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.

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

Archbishop Desmond Tutu: If we are to toss AIDS into the dustbin...

If we are to toss AIDS into the dustbin, we must do our best to understand the intersections of scientific discovery and community wisdom, address the truths in both, and move forward with decisions that take into consideration a full, robust interpretation of the evidence base.
- Archbishop Desmond Tutu

These are extraordinary times in which we are living. More than three decades into the global HIV pandemic, discussing ‘the end of AIDS’ is more than a rhetorical flourish, more than political grandstanding, and more than wishful thinking.

At this very moment, we have ‘the end of AIDS’ in our collective sights in a way we have never had before. Even as the epidemic continues to wreak havoc in the lives of far too many of our precious daughters, sons, sisters, brothers, mothers, fathers, friends and colleagues across the world – new and exciting scientific discoveries are pointing to a future where AIDS is a brutish artefact of history.

Science has shown us that treating HIV-positive people with a combination of antiretroviral drugs (ARVs) is not only good for the individual being treated, but also imparts a prevention benefit for the broader community as well. People on successful treatment do not get sick and die, and are much less likely to pass their infection to their partners.

Science has also shown that ARV drugs provided to HIV-negative individuals can protect them from the virus if exposed, much like anti-malarial drugs prevent malaria. And there are new, user-friendly ways to deliver ARVs being developed and tested at this very moment.

We simply must take the critical next steps to end AIDS now that science proves it can be achieved. If enough global citizens, people of faith, members of the private sector and world leaders summon the courage to accelerate and increase their investments in the global response to overcome AIDS, we have a very good chance of containing the worst viral scourge the world has ever known.

Conducting research in India, South Africa and the US, Mapping Pathways has taken such a step, one that helps make ‘real-world’ sense of the incredibly dynamic nature of the science. With new discoveries and insights coming so quickly it is hard to keep up.

Much like politics, all science is local. The understanding of what this new science means is local. Its utility is local. Yes, we have compelling results from clinical trials, and make no mistake, we will have more. But the opinions, perspectives and lived wisdom of communities, from the grassroots to the grasstops, matter just as much as the peer-reviewed scientific data that are coming at us fast and furiously. How communities absorb, understand and prioritise the science matters.

Placing a premium on a ‘people-centred’ interpretation of the science, Mapping Pathways has tapped the smarts, and the hearts, of advocates, researchers, clinicians, policymakers, pharmacists, funders, public health workers and people living with HIV. The results of their journey are illustrated in this monograph. I hope these findings will help communities across the globe grapple with the promises, and the marked complexities, of this thrilling new prevention paradigm in which we find ourselves.

I recommend Mapping Pathways – Developing evidence-based, people-centred strategies for the use of antiretrovirals as prevention. If we are to toss AIDS into the dustbin, we must do our best to understand the intersections of scientific discovery and community wisdom, address the truths in both, and move forward with decisions that take into consideration a full, robust interpretation of the evidence base.

Let us map new pathways together, for our generation and for those who follow. Let us be the generation to make the difference.

Let us be done with AIDS.

-Archbishop Desmond Tutu

[This is the foreword penned by Archbishop Desmond Tutu in the new Mapping Pathways report "Developing evidence-based, people-centred strategies for the use of antiretrovirals as prevention."  Click here for podcasts, an infographic, and a video associated with this report.]

[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.”


[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.]

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 Value Of HIV Treatment In Couples

via NPR, by Richard Knox

Dr. Rochelle Walensky thinks the 19th International AIDS Conference will be remembered as the moment when the world began to mobilize to end the pandemic.

The Harvard researcher probably speaks for many of the 23,000 scientists, activists and policy mavens who came to the Washington conference. But they're going home with a big question on their minds: Can the world afford it?

Walensky and her colleagues provided the beginning of an answer with a presentation on the final day of the conference. They looked at the cost implications of expanding anti-retroviral treatment to all HIV-positive people in couples where one partner is not infected.

"Is it worth paying for? The answer is yes, it's very cost-effective," Walensky told Shots. At least that's the case in South Africa and India, which the researchers chose for their analysis, and for the limited situation of these so-called discordant couples.

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.]

HIV/AIDS: WHO issues guidelines on PrEP

via PlusNews

NAIROBI/KAMPALA, 20 July 2012 (PlusNews) - Days after US officials gave unprecedented approval for the use of an antiretroviral drug by HIV-negative people to reduce the risk of their acquiring the HI virus, the World Health Organization (WHO) has issued guidance to governments on so-called pre-exposure prophylaxis (PrEP).

WHO's guidelines, which call for a cautious and gradual roll-out, will likely see many countries begin to add PrEP to the growing arsenal of tools in the fight against HIV.

The guidance is based on evidence from clinical trials on the daily use of ARVs for HIV prevention among high-risk HIV-negative people. A 2010 study - Iniciativa Profilaxis Preexposicion, or Prexposure Prophylaxis Initiative (iPrEX) - among men who have sex with men (MSM) and transgender people, found that a daily dose of the ARV, Truvada - a combination of emtricitabine and tenofovir disoproxil fumarate - reduced HIV infection risk by about 42 percent.

The 2011 Partners PrEP study in Kenya and Uganda concluded that a daily dose of Truvada, taken by the HIV-negative partner in a heterosexual HIV-discordant relationship - where one sexual partner is infected and the other is not - could reduce the risk of HIV transmission by up to 75 percent.

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.]

WHO issues first guidance on use of antiretrovirals by HIV-negative people at high risk to prevent infection

via World Health Organization

20 JULY 2012 | GENEVA / WASHINGTON DC - WHO has issued its first guidance to countries that are considering offering HIV medications, known as antiretrovirals (ARVs), to protect people who do not have the virus but who are at high risk of HIV infection.

Pre-exposure prophylaxis (PrEP):

The guidance is based on clinical trials indicating that a daily dose of oral antiretroviral medication, known as pre-exposure prophylaxis (PrEP), taken by HIV-negative people to reduce the risk of infection, is both safe for people to use and effective in preventing HIV. The iPrEX study shows that use of PrEP can reduce HIV infection by around 40% among men who have sex with men – and up to 73% among those who took the medicine regularly. The Partners PrEP study found 75% protection among serodiscordant couples (couples in which one person is HIV positive) in Kenya and Uganda.

The range of results in these studies highlight the potential benefits of PrEP, but also the importance of combining it with consistent use of condoms, as well as frequent HIV testing, counselling, and treatment of sexually transmitted infections.

They also emphasize the importance of taking medicines every day. Many people who are at high risk for HIV may not easily be able to incorporate the diligent treatment regimen required, so the next challenge is to ascertain how best to deliver PrEP to those who would benefit from it in ‘real life’ settings in order to achieve the necessary adherence and maximum public health gains.


PrEP projects in countries:

To better understand how PrEP can best contribute to a combination HIV prevention programme, WHO is encouraging countries wishing to introduce PrEP to first establish small projects to help public health workers to better understand and realize its potential benefits. In these projects, ARVs would be given to people at high risk of HIV infection. These could include uninfected men or transgender women who have sex with men who have a high risk of being HIV-positive. The aim is to identify which groups will benefit most from PrEP, and ascertain the best ways to deliver the services to them.

WHO will evaluate the outcome of these projects, together with the evolving scientific evidence. The results will help determine the best way to integrate PrEP guidance in future consolidated WHO guidelines on the use of antiretrovirals for preventing and treating HIV infection, which are expected in the summer of 2013.


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.]