IRIN Coverage of Mapping Pathways ARV-Based Prevention Report: “Here’s all this science - now what?”

via IRIN

 Excerpt:
According to Mapping Pathways, the ideal approach to implementing treatment as prevention should consider not only the clinical goal of efficacy (works in a lab), but also effectiveness (how to apply the solution in a community).

“I know that if you get anti-retroviral drugs into someone’s blood, they suppress the virus. We have amazing proof of that - it’s a major scientific breakthrough in the history of humankind,” said Linda-Gail Bekker, chief operating officer of the Desmond Tutu HIV Foundation, based in South Africa.

“But now we have to put this together so it works, which means engaging with a wide range of human beings who live very different lives than those of us who run these programmes might imagine,” she said.

Effectiveness requires behaviour change and, therefore, varies across cultures, governments, and communities based on “the firms that produce the drugs, the healthcare clinics that deliver the drugs, the community centres that provide education, and the partnerships developed,” according to Mapping Pathways.

“Human beings will behave like human beings. What does that mean? Well, social sciences have been trying to figure that out for centuries and don’t have one single theory, so why should our HIV programmes?” asked Bekker.

“The notion that in HIV programmes `one size fits all’ has backfired on us and it has been a humbling moment for those of us who work in this field.”

Read the whole article on IRIN.


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NEW Podcast on the Promise of PEP, and the Unfortunate Lack of PEP Implementation

Jim and Jessica (pictured above) from the Mapping Pathways team are back with a new podcast - and this time the topic is PEP - post-exposure prophylaxis for HIV prevention.

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

In this new podcast,  Jessica Terlikowski and Jim Pickett discuss the promise of PEP, and the unfortunate lack of strong implementation that characterizes this intervention in nearly every part of the world.

Other podcasts

Click here for a previous podcast in which Jessica and Jim  introduce the Mapping Pathways report (published by Mapping Pathways partner RAND) and explain its relevance for multiple audiences. Click here for their second podcast where they chat about PrEP - pre-exposure prophylaxis.

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.

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

Podcast: A Little PrEP Talk Inspired by New Mapping Pathways Report

This 10-minute podcast (click to listen) was produced by AIDS Foundation of Chicago (AFC) and is the second in a series of discussions inspired by "Developing Evidence-Based, People-Centred Strategies for the Use of Antiretrovirals as Prevention."

This new Mapping Pathways report was published 19 June 2013 by RAND Europe and AFC.

In this new podcast, AFC staffers and Mapping Pathways team members Jessica Terlikowski and Jim Pickett chat about PrEP - pre-exposure prophylaxis.

Click here for Jessica and Jim's previous podcast - posted June 21, 2013 -  which introduces the report and talks about why it is relevant for multiple audiences.

Keep your eyes and ears open.

Jessica and Jim will be back soon to talk about the other ARV-based prevention strategies that were explored in the report: PEP (post-exposure prophylaxis), TLC+ (testing, linkage to care, plus treatment) and microbicides. And you will find out about it right here.


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

Providing a range of prevention options: In conversation with Linda-Gail Bekker

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

[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.]

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

[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.]