why they gave a particular care strategy a lower or higher score and would be given the chance to change their answer in the following round.

We reminded participants during the process that we were not trying to lobby or push people in any particular direction towards any particular strategy. What we were trying to do was generate an evidence base that would help decision makers make decisions on which strategies, if any, were appropriate for their contexts. Our goal, as with the Mapping Pathways project, is to explore which of these pathways may be right in which context.

Stay tuned to the blog as we bring you the second part of the series as well as slides and posters being presented by the Mapping Pathways team at AIDS 2012. All Mapping Pathways posters, presentations and materials will be archived here.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

HIV/AIDS: WHO issues guidelines on PrEP

via PlusNews

NAIROBI/KAMPALA, 20 July 2012 (PlusNews) - Days after US officials gave unprecedented approval for the use of an antiretroviral drug by HIV-negative people to reduce the risk of their acquiring the HI virus, the World Health Organization (WHO) has issued guidance to governments on so-called pre-exposure prophylaxis (PrEP).

WHO's guidelines, which call for a cautious and gradual roll-out, will likely see many countries begin to add PrEP to the growing arsenal of tools in the fight against HIV.

The guidance is based on evidence from clinical trials on the daily use of ARVs for HIV prevention among high-risk HIV-negative people. A 2010 study - Iniciativa Profilaxis Preexposicion, or Prexposure Prophylaxis Initiative (iPrEX) - among men who have sex with men (MSM) and transgender people, found that a daily dose of the ARV, Truvada - a combination of emtricitabine and tenofovir disoproxil fumarate - reduced HIV infection risk by about 42 percent.

The 2011 Partners PrEP study in Kenya and Uganda concluded that a daily dose of Truvada, taken by the HIV-negative partner in a heterosexual HIV-discordant relationship - where one sexual partner is infected and the other is not - could reduce the risk of HIV transmission by up to 75 percent.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

WHO issues first guidance on use of antiretrovirals by HIV-negative people at high risk to prevent infection

via World Health Organization

20 JULY 2012 | GENEVA / WASHINGTON DC - WHO has issued its first guidance to countries that are considering offering HIV medications, known as antiretrovirals (ARVs), to protect people who do not have the virus but who are at high risk of HIV infection.

Pre-exposure prophylaxis (PrEP):

The guidance is based on clinical trials indicating that a daily dose of oral antiretroviral medication, known as pre-exposure prophylaxis (PrEP), taken by HIV-negative people to reduce the risk of infection, is both safe for people to use and effective in preventing HIV. The iPrEX study shows that use of PrEP can reduce HIV infection by around 40% among men who have sex with men – and up to 73% among those who took the medicine regularly. The Partners PrEP study found 75% protection among serodiscordant couples (couples in which one person is HIV positive) in Kenya and Uganda.

The range of results in these studies highlight the potential benefits of PrEP, but also the importance of combining it with consistent use of condoms, as well as frequent HIV testing, counselling, and treatment of sexually transmitted infections.

They also emphasize the importance of taking medicines every day. Many people who are at high risk for HIV may not easily be able to incorporate the diligent treatment regimen required, so the next challenge is to ascertain how best to deliver PrEP to those who would benefit from it in ‘real life’ settings in order to achieve the necessary adherence and maximum public health gains.


PrEP projects in countries:

To better understand how PrEP can best contribute to a combination HIV prevention programme, WHO is encouraging countries wishing to introduce PrEP to first establish small projects to help public health workers to better understand and realize its potential benefits. In these projects, ARVs would be given to people at high risk of HIV infection. These could include uninfected men or transgender women who have sex with men who have a high risk of being HIV-positive. The aim is to identify which groups will benefit most from PrEP, and ascertain the best ways to deliver the services to them.

WHO will evaluate the outcome of these projects, together with the evolving scientific evidence. The results will help determine the best way to integrate PrEP guidance in future consolidated WHO guidelines on the use of antiretrovirals for preventing and treating HIV infection, which are expected in the summer of 2013.


Read the rest.



[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

AIDS 2012 and FDA approval: Seminal events in the world of HIV prevention

Original content from the Mapping Pathways blog team

Even in the dynamic world of HIV prevention, July 2012 is already a landmark month – even before nearly 25,000 people descend on Washington, DC for the International AIDS Conference (AIDS 2012).

The news that has most advocates and program implementers excited is the U.S. Food and Drug Administration (FDA) approval of a new prevention indication for Truvada, an ARV drug commonly used for HIV treatment. Truvada can now officially be used as PrEP (pre-exposure prophylaxis) for people at high risk of acquiring HIV through sexual activity. These “at-risk” individuals include HIV-uninfected gay men and other men who have sex with men (MSM) and HIV-uninfected partners in seriodiscordant relationships.

In approving Truvada for PrEP, the FDA followed the recommendation of a panel of experts that voted to approve the drug on May 10.

Here is what the new Truvada label and prescribing information will look like.

The FDA directed drug maker, Gilead Sciences, to come up with a Risk Evaluation and Mitigation Strategy (REMS) to minimize the risk to uninfected individuals of acquiring HIV infection and to reduce the risk of resistance.

Some concerns remain, the most crucial of them being cost. Truvada is not a cheap drug – costing as high as $13,000 a year retail in the United States (it is available as a generic for a fraction of this cost outside the U.S.) – and it will be a challenge to get the drug to the most “at risk” groups, many of whom lack access to any healthcare. Adherence support, behavioral counseling, and regular HIV testing and monitoring for potential drug toxicities will also be very important. It is clear that PrEP needs to be embedded in a holistic healthcare construct – and it’s much more than individuals simply taking a pill every day.

Addressing these issues (and others) are paramount, and will occupy the energies of advocates, researchers and community organisers, many of whom will convene and share findings at AIDS 2012.

AIDS 2012, the “granddaddy of all conferences,” according to Jim Pickett, Director of Prevention Advocacy and Gay Men’s Health at the AIDS Foundation of Chicago, is a great opportunity for the Mapping Pathways project to disseminate information and findings.

The Mapping Pathways team will be participating in a number of sessions at AIDS 2012 starting with a satellite session on Sunday, July 22 titled “From Revolution to Reality: How Will New Science Impact the U.S. National HIV/AIDS Strategy?” Molly Morgan Jones from RAND Europe, a Mapping Pathways partner organisation, will be one of the presenters in this session and will share analyses specific to PrEP in the U.S. context. .

Jones, along with other Mapping Pathways team members, will also be presenting two new posters at AIDS 2012, which will include information gathered from the community surveys, policy interviews, the literature review and the ExpertLens.

Presentation slides and posters will be featured on the blog during the conference.

Stay tuned to the blog as we continue to bring you updates from AIDS 2012 as well as reactions from advocates and stakeholders on the FDA approval of Truvada.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position. Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]