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.]

The social drivers of HIV: In conversation with Charles Stephens Part 3

Original content from our Mapping Pathways blog team

"I'd like to see us...reflecting on our successes. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes."

In the final part of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the successes in the HIV prevention landscape and some of the challenges faced by people in rural areas. Read part one here and part two here.

MP: What are the things being done well in the HIV prevention landscape?

CS: Models like the Mapping Pathways project excite me. The process of collecting data from a variety of different experts and stakeholders on the field and using that data to make a strong case is an excellent model. Other interesting models are AVAC’s HIV prevention research advocacy working group, which I’m a part of, and the community education and research advocacy work of the Black AIDS Institute. Most importantly, stakeholders and leaders within communities are trained and supported to go back to their communities with new biomedical HIV prevention information to disseminate it within their communities.

One of the things I’d like to see more of is reflecting on our successes and planning how to build on the victories we’ve seen over the last few years. It has been proven that testing someone for HIV and, if positive, linking them to services and care as soon as possible has very positive health outcomes. Also from the community perspective we have achieved certain successes like reducing stigma, mobilising communities and providing support networks and services. I’m extremely interested in finding out how we can build on these successes.

MP: What are some of the challenges individuals and communities face in rural areas?

CS: Capacity is one of the main challenges in rural areas. I find that the doctors on the ground are often very knowledgeable, passionate and committed, but the problem that is there just aren’t enough doctors and medical resources. 

Transportation is another huge barrier in rural areas. People have a hard time getting to their doctors, as the transportation infrastructure isn’t always in place. Some people have to travel three or four hours to get to their physicians.

Addressing these barriers has been a challenge, but there have been some innovations like telemedicine, where doctors can remotely provide medical information and check in with their clients from a different location.

MP:  Are there any trial results that came out recently that you have followed closely? Are there any upcoming trials you are interested in?

CS: The HPTN 061 study, which looked at 1553 black, American MSM, shared initial results at AIDS 2012 that reinforced what a lot of us had been seeing on the field. One of the most startling projections of the study was that unless improvements are seen, more than half of all young black gay men who are gay or bisexual will be infected by HIV within the next decade.

Other upcoming trials I will be following with interest are the HPTN 073 study which looks at ways to optimise PrEP adherence in black MSM and the HPTN 069 study, also called NEXT PrEP, which seeks to assess the efficacy of four ARV drug regimens used as PrEP to prevent transmission of HIV in a population of at-risk MSM.

[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 social drivers of HIV: In conversation with Charles Stephens Part 2

Original content from our Mapping Pathways blog team

"HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors." 

In the second of this three-part series, Charles Stephens of AIDS United, a Mapping Pathways partner organisation, speaks about the social drivers of HIV and its impact on vulnerable communities. Click here for part one.

MP: According to the Centers for Disease Control and Prevention (CDC) figures, men who have sex with men (MSM) accounted for 61% of all new HIV infections in the U.S. 2009. There was also a 48% increase in HIV incidence figures among young black gay men (aged 13-29). Why has the HIV epidemic seemed to have disproportionately affected this demographic?

CS: I think there are a number of researchers right now investigating that question. I feel we are still at the stage of trying to figure out what questions we should be asking. For example, a number of researchers have done work that suggests that black gay men don’t necessarily engage in any higher sexual risks or drug-taking risks than white gay men. However, there is a higher incidence of HIV among black gay men – so why is that?

One argument is that there is a higher prevalence of HIV within existing black, gay male sexual networks, which leads to higher incidence numbers. There is also some thought about ways that poverty, stigma and other social factors can play a role in driving the HIV epidemic among black gay men.

HIV has never been just a question of behavior. It forces us to look at science in a critical way and examine behavioral and social factors. One of most exciting conversations I’ve witnessed in the research and advocacy realm is ‘What are the social drivers of HIV and how do those social drivers disproportionately impact some communities over others?’

I think researchers should be looking at lot of areas. But more importantly, considering the impact of HIV among young black gay men in particular, I think its important that researchers, policymakers and community members all come together in grappling with this really severe epidemic.

MP: Can you elaborate on some of the social drivers you talked about?

CS: Some of the questions we have to ask are: What is the role of housing or joblessness? What are the roles of social class, stigma and homophobia? These questions force us to think about HIV in a very intersectional way. By intersectional, I mean the challenge and issue of HIV is also connected to these other larger social issues.

An intersectional approach forces us not to operate in silos. It forces us to be very innovative in how we think about grappling with HIV. It’s impossible to think about HIV without some analyses of social issues because very often those social issues reinforce the impact of HIV, particularly in vulnerable communities.

Ultimately, it is important to look at communities that are most vulnerable. But what we seem to find is that communities vulnerable to HIV are also vulnerable to a number of other social issues, which means that we have to think very critically about the role that these other social drivers of HIV play – particularly in the lives of young black gay men.

MP: What are some of these challenges and issues that young black gay men seem to face in particular? What makes them so vulnerable?

CS: I think that, again, is a research question. There needs to be a research agenda around young black gay men, particularly in the context of HIV, that asks those very questions. Some of the questions to be asked are: How do we understand the vulnerability of this population? What are some of the forces that contribute to this vulnerability?

The research agenda should bring together researchers from multiple disciplines and approaches. This research agenda requires diverse methodologies, skillsets and worldviews. In effect, this would not just be a research agenda but a research and advocacy agenda, with the research helping drive the advocacy.

Current vulnerabilities include, but are not limited to, joblessness, poverty and stigma. We talk about stigma, in particular, as a barrier to someone accessing prevention or care services. Someone might be unwilling to get an HIV test because they don’t want to be seen going to an AIDS service organisation because of the stigma associated with HIV. Someone diagnosed with HIV might not tell people and thus fail to build a support system around them.

Lack of healthcare access is another vulnerability in this population. Communities that are marginalised because of race, class or gender sometimes don’t have access to the best healthcare resources, which contributes to negative health outcomes.

A number of steps have been taken to make HIV testing as accessible as possible. There are efforts to bring HIV testing to communities and one sees HIV testing events at community centers and mobile testing.

Stay tuned to the blog as we bring you part three of our conversation with Charles, where he speaks about some of the challenges faced by people living with HIV in rural areas and shares his thoughts on the good work being done in the HIV prevention landscape. 

[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 social drivers of HIV: In conversation with Charles Stephens

Original content from our Mapping Pathways blog team

"There was a charge at the conference to do more, research more and advocate more because what we are looking at is quite devastating." 

In the first of this three-part series, we speak to Charles Stephens of AIDS United, a Mapping Pathways partner organisation, and get his perspectives on the recently-concluded AIDS 2012 conference in Washington D.C. and the FDA ruling on Truvada for PrEP.

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

CS:  My name is Charles Stephens and I’m the Southern Regional Organiser for AIDS United. In that role, I work with our partners and grantees in the southern region of the U.S. to help build their capacity to engage in and implement advocacy work. I am very passionate about HIV prevention research and my goal is to bridge the gap that sometimes exists between communities and academia, researchers and practitioners.

I provide workshops on advocacy and help to build and sustain coalitions that might develop around an issue or campaign. I also help create tools such as factsheets, which are used by some of our grantees and partners in their advocacy efforts.

My role with AIDS United has given me the opportunity to work with the Mapping Pathways project by helping to disseminate findings and using the project as a community education tool to raise awareness about biomedical HIV prevention in general and ARV-based HIV prevention in particular. Being on the ground with various communities gives me the opportunity to draw upon the perspectives of a wide range of stakeholders to help make the case for the significance and value of ARV-based prevention, which is one of the aims of the Mapping Pathways project.

MP: How did the AIDS 2012 conference go? What were some of the conversations taking place there?

CS: AIDS 2012 was extremely exciting! It was the first time in a long time that a conference was held in the U.S. Several conversations centered on the possibility of ending AIDS as we know it is and we feel this possibility is within our grasp.

There have been a number of scientific breakthroughs, particularly in the context of biomedical HIV prevention, that have given us a lot of hope. TLC+, PrEP and other technologies and strategies were prominently discussed and debated.

There was also a lot of discussion about the catastrophic HIV rates among young black gay men and possible strategies to combat that problem. There was a charge at the conference to do more, research more and advocate more because what we are looking at is quite devastating. There was a contrast, though, between the optimism of envisioning an AIDS-free generation and at the same time looking at the dismal HIV rates among young black gay men. Overall though, I get the sense that many of us left empowered and energised.

MP: What is your opinion on the recent FDA ruling on Truvada for PrEP?

CS: The FDA approval of Truvada for PrEP was another exciting development that lent an air of positivity to the conference. The FDA approval gives us more opportunities to engage in research and demonstration around PrEP and answer key questions.

We have to understand better how PrEP will work in real-world settings. There are a number of questions that a lot of communities and researchers have around PrEP and I think that the FDA approval will allow us to look for the answers to those questions

From an advocacy perspective we are at a unique time. However, we still have to work out accessibility issues and think about how people and communities, particularly vulnerable communities, can afford the drug. Advocates are also having conversations about the Affordable Care Act and other health-care reform.

MP: Is there anything else coming up in the near future that excites you?

CS: I’m looking forward to The National Gay Men’s HIV/AIDS Awareness Day that is coming up on September 27. The U.S. celebrates a number of National HIV/AIDS Awareness days through the year. These provide opportunities to raise awareness and also help de-stigmatise HIV by acknowledging the impact HIV has on certain communities and commemorating unsung heroes in the movement.

The impact of HIV and AIDS on my community motivates me to go out everyday and do all that I can to change the direction things are going in. I’m also thrilled at having the opportunity to work with a number of very talented, skilled and committed individuals. Watching their work inspires me and I think their stories need to be told.

Stay tuned to the blog as we bring you part two and three of our conversation with Charles, where he speaks about some of the social drivers of HIV and the disproportionate impact of HIV on some communities.

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[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.]