Mapping Pathways Launches NEW Report - "Community-driven strategies for the use of ARVs as prevention: United States Workshop Report"

The Mapping Pathways United States Workshop Report is launched today, providing the results of three HIV prevention scenario-development workshops held in 2013 in the United States.

The "Community-driven strategies for the use of antiretrovirals as prevention: United States Workshop Report" analyses, aggregates and synthesises different factors, issues, and drivers identified by workshop participants and constructs a future scenario for HIV prevention strategies using ARV (antiretroviral) drugs in the United States. Integration - of factors and systems involved in both treatment and prevention - is the main driver of success.

We hope you will read the report and utilize it in your organizational/jurisdictional planning processes for HIV prevention and care services. Please share the report with colleagues you think will be interested.

 In 2013, a subset of the Mapping Pathways team conducted knowledge-exchange workshops in San

Atlanta workshop participants

Francisco, Atlanta, and Washington, D.C., to further share the findings of our 2013 report ("Developing evidence-based, people-centred strategies for the use of antiretrovirals as prevention") and to continue enhancing the community-driven, locally informed approach to the wider evidence base for ARV-based prevention.

The cities were selected based on geographic diversity as well as the diversity of experience and expertise that can be found in each setting.

All three workshops included a mix of approximately 20 researchers, advocates, policy experts, public health officials, and service providers; they were diverse in terms of age, race, gender identity, sexuality, sero-status, and years in the field, with a blend of local to national experiences and perspectives.

Participants collaboratively developed a range of future scenarios and potential strategies linked to prevention programming goals and objectives. They were asked to think ahead to the year 2025, and envision an array of outcomes associated with the implementation of ARV-based prevention.

Based on participant ideas and concepts synthesised across all three workshops, we developed a ‘Mapping Pathways’ scenario for the future which has a strongly integrated approach at its core. The main driver of this future scenario is one of integration across political, economic, social, educational, and technological factors, and integration across the broader scientific, healthcare, and delivery systems. This means that we integrate both treatment and prevention strategies, including how we develop them, how we fund them, and how we deliver them, into one holistic approach.

Political and economic factors considered by workshop participants

The Mapping Pathways scenario was informed by these key themes common to all the workshops:

• Participants emphasised the need for a more holistic approach to HIV services in which prevention and treatment were not seen as mutually exclusive.

• Social and behavioral research must be supported and integrated with biomedical research.

• Digital web and device-based technologies and information sharing will affect access, uptake, and adherence.

• The Affordable Care Act (ACA) offers major opportunities for expanding access to healthcare, and poses challenges in HIV prevention and care delivery as the landscape evolves.

• Community-based organizations have a leading role to play in the new healthcare paradigm being ushered in with the ACA. They can help generate political will, drive research agendas, and deliver integrated care to communities and populations in need.

• Diversified funding streams are needed, and many of the optimistic scenarios generated by participants included strategies to engage a wide range of funders.

Click here for the United States Workshop Report.

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Podcast: Mapping Pathways' San Francisco "Knowledge Exchange Workshop" - More Robust, Better Resourced Behavioral and Implementation Science is Needed!

Jim and Jessica from the Mapping Pathways team have podcasted again!

This new 12-minute podcast (click to listen) was produced by AIDS Foundation of Chicago (a Mapping Pathways partner) and is the fourth in a series of discussions inspired by our new report "Developing Evidence-Based, People-Centred Strategies for the Use of Antiretrovirals as Prevention."

In this new podcast,  Jim and Jessica talk about the recent Mapping Pathways "Knowledge Exchange Workshop" at the beautiful San Francisco AIDS Foundation which included researchers, public health officials, policy experts, advocates, and prevention staffers from the Bay Area. Our report provided the backdrop - and the launch pad - for rich discussion/debate and a series of future-thinking exercises focued on ARV-based prevention strategies and scenario planning. The above pic is an "action shot" from the workshop.

Big take-aways from our two days together include the need for more robust (and better resourced) behavioral science and implementation projects - and for advocacy devoted to both these areas. We have vaccine advocates, microbicide advocates, treatment advocates, PrEP advocates.... it's about time we have some concerted advocacy for behavioral science and implementation science too! Without more attention and adequate funding for these activities - it won't matter how efficacious a biomedical tool proves to be in a clinical trial. Things like PrEP, etc.  need to work in the REAL world - which a clinical trial does not accurately represent .

Here are the presentation slides used during the workshop.

Other podcasts

Click here for previous podcasts on topics like PEP and PrEP.

And please stay tuned for future podcasts on topics like microbicides, the use of treatment for prevention, and more. Feel free to leave comments or questions here, on the podcast itself, of by sending an email to mappingpathways@gmail.com. [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.]

Mapping Pathways VIDEO: New Report's Lead Author Discusses ARV-based Prevention

90 Seconds: Molly Morgan Jones, a Research Leader in RAND Europe, and lead author of the new Mapping Pathways report "Developing Evidence-Based, People-Centred Strategies for the Use of Antiretrovirals as Prevention" discusses how antiretroviral (ARV)-based HIV prevention strategies need to be closely tailored to local contexts and cultures in order to make an impact on new HIV infections globally.

Watch below. Access the report here. Check out the report's Research Brief here.

[Please look for us on Facebook here www.facebook.com/MappingPathways and you can follow us on Twitter @mappingpathways as well.]

New International Report on HIV Prevention Urges Localized Consideration of Antiretroviral Strategies

First Report on Antiretroviral Drugs for HIV Prevention to Bring Science Together with the Wisdom of Communities

June 19, 2013 – To make an impact on new HIV infections globally, antiretroviral (ARV)-based HIV prevention strategies need to be closely tailored to local contexts and cultures, according to a new report released today by RAND Europe and AIDS Foundation of Chicago.

“‘Mapping Pathways: Developing Evidence-Based, People-Centred Strategies for the Use of Antiretrovirals as Prevention’ [available by open access online on the RAND Europe website, and on the Mapping Pathways blog] provides an important resource to help communities, prevention programmers, funders and policymakers decide whether, and how, an ARV-based strategy could work in their locality,” said Jim Pickett, director of prevention advocacy at AIDS Foundation of Chicago and project director.

Last year, more than 2 million people globally became infected with HIV suggesting current prevention strategies are not doing enough to halt HIV transmission. Research suggests that some of the most promising prevention strategies are based on ARV drugs, such as pre-exposure prophylaxis (PrEP) and treatment.

“However, just because we know that ARVs can prevent HIV infection does not mean that we will, in practice, successfully implement their use in communities that need them,” said lead author Molly Morgan Jones, research leader at RAND Europe in Cambridge, UK.

Mapping Pathways is a community-led research project on the strategic use of ARV drugs for HIV prevention, involving RAND Europe, AIDS Foundation of Chicago and other partners in India, South Africa and the United States.

The group engaged more than 1,000 community respondents with an online survey and interviewed several dozen key stakeholders, including policy experts, program implementers, health care professionals and advocates. Participants rated the importance of various ARV-based prevention strategies, shared their perspectives regarding barriers to implementation and suggested the kinds of information they needed to make informed decisions about whether to implement any ARV-based strategy.


Click to enlarge

Additionally, an extensive literature review was conducted during 2011 and 2012 to assess the published scientific evidence. Detailed snapshots from these activities are highlighted in the report and provide rich, localized context that reveal the opinions and concerns of a wide array of individuals and underscore important gaps in the evidence.

Community members and key stakeholders in each country consistently agreed they must address three key challenges in order to maximize the prevention potential of ARV drugs:

• First, structural issues such as community-level living conditions that affect access, such as proximity to appropriate health care and other social determinants of health, are as important as individual-level behaviors.

• Second, more information about implementation is needed by policymakers, funders and prevention programmers in order to determine what mix of ARV-based prevention strategies, if any, are appropriate.

• The third challenge is to adapt ARV-based prevention strategies for local contexts, as reflected in the book’s foreword written by Archbishop Desmond Tutu (“All science is local”).

The research found that within each country, and among varied types of people, the same sets of scientific data were interpreted and framed in different ways depending on the local context and perspectives. For instance, participants in South Africa and India tended to view the scientific data with more skepticism than individuals from the United States, so the successful adoption of ARV-based prevention strategies, such as PrEP, requires consideration of both the science and the local context.

 “It is important to marry the published evidence with the wisdom of communities to make decisions on prevention programming that make sense locally, for communities to map out their own, unique pathways,” Jones said.

Moving forward, there are many considerations for the use of ARVs as prevention in localities.

“Different countries and communities are at different places,” said Dr. Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Foundation in South Africa and a Mapping Pathways partner. “We all have to ask policymakers, funders, and ourselves a host of questions. How will we implement a certain strategy? How will we pay for it? Is it for the generalized epidemic or is it only for certain key populations? What are the social factors that make certain populations vulnerable? Is this strategy ethical? Does it make sound public health sense? What won’t be afforded if we go this route? Who will benefit if we do?

“Meanwhile, we must continue to advocate and conduct implementation science so that we can show policymakers what is feasible and what the impact in the public sector could be.”


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Three-quarters of clinicians in the US willing to prescribe early HIV treatment for the purpose of prevention

via aidsmap.com, by Michael Carter

There is an overwhelming consensus among clinicians who prescribe HIV treatment in the US that people who are taking antiretroviral therapy are less likely to transmit HIV to their sexual partners, according to results of a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Results also showed that over three-quarters of care providers would be willing to prescribe early therapy to people with an HIV-negative partner for the purposes of prevention.

The study involved 165 prescribing clinicians working at HIV clinics in the Bronx, New York, and Washington DC. It was conducted in 2010 and 2011, well before the publication of the results of the HPTN 052 study in the summer of 2012, which showed that virologically suppressive HIV treatment reduced the risk of transmission by 96%. US HIV treatment guidelines were updated in 2012 to endorse early treatment to reduce the risk of transmission.

“This survey of HIV clinicians in two US cities found most clinicians believe that ART [antiretroviral therapy] can reduce HIV transmission, even before the results of HPTN 052 demonstrated ART to be effective for this purpose, and before 2012 treatment guideline changes recommending ART for patients at risk for HIV transmission,” write the authors.

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.]

Newly infected individuals sustaining HIV epidemic in Geneva

via aidsmap, by Michael Carter

Individuals with recent HIV infection are sustaining the epidemic, a Swiss study published in the online edition of AIDS suggest. The investigators believe that their results further support the use of antiretroviral therapy as prevention, but also show that its impact on the epidemic will be blunted because of the high number of transmissions which can be attributed to individuals who have been recently infected with HIV and who are not yet taking treatment.

Phylogenetic analysis showed that only a handful of infections in individual diagnosed between 2008 and 2010 could be attributed to patients diagnosed before 2000. Patients with longer-term HIV infection were the group most likely to be taking antiretroviral therapy and to have an undetectable viral load.

“Recent HIV infections were a significant source of HIV spread,” comment the authors. “By contrast, HIV individuals diagnosed before 2000 were rarely the source of new infections before 2008.”

It is now widely accepted that patients who are taking HIV therapy that suppresses their viral load to undetectable levels are highly unlikely to transmit the virus to their sex partners.

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.]

Changing the way HIV prevention is delivered – a roadmap

via aidsmap, by Roger Pebody

In the last few years there has been a wealth of dramatic data on the efficacy of new HIV prevention methods, including male circumcision, pre-exposure prophylaxis and treatment as prevention. While last week’s 19th International AIDS Conference (AIDS 2012) didn’t deliver similar headline-grabbing studies, there were important discussions about how policy makers can implement effective HIV prevention strategies.

“We need to start thinking about the populations who are most at risk for targeted interventions,” Nelly Mugo of the University of Nairobi told a plenary session. “Then we will need to prioritize those interventions that work within those populations, and deliver them in combination with high coverage for us to get high impact.”

Speakers at other sessions gave numerous examples of the choices and dilemmas involved at each stage, drawing upon experience in the United States and in African countries.

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.]

Helen Epstein's wrong about SA's response to AIDS

via politicsweb, by Nathan Geffen

Helen Epstein is an influential journalist and regular contributor to one of the world's most prestigious literary journals, the New York Review of Books (NYRB). It is therefore unsettling that she has written an article on the NYRB blog that contains serious errors about the South African HIV epidemic and the important prevention benefits of antiretroviral treatment (ART) (see here).

In her first sentence Epstein writes, "When I first visited South Africa in 2000 to report on the AIDS epidemic there, one adult in five was HIV positive, and a million children had lost one or both parents to the disease." These numbers are simply wrong. UNAIDS estimates that by 2001 there were 580,000 children who had lost one or both parents to AIDS. This is a horrific figure, but substantially less than Epstein's. 2 The Actuarial Society of South Africa estimates the number of children who had lost a mother or both parents to AIDS by mid-2000 and they reach a considerably lower estimate of about 120,000. 3 Epstein also overstates the percentage of adults infected with HIV in 2000.

Epstein writes, "Although the HIV infection rate has finally begun to fall in neighboring countries like Botswana and Zimbabwe, it remains stubbornly high in South Africa. After studying the African epidemic for two decades, I've come to believe that shame and silence are the primary reasons ..."

She is wrong that South Africa's infection rate is not falling. Also wrong is her implication that shame and silence make the South African epidemic signally different from those in Botswana and Zimbabwe.

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 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.]