Jim Pickett is the Director of Prevention Advocacy and Gay Men's Health at the AIDS Foundation of Chicago. He is chair of IRMA (International Rectal Microbicide Advocates), and a member of the Mapping Pathways team.
How was the Mapping Pathways initiative conceived?
JP: It’s a really exciting time for prevention. We have had some good theories and, now, initial data that we can safely and effectively use antiretroviral (ARV) therapies in the service of prevention, but our understanding is still evolving. While we’re researching and developing new tools (microbicides and PrEP) that we desperately need, and gaining new insights into how treatment for people living with HIV can also mean community prevention, there’s still a lot of confusion and debate surrounding these tools. So our team thought, ‘How do policymakers and programmers in all these different countries, how do they make sense of all of this complex, evolving data?’ Mapping Pathways is about trying to synthesize everything we know in the research arena with what community folks are saying, and doing some cost and evidence-based analysis to help come up with recommendations, or paths, to follow. It’s not about telling people to go down any one pathway; it’s about providing an array of pathways that are illuminated with a little more analysis with which to shape informed policies and programs.
Why is Mapping Pathways launching now versus 10 years later or 10 years earlier? Why now?
JP: In all the years of doing research into new prevention technologies – vaccines, microbicides, PrEP – we have not had anything show a glimmer of what we all could agree was ‘success.’ Results have tended to be flat. In this last year, we now have proof of concept that we really can create new ways to protect ourselves from HIV; in the field of biomedical prevention, the results from the
IPrEx and
CAPRISA trials are seen as the first real ‘win.’ So the second half of 2010 was the first time that we found strategies that actually could work. It was a momentous, revolutionary year for prevention, and we can now start building on that.
This is huge. Are people jumping up and down with excitement about the results from the IPrEx and CAPRISA trials?
JP: Yes, we are jumping up and down! In some ways, it’s been like Christmas every day since July at the International AIDS Conference in Vienna when the CAPRISA study results came out. But, jumping aside, we also are being very realistic. We’re saying, ‘Well, yes, so all these years we’ve been preparing ourselves for failure, and managing disappointment after disappointment, now we have success. And now that we have success, we have another 110% to do.’ We’ve gotten over this first hurdle; we’ve proven that we can create new ways to prevent HIV through the use of ARVs taken orally or applied topically but now we have to figure out how to get that pill, or gel, or whatever into the right hands in the right place at the right time. We’re grappling with all the problems that come with success. We’re certainly very excited to have these ‘problems’ – these are wonderful problems to have! Much better than flat results that haven’t allowed us to move forward. Now we’re over this hill and we’re moving forward and there’s another mountain to climb to address the next set of issues. But it’s a mountain we’re very happy to climb.
Could you spell out some of the main concerns or questions policymakers and communities are grappling with?
JP: Yes, first of all, this is new research… most folks, community people, program implementers want more information before moving into licensing and regulatory issues. Many policymakers are also reticent about PrEP because of cost, and they want to know more. But cost is a huge issue. In each of the countries where Mapping Pathways is focused – India, South Africa, and the United States – everyone who needs prevention does not have access. Not everyone who needs treatment is able to get on treatment. In many cases it is simply because there just aren’t enough resources. So where are they going to find the money? Where are these resources going to come from? What are they going to need to do to reprioritize their budgets and find the resources if they do think any of these interventions should be prioritized?
There are other concerns beyond fiscal issues. What’s going to happen to behavior in the community if we roll out PrEP? Will people stop using their condoms and will we actually have a bigger problem on our hands, since these tools as they are now (microbicides and PrEP) are less effective than condoms? Major ethical questions have also arisen over the use of ARV medications by healthy individuals when people living with HIV do not have access to treatment. In the US, we have an HIV drug waiting list right now – around 8,000 individuals. They are living with HIV and don’t have access to treatment. How do we provide PrEP to HIV-negative people in that context? How do we get those folks on treatment AND provide PrEP to those most in need, most vulnerable?
These are big questions that all of us (communities, policymakers, program implementers, donors) are going to need to answer. This discussion is of the moment, everything has just coalesced now, everything is happening now, and communities across the world are grappling with these strategies, wondering, ‘How in the world do we do this when we have all these other struggles? But on the other hand, how do we ignore it; how can we possibly ignore a new tool that could reduce so much suffering?’ And we have to realize that there are going to be different answers for different places in the world, or even in different parts and populations of one country. We’re hoping that the Mapping Pathways initiative will be able to provide some guidance to help figure all this out. There are so many complex issues to unravel and it is our duty to weed through all of these challenges, all of the promises, and all of the potential perils of these new strategies.
It sounds like you have quite a task ahead of you. How will Mapping Pathways know it has succeeded? How will you measure success?
JP: We will have succeeded if we’re able to provide analysis that is a blend of academic and scholarly work along with the wisdom from the folks on-the-ground delivering services and the people making policies at the government level. If we can bring together all of that knowledge and create tools that are usable for the various stakeholders, we will have succeeded. So, for example, if here in Chicago I can take these findings to the Chicago Department of Public Health and it can help inform their community planning process around the prioritization of prevention and care dollars. Or, in India you could take the results of our outputs and take it to the Minister of Health in Delhi and say, ‘Here is something to help us help you think about and plan how you’re going to allocate resources or roll out potential programs…or not.’ Maybe a jurisdiction will decide it will not focus on PrEP, and instead will focus on getting more people tested and treated and on doing a better job on getting people condoms. Basically, we want to help create a package of tools that people can then use to actually influence policy and do good programming in their particular context. At the end of the day, and this is the big picture, we want to avert HIV infections. We want less people to become infected and we want more people who are infected to be linked to appropriate care and treatment. And if our project can, in some small way, help create policies and programs that prevent more infections and get more people into care and treatments that are sustainable and appropriate, then I think we are successful.
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