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.

03 January 2013

Searching for comprehensive solutions: In conversation with Linda-Gail Bekker

Original content from our Mapping Pathways blog team

"The days of behaviourists, clinicians, scientists and legal policymakers being in separate rooms are over. We have to get into one room and work this problem out together."

In the fourth of this five-part series, Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation, speaks about her involvement in the HPTN 067 study and about issues that make HIV the complicated problem it is. Read parts one, two and three

MP: What are some of the other issues that make HIV the complicated problem that it is?

LGB: For 30 years, many people thought HIV was a behavioural issue only - that using condoms, abstaining and being faithful would sort the whole problem out. On the other hand, the biomedically thinking people scrambled around trying to find something that worked, without a whole lot of success. Now the biomedical protagonists  have tools that work, such as PrEP and microbicides. The obvious mistake to be avoided at all cost would be to throw the behavioural science out and go entirely with the biomedical tools.  
This is a trap that medical people often fall into: (and I am one of them!!) they love to fix things with pills and find it easier to offer something tangible to a patient rather than wait for them to change their behaviour.  But pills and microbicides will not work unless they get to the people that need them and those people have the ability to take them. For example, if there’s a structural component in ones life that is a barrier, such as a violent partner, ones ability to reduce one’s risk may be compromised.

The days of behaviourists, clinicians, scientists and legal policymakers being in separate rooms are over. We have to get into one room and work this problem out together otherwise we may again end up with failure because we’re not coming up with comprehensive solutions. After 30 years thinking about a multi-sectoral approach seems the only way to go about it.

MP: Please tell us a little about the ADAPT study that you are involved in.

LGB: The HIV Prevention Trials Network (HPTN) is funding the ADAPT study, also known as HPTN 067, in three sites. Cape Town, which I am PI of, is looking at women who have sex with men, while Bangkok and Harlem are enrolling  MSM. My site has enrolled 180 at-risk women who have sex with men and we are in the process of follow-ups with them.

The women are randomised to daily PrEP, intermittent PrEP and event-driven PrEP using Truvada. The pills are put into a ‘wise pill carrier’ and when it is opened to take a dose, a signal goes to the server.  Our staff call up the young women weekly to discuss what happened over the week. It is an intense study for the participants since they have to share intimate data with site staff on a regular basis but the idea is to look at feasibility and suitability to people of these various dosing modalities to see what works, what doesn’t work, and what people can actually adhere to. It has really needed committed participants and caring site staff with a great deal of trust between them!

The primary goal is to discover if people can use the pills the way they are meant to be used. There obviously are other issues like looking at side effects, safety and other data but the primary end point is feasibility and acceptability of a dosing strategy.

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 the final part of our conversation with Linda-Gail, where she speaks about her the importance of adherence, both in clinical trials and the real world, and the challenges and issues facing adolescents. 

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

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