Original content from our Mapping Pathways blog team
We need options. Not everyone in the world is a good pill taker. Like so many things in life, we may realise that people need different prevention options since they have different personalities.
In the final part of this five-part series,
Linda-Gail Bekker of the Desmond Tutu HIV Centre, a Mapping Pathways partner organisation,
speaks about the importance of adherence, both in clinical trials and
the real world, and the challenges and issues facing adolescents. Read parts
one, two, three and four
MP: You have
mentioned adolescents as a particular vulnerable group in South Africa. In an interview
conducted earlier this year, your colleague, Dr. Melissa Wallace, also talked
about adolescents as an especially at-risk group. What are some factors that
make them so vulnerable?
LGB: One
particular reason why adolescents are highly at risk for HIV is because many
are at the stage of their lives where they may be experimenting with their
sexuality. They may also find themselves in relationships where negotiating
condoms may be incredibly difficult.
This maybe the case with younger women whose relationships can
be with older men and young MSM outing themselves for the first time and who
may then choose to go out with older men.
In that situation, being able to use a PrEP tablet discreetly and under
their own control could be a life-saving step.
So putting prevention into the hands of the vulnerable
becomes a very important tool. But we can only do this if we are sure it’s safe
in this population, which requires carefully run clinical research in order to
adequately test the product in the relevant populations.
This requires resources and investment from sponsors and funding
agencies even though this is often regarded as “high risk investment”. In that
regard, I’m delighted that we’ll be starting an MP3 project (methods of
prevention) based on a grant awarded to us by the National
Institutes of Health (NIH) to look at PrEP and other biomedical prevention
modalities in adolescents between 14-17 years old.
MP: Adherence
is an issue that has come up quite a bit this year, from M2012 to AIDS 2012. How
much are people talking about adherence and about taking lessons learned from trials
into the real world?
LGB: Adherence is
the Achilles heel of the HIV prevention and treatment worlds. This is where
biology meets behavior. We know that the pill is efficacious – Partners
PrEP showed that beautifully. In fact, every single one of the clinical
trials has shown that once adherence increases there is a direct correlation
with efficacy in the results. Starting with the 39% in the CAPRISA study leading on
to 44% in the iPrEx
study and going on to an astounding 75% in the Partners PrEP study – each one
had an increased overall adherence rate and with this an increase in point efficacy,
so the correlation appears to be a real phenomenon.
In addition, the sub-studies done in every trial showed that
high adherers within a study had a better efficacy compared to the lower
adherers. So we can quite confidently say there is a robust relationship
between adherence and efficacy.
So how do we get people to adhere? Motivations play a great
role. Partners PrEP which enrolled discordant couples had a great in-built motivation
that one was protecting a loved one by taking the pill, which may be the reason
we saw particularly high adherence for that population.
I think we also need to understand that not everybody in
this world is a good pill-taker. There will be those who just cannot bring
themselves to swallow pills on a daily basis. So PrEP may not be a very good
idea for them. In that situation, maybe a rectal microbicide or a microbicide
that’s part of a lubricant may work very well for that individual.
We need options. If we get to that stage in the future where
other prevention technologies are available, like getting a shot in the arm
that lasts three months, then we need that option on the table too. Like so
many things in life, we may realise that people need different prevention options
since they have different personalities.
MP: What are some
of your final thoughts on what needs to happen to stem the HIV epidemic?
LGB: We need to
have conversations on several different levels: ethical, scientific, public
health, politics and priorities. Different countries and communities will be at
different places. Some of the hard questions are : Who pays? How will we implement
this prevention strategy? Is this strategy for the generalised epidemic or is
it only for selected key populations? Who are the key populations? What are the
social factors that make them vulnerable? Is this ethical? Does it make sound
public health sense? What wont be afforded if we go this route? Who will
benefit if we do?
Those are all very hard questions but they deserve to be
asked and certainly require ongoing dialogue. This brings us back to the
Mapping Pathway- we have been contributing to the dialogue through this
project. We also need to do the modeling exercises and implement some
feasibility type projects and then continue to raise more questions., It’s a
wonderful thing that we are at a point where we can actually have these
conversations. They are not hypothetical questions anymore. It is urgent to
have these discussions in such a way that the next steps become clear and
infections can be averted before too much more time is lost.
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 for the Mapping Pathways monograph, coming in early 2013
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