The prevention revolution is underway: In conversation with Linda-Gail Bekker

Original content from our Mapping Pathways blog team

"We have to continue to advocate and do the implementation science so that we can show policymakers what is feasible."

In the third of this five-part series, Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation, speaks about the AIDS 2012 conference and her thoughts on the FDA approval of Truvada for PrEP. Read parts one and two

MP: What were some of the conversations around the AIDS 2012 conference?

LGB: AIDS 2012 confirmed that the prevention revolution is currently underway. The energy around prevention was palpable. AIDS 2012 had me running around between presentations on microbicides to PrEP to treatment as prevention (TasP) and back again to microbicides. Since I am involved in both treatment and prevention, I am usually very torn in conferences on what to attend. This time, I did one talk on treatment of HIV-infected adolescents but everything else was related to prevention, PrEP and microbicides. This is great because this is where the science is at the moment.

I also participated in some very important and in-depth conversations about some of the studies where the results have looked less than ideal. There were conversations about what actually happened in the FEM-PrEP trial and the VOICE trial. Those conversations are ongoing and data is beginning to filter through and things are becoming clearer.

MP: The U.S. Food and Drug Administration (FDA) approval of Truvada for PrEP was another major event this year. What is your reaction to that and how does that change things?

LGB: I attended this FDA meeting and it was absolutely thrilling. Gilead and the key scientists did a great job presenting the science and I thought the discussions were very robust and thorough. I came away from the process very impressed with the way drugs are reviewed. I also subsequently read the statements from people on the panel about why they voted the way they did and felt their opinions were informed, valid and thoughtful.

However, we are now in an era where we need to be practical while still doing the science. In that sense, I’m not sure how much the FDA approval changes things in the South African context. I would be delighted if Gilead takes this forward locally (in terms of an application to the SA Medicines Control Council) because I think it would give us impetus to move forward with prevention, but clearly much will depend on our policymakers and their thoughts about cost and and further decisions of key population implementation versus a generalised population implementation.

We have to continue to advocate and do the implementation science so that we can show policymakers what is feasible and what the impact in the public sector may be so that they can understand what the logistics are.

Linda-Gail Bekker is deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape Town. She also serves as the chief operating officer of the Desmond Tutu HIV Foundation, a Mapping Pathways partner organisation. 

Stay tuned to the blog as we bring you part four of our conversation with Linda-Gail, where she speaks about her involvement in the HPTN 067 study and about issues that make HIV the complicated problem that it is. 

Stay tuned for the Mapping Pathways monograph, coming in early 2013

[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.]

Biomedical science, behavioural interventions and a dollop of justice and rights: In conversation with Linda-Gail Bekker

Original content from our Mapping Pathways blog team

"I’m a great protagonist of putting effective biomedical technology next to proven structural and behavioral interventions, including a good dollop of justice and rights and then asking: how does one actually make the prevention package focus on this particular population at hand?"

In the second of this five-part series, Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation, speaks about vulnerable populations in Africa and the burden of HIV there. Read part one here

MP: We recently spoke to Charles Stephens of AIDS United who spoke about disturbing trends in vulnerable communities such as young black gay men in the U.S. What is your take on Africa, which carries the bulk of burden of HIV?

LGB: Southern Africa is the region where the HIV burden is greatest. . We have seen reductions in East Africa and West Africa is, to a certain extent, less troubled. The southern tip of Africa has really struggled with the HIV epidemic and my own country South Africa, with the greatest per capita of HIV, is particularly hard hit. While we obviously have contributions of perinatal infections, with universal PMTCT, we are hoping that eradicating pediatric HIV is an achievable goal.

But while the perinatal burden is happily on the downswing, there is an ongoing  incidence in young women, starting at sexual debut and peaking at the age of 25.  The incidence in young men starts later, in the 20s and peaks at the age of 35. So we see this alarming increase in incidence, particularly among young women from Africa who engage in penetrative, vaginal, heterosexual sex. So for our African context this is THE vulnerable population and we have to find prevention packages for that population in particular. People sometimes make the mistake of thinking of adolescents as small adults.  This is wrong. Adolescents need and deserve their own tailor-made prevention packages.

MP: What are some of the other vulnerable populations that are at risk in Africa?

LGB: We do also have concentrated epidemics in key populations that are vulnerable and in this age of biomedical technology, they too need tailor-made packages for prevention. My group has been focused on men who have sex with men (MSM), particularly MSM of colour, since the prevalence in this community is much higher than men in general, regardless of colour. Migrant populations, incarcerated populations and people who sell sex all have higher rates of HIV.

MP:  What needs to be done to address the problems facing these vulnerable populations?

LGB: I’m a great protagonist of putting effective biomedical technology next to proven structural and behavioral interventions, including a good dollop of justice and rights and then asking: how does one actually make the prevention package focus on this particular population at hand?

We have a lot of work ahead of us to specifically design, implement and test for effectiveness in each of these packages in each one of these populations.

Imperfect as it may be, we need to start trying to work out how to put these things together in very specific way. But it does require that we know our populations and understand their vulnerabilities.

But what stalls this progress is prejudice, judgmental thinking and mythical perceptions. This is where a project like Mapping Pathways is important since it tries to understand what people are thinking at the moment about these things. Too often, people’s opinions are actually what decide what happens and decisions made in the medical field are sometimes driven by emotion and not by hard fact or evidence. The Mapping Pathways project seeks to find out how people feel so that feelings can be contested by facts.  Hopefully by employng this very pragmatic approach, we can move best approaches forward as soon and as urgently as we can.

Stay tuned to the blog as we bring you part three of our conversation with Linda-Gail, where she speaks about the AIDS 2012 conference and the FDA approval of Truvada for PrEP. 

Stay tuned for the Mapping Pathways monograph, coming in early 2013

[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.]

Combining behavioural science and biomedical tools: In conversation with Linda-Gail Bekker

Original content from our Mapping Pathways blog team

"This project is an attempt to be representative of the HIV epidemic around the world, including Africa, which carries the bulk of the burden but is often forgotten when it comes to opinion." 

In the first of this five-part series, Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation, speaks about the evolution of the project and the recently-released South Africa guidelines for PrEP in MSM.

MP: Please give us some of your thoughts on the Mapping Pathways project as it has evolved over time.

LGB: A key component of the Mapping Pathways project is its concept of being multi-continent, which imparts depth and relevance. The world is a big place and this project is an attempt to be representative of the HIV epidemic around the world, including Africa, which carries the bulk of the burden but is often forgotten when it comes to opinion!.

The project is a wonderful attempt to gather and document important views from opinion leaders as well as from people in the street around the world on important topics in prevention. This is enhanced by the fact that we are at a very exciting time in HIV prevention, which is quite a volatile, polarised and changing field. Things move at such a rapid pace in this field that sometimes, things done a month ago can quickly be out of date.

We have shared some of our Mapping Pathways data and findings informally at conferences like the Microbicides 2012 (M2012) conference in Sydney and the AIDS 2012 conference in Washington D.C. We are now looking forward to all the data collected being put together in a more formal, structured way. RAND Europe, one of the project partners, is working to create a book that will cover results and analyses of the four methods of data collection used in this project; the Literature Review, online survey, the ExpertLens and stakeholder interviews. It is great that all the sites and partners are contributing to this.

On a personal note, I feel Jim Pickett, Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago and Mapping Pathways project member, is one of the most charismatic and compelling people I have worked with. His “can-do” attitude, enthusiasm for prevention and vision has been essential for the success of this project, considering its scope and scale spanning three continents. 

MP: Please tell us about the South Africa guidelines that recently came out based on a consensus group that you chaired.

LGB: The Southern African HIV Clinicians Society writes consensus guidelines for clinicians in the country on a variety of topics. I chaired one such consensus group to come up with guidelines for PrEP in MSM in South Africa. These guidelines were written and published earlier this year and are available online.

The rationale is that Truvada is currently available in country and we imagine that some men may wish to use it and clinicians would need guidance as to how to do that safely. The guidelines provide practitioners with a go-to document to enable them to use the drug in a safe and effective way should they have a client who wishes to and can afford to do so.

Stay tuned to the blog as we bring you part two of our conversation with Linda-Gail, where she speaks about vulnerable populations in Africa and the burden of HIV there.

Stay tuned for the Mapping Pathways monograph, coming in early 2013

[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.]