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.]

In Conversation with Kate Morrow: Of Microbicides, Sensations, and Adherence (Part 2)

Original content from the Mapping Pathways blog team

Kathleen (Kate) Morrow is a staff psychologist at the Miriam Hospital and an associate professor (research) of Psychiatry and Human Behavior at the Alpert Medical School of Brown University. She is driving two innovative microbicide projects – Project LINK and Project MIST. Kate is also a member of the IRMA Steering Committee.

(In Part 1 of this interview, Kate talked about Project LINK and how she got started down this career path.)

MP: Could you describe your work with Project MIST? How does it broaden the scope of your earlier work with Project LINK?

KM: Like Project LINK, Project MIST is also part of the Microbicides Innovation Program. I’m doing the acceptability piece on that project, whose Principal Investigator is Robert Buckheit at ImQuest BioSciences. Out of Project LINK, we understood that women could feel the differences among various gels well enough to discern, with their ratings, one product from another. The women finally had a choice to make at the end of the study. Their experiences impacted the product they chose – different women chose different experiences.

We’re in the process of completing LINK analyses now, and one of the things we feel like we don’t have a handle on is how gel volume would play into, and impact, a woman’s perception and experience with a product. So, if we had the exact same gel, but in different volumes, would she experience different things? That’s a question in the field as well – how much gel do we need to apply? That depends on the dosage, the amount of drugs in each measure of gel. That’s still an open question – and we decided we needed to answer that question from the perspective of the user, so that, if we could, we could optimize the volume for drug delivery, as well as the user experience.

And for me, the big question hanging out there was – what do the guys think? From LINK, we now know what women feel and what they think about those feelings and sensations, but we don’t have any understanding of what their male partners feel and how that will drive their preferences for gels.

Last but not least, MIST also gave us the opportunity to try a quick-dissolving film developed by Lisa Rohan at the University of Pittsburgh. So, we’re looking at those three issues in Project MIST: volume and the difference between a gel and a film with respect to user experiences, and exploring male sexual partners’ sensory perceptions and experiences. Like LINK, it’s a mix method study: this time we’re incorporating the male partners into the qualitative data mix to understand their experiences.  We’ll continue to use the validated scales from LINK.

MP: What inspires you?

KM: Well, to begin with, there’s the work itself. I mean, I do this work because I think it’s really important – I think it’s a piece that’s missing otherwise from the field. There are some of us who focus on things like sexual pleasure (Anne Philpott among them), but we have to understand the mechanisms of sexual pleasure – how do we help with that process? These projects, LINK and MIST, uniquely do that. We’re very unique in the fact that what we are trying to understand is which sensory perceptions and experiences impact willingness to use a product and hopefully, down the line, adherence to product use. That way, we can better create a formula that will not only deliver the drug well, but also will make the sexual experience one that people will want to have – so they’ll continue to use the product. What gets me excited every day is trying to figure out that puzzle, and hoping that in the long run this work will have a beneficial impact on the field and our ability to end the HIV epidemic.

But, you know, research can get drab, it can drag along…you meet your small goals often but the big end points don’t come, I think, as often as we’d like them to! So it’s the little things every day that keep us going. I think the thing that inspires me the most in that sense is my participants. Personally, they’re not getting any benefit out of doing these studies with my team – they know it’s a placebo study. But they come in, they try the products, they give us their opinions… To me, they’re the experts, they’re the ones that are the key to my success and my ability to get the data in this field.

Since we started LINK, we’ve seen more than 400 women walk through our doors saying, “I want to help you do this.” They tried all the different products – and I know they weren’t all pleasant! Yet, our retention rate in the studies is well over 90% – it’s a group of women who really want this to happen. They’re dedicated, they try to be as honest as they can…you know, frankly, we ask them some difficult questions. In the qualitative interviews, they’re sitting across from us telling us the story of their experience – and that can’t be easy to do. At some level it’s got to be a little uncomfortable to talk about your sexual experiences in such detail. And now their male partners are also on board. They all understand the medical necessity of the study. They understand that a pleasurable sexual experience is important to microbicides and their ultimate use. I am constantly amazed by our participants.

MP: As a behavioral scientist, what is your role in this process?

KM: Well, it’s possible (in fact, it’s probable) that we will not be able to make one, single ideal microbicide for women. Everybody likes different things in sex, and people like different characteristics. What we’d like to do is raise the floor – get rid of the absolute bad characteristics and make the properties and performances of these gels good enough for people to use them.

Once we end up with a tolerable gel and begin to move into uptake and access and use, what we can then do as behavioral scientists is educate women and their partners about the not-so-great characteristics that might remain but that have to be there in order for the drug to be efficacious. It’s a balancing act between the experience of the user and the efficacy of the product. At some point, we’re likely to run into “we need it to be like this for the efficacy, we can’t change that”. So then, as a behavioral scientist, I have to say, “Okay, if you can’t change that, what impact is it going to have on the user and how can I help the user to cope with that?”

So, there are two things going on for me: on one hand, let’s make the best one possible to begin with. Then, if there are things we can’t change due to efficacy, how do I help people deal with those remaining issues? Even though it’s not going to be perfect, there are still things we can do as behavioral and social scientists to help deal with those imperfections.

MP: What’s the hardest part about your job?

KM: Not having enough time in the day! There’s just so much to do. I’d like it to move a whole lot faster than it can – but that’s just what it is. Obviously, I wish that we were there already. But day in and day out, I love my work. I love the science. I’m very appreciative of my participants and the efforts that they put in. My team is amazing and I think we’re doing good work and that we’ll be able to contribute, ultimately, to a better microbicide.

MP: What are you most excited about for 2012?

KM: Finishing up the LINK data and figuring out which of our scales are most useful to us in the process of evaluating candidate gels. And, of course, continuing with and finishing MIST and incorporating the male partner experience into the mix. Down the road, I’m hoping that we start a project to do similar kinds of science around rectal microbicides both with men who have sex with men (MSM) and women. I’m keeping my fingers crossed that it will get funded and take off this year. I’m just really excited about moving forward and trying to keep all of us moving forward.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

In Conversation with Kate Morrow: Of Microbicides, Sensations, and Adherence (Part 1)

Original content from the Mapping Pathways blog team

Kathleen (Kate) Morrow is a staff psychologist at the Miriam Hospital and an associate professor (research) of Psychiatry and Human Behavior at the Alpert Medical School of Brown University. She is driving two innovative microbicide projects – Project LINK and Project MIST. Kate is also a member of the IRMA Steering Committee.



MP: What got you started down the path of HIV prevention?

KM: From a personal perspective, I spent much of the ’80s losing people to the epidemic – that was a very powerful experience in my life. Then, after I trained to become a clinical psychologist, I worked as a clinician in an outpatient substance abuse clinic and many of my patients were infected with HIV. At that point, I was a Masters level clinician. When I went back for my doctorate, I decided to study HIV prevention – and it’s been my work ever since.

MP: And how did microbicides come into the picture?

KM: In the course of my post-doctoral fellowship I was introduced to microbicides by my mentor, Ken Mayer. Like many people, I didn’t even know what a microbicide was at that point! He asked me to pursue the notion of acceptability and how these new products would fare in that regard. I became very interested in how that was going to work, and it just…suited me as far as what I wanted my career to be about. It was about so many things close to my heart – giving people (especially women) the power and control to prevent HIV, something that didn’t interfere with their lives… My work primarily focused on women to begin with. Ultimately, I’ve gotten involved in the broader reality of what microbicides will be (I hope!), including vaginal and rectal microbicides for both men and women.

In my work with acceptability, a big issue for me was that we were conceptually equating acceptability and adherence. It’s like we were saying if they adhere to it, it must be acceptable and if it’s acceptable they’ll adhere to it. In my mind, that’s not a given. I mean, I would love to believe that if it’s acceptable, everyone will use it – but I don’t think that’s necessarily true given the relational and contextual issues that surround microbicide use.

MP: What is Project LINK all about?

KM: Project LINK began in 2006. It is funded primarily by a grant from the National Institutes of Health, and was also supported by CONRAD. It is part of the NIH’s Microbicide Innovation Program.It is focused on the female user experience. The main idea is to try to understand how the formulation of a microbicide – the properties and characteristics of the gel itself – relates to the experiences the users have. The study involves approximately 350 women. The data collection is now complete, and we hope to have the results in the coming months.

We’ve been running into a lot of adherence issues across microbicides trials since the very beginning. LINK is trying to understand what the user experience is given the kind of formulations that they’re using and the properties of those formulations. Each product has its own constituents, its ingredients, and the way they interact with each other and with other external factors. If we can link these formulation characteristics to a woman’s experience, then maybe we can fix or enhance that experience and make it something that women can at least tolerate – if not enjoy.

MP: Could you explain with an example?

KM: Take, for example, leakage. Leakage is something that we always deal with when it comes to vaginal gels. Some gels leak while others are good at not leaking out. If leakage is a bad experience for women then we can alter the “recipe” of the formulation, so to speak, to minimize that leakage or to make it happen at a different, more preferable point in time. The idea is to figure out what women can feel and experience at a very sensory level, in their vaginas, and pinpoint which sensation is being driven by which of the gel’s properties or performance characteristics.

MP: What stage is Project LINK at currently? And what’s the end goal?

KM: We’ve developed a set of scales to show the range of different sensations and experiences reported by women when they use the products. Basically, these scales allow women to rate products given specific statements. We then tested four novel gels using these scales. The idea was to capture a range of women’s experiences from a relatively low-viscosity gel to a high-viscosity gel, along with other varying parameters (yield stress, dilutions properties, etc.). When the women had evaluated all four gels, at the end of their final visit in the study, they provided data on which formulation they would prefer. Their experiences impacted the product they chose – different women chose different experiences.

Now, we’re analyzing the data to understand the correspondence (hence, Project LINK) between the sensations and the properties of the gels. Once we’ve done that, we can try and make the microbicides feel better to the user – and make them work better, too. Obviously, the formulation is primarily about delivery and efficacy – to get the active ingredient where it needs to go, do what it needs to do, and stay there for as long as it needs to. That’s key. But if we can figure out how to make the best formulation for drug delivery and make it one that women can at least tolerate, if not like, then we have a better shot at effectiveness overall. If it feels good, women will use it.

Actually, there are two ways of looking at microbicide gels. First, you could think of it as a product with a neutral impact on the sexual experience – some people enjoy sex the way it is and don’t want it altered by a product. This would also be useful for women who need the microbicide to be covert. Second, you can develop a product that actually enhances sexual pleasure. Hopefully, if people like it, that would increase the likelihood of their using it. And if it’s efficacious to begin with, then that means we’re reducing the possibility for HIV infection.

Watch this space for Part 2 of this interview, where Kate talks about the broadening scope of her research in Project MIST, behavioral science, what inspires her, and the hardest part about her job.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Attitudes and acceptance of PrEP among key populations

via PLoS ONE, by Andreas B. Eisingerich, Ana Wheelock, Gabriela B. Gomez, Geoffrey P. Garnett, Mark R. Dybul, Peter K. Piot

Background

The use of antiviral medications by HIV negative people to prevent acquisition of HIV or pre-exposure prophylaxis (PrEP) has shown promising results in recent trials. To understand the potential impact of PrEP for HIV prevention, in addition to efficacy data, we need to understand both the acceptability of PrEP among members of potential user groups and the factors likely to determine uptake.

Methods and Findings

Surveys of willingness to use PrEP products were conducted with 1,790 members of potential user groups (FSWs, MSM, IDUs, SDCs and young women) in seven countries: Peru, Ukraine, India, Kenya, Botswana, Uganda and South Africa. Analyses of variance were used to assess levels of acceptance across different user groups and countries. Conjoint analysis was used to examine the attitudes and preferences towards hypothetical and known attributes of PrEP programs and medications. Overall, members of potential user groups were willing to consider taking PrEP (61% reported that they would definitely use PrEP). Current results demonstrate that key user groups in different countries perceived PrEP as giving them new possibilities in their lives and would consider using it as soon as it becomes available. These results were maintained when subjects were reminded of potential side effects, the need to combine condom use with PrEP, and for regular HIV testing. Across populations, route of administration was considered the most important attribute of the presented alternatives.

Conclusions

Despite multiple conceivable barriers, there was a general willingness to adopt PrEP in key populations, which suggests that if efficacious and affordable, it could be a useful tool in HIV prevention. There would be a willingness to experience inconvenience and expense at the levels included in the survey. The results suggest that delivery in a long lasting injection would be a good target in drug development.

Read the full study here.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Efficacy of Behavioral Interventions to Increase Condom Use and Reduce Sexually Transmitted Infections

via Medscape, by Scott-Sheldon, Lori A. J. PhD; Huedo-Medina, Tania B. PhD; Warren, Michelle R. BA; Johnson, Blair T. PhD; Carey, Michael P. PhD

Objective

In the absence of an effective HIV vaccine, safer sexual practices are necessary to avert new infections. Therefore, we examined the efficacy of behavioral interventions to increase condom use and reduce sexually transmitted infections (STIs), including HIV.

Design

Studies that examined a behavioral intervention focusing on reducing sexual risk, used a randomized controlled trial or a quasi-experimental design with a comparison condition, and provided needed information to calculate effect sizes for condom use and any type of STI, including HIV.

Methods

Studies were retrieved from electronic databases (eg, PubMed, PsycINFO) and reference sections of relevant papers. Forty-two studies with 67 separate interventions (N = 40,665; M age = 26 years; 68% women; 59% Black) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed-effects and random-effects models, were calculated. Potential moderators of intervention efficacy were assessed.

Results

Compared with controls, intervention participants increased their condom use [d+ = 0.17, 95% confidence interval (CI) = 0.04, 0.29; k = 67], had fewer incident STIs (d+ = 0.16, 95% CI = 0.04, 0.29; k = 62), including HIV (d+ = 0.46, 95% CI = 0.13, 0.79; k = 13). Sample (eg, ethnicity) and intervention features (eg, skills training) moderated the efficacy of the intervention.
 Conclusions: Behavioral interventions reduce sexual risk behavior and avert STIs and HIV. Translation and widespread dissemination of effective behavioral interventions are needed.*

Read more here.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

The Complexity of Changing Behaviors

via Newsworks, by Maiken Scott

So, what have we learned about prevention?

Inform, plead, scare them straight—HIV-prevention messages have covered it all.

Those working in prevention thought that if they gave people information about the disease, it would help protect them, according to Dr. Jennifer Lauby, a researcher at the Public Health Management Corporation.

"We found out that it's more complicated than that," she said.

Her colleague Lee Carson agreed. "Education alone doesn't equal behavior change," Carson said. "We see that in smoking and things like that."

Prevention has to be more comprehensive, Lauby said.

"There're really a lot of factors that go into making people at risk for HIV, including social factors, community factors, access to care," she said. "We have to look at all of those factors when we talk about HIV prevention."

Focusing on specific groups

To get a better sense of those factors, researchers such as Lauby and Carson started looking at specific groups with very high infection rates. One such group is African American men who have sex with men—and women.

Andrew Jackson, who helps out with a research project involving this group at the Public Health Management Corporation, said it is hard to reach this population because the men are very secretive about their lives and sexual activities.

Jackson is African American, gay, and HIV positive. Growing up in an Ohio steel-mill town, as a member of the Baptist church, secrecy became part of his life early on.

"You had to be all man, you couldn't divulge if you had a secret that you didn't want to give out," Jackson said.

Mum is the word not just when it comes to the behavior itself, but also when it comes to HIV, said Philadelphian Douglas Van Lue. And that puts men at risk.

"If nobody is talking about it, then nobody is asking about it, and then there's just the sexual behavior going on," he said

Both Van Lue and Jackson help spread the word about the research project.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Is a Shift From Behavioral to Biomedical Interventions the Answer?

via gaycitynews.com, by Perry N. Halkitis, Ph.D., M.S.

Despite our best attempts over the last 30 years, the HIV epidemic continues unabated. There are 1.2 million identified infections in the United States, with another several hundred thousand likely undiagnosed. The impact of this ongoing health challenge is noted most dramatically and definitively evidenced among gay men, who represent somewhere in the vicinity of two to five percent of the population — but constitute 50 percent of all AIDS-related deaths, over 50 percent of all infections and over 50 percent of newly diagnosed infections.

With millions and millions of dollars spent on HIV prevention and research — and despite the best attempts of behavioral researchers and leading AIDS service organizations to modify our risk behaviors — the epidemic continues. Initial campaigns focusing on using a condom have, over time, morphed into programs underscoring the importance of efficacy, temptation and motivation to help shape behavior. But the infections continue to spread. So what has gone wrong?

Some, including myself at times, have pointed the finger at behavioral change programs that are overly simplistic, focusing on sex as an act free of emotion or passion (and in many cases, drugs). But sex is more than simple logic, or rational decision-making. Many behavioral programs have oversimplified a very complex behavior — and the programs we have developed or the research we have enacted has ultimately failed to translate to real lives. I often wonder if the folks developing these programs actually have sex themselves.

Some may argue that we have contained the disease. But how true is that when young gay men, especially Blacks and Latinos, are seroconverting at such high rates? Even among White men, there is an uptick in the incidence of new infections as this group navigates its 30s. We simply haven’t gotten it right.

The Center for Disease Control and Prevention (CDC) might beg to differ. For the last several years they have documented programs they refer to as DEBIS (Demonstrated Effective Behavioral Interventions) — which have demonstrated some feasibility in research trails for changing risk behaviors. Small subsets of these were developed for gay men. At a lunch a few years ago, a colleague asked me, “What do you think is the best DEBIS?” My answer was quite simply, “None of them. We still have an HIV epidemic, so nothing is clearly working that well.” For me, these interventions are like a topical ointment or a Band-Aid used to treat a deep skin infection — when what is really needed is a powerful oral antibiotic.

With no effective behavioral change programs in sight, newly developed and tested biomedical interventions have captured the attention of the public, of our leading community-based agencies and of policy makers at all levels of government.

Read the rest.


[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]

Using Antiretrovirals to Prevent New Infections

Mark Chataway is co-chairman of Baird’s CMC, a Mapping Pathways partner organisation. Here, he outlines the various prevention strategies.

I have been involved in fighting AIDS since 1983. I was the first full-time communications director of an AIDS organisation in the US. At the time, none of us imagined how terrible the epidemic would get – I remember a time when most of my colleagues thought that only people who had had over 100 sexual partners a year were at risk.

Like most people who’ve been so close to the epidemic, I often lose sight of how much progress we have made. The epidemic peaked long ago and the number of cases is falling every year. That is the kind of public health success that has not often been seen in the modern era. We are most of the way towards eliminating AIDS in the industrialised world although shocking epidemics still exist in many developing countries. There are still a tragically large number of caofses in Southern and Eastern Africa and the threat of HIV breaking out at-risk communities persists in parts of Asia and maybe even Eastern Europe.

There is a threat – still distant but definitely visible – that we will lose this astonishing success through complacency. Very few of us realised how fast we could cripple the epidemic once we started treatment. A few of us risk forgetting how fast the epidemic will bounce back if we allow treatment rates to slip.

We can make AIDS rare – and eliminate it entirely from rich countries – using technologies that we already have. The question is whether we have the will to do it.

There are three promising strategies for using the medicines we have as prevention.

1. Treat enough HIV-positive people with antiretroviral medication, in an effective manner: If we improved access to treatment for people living with HIV, including the offer of treatment earlier in the course of the disease, there is evidence that the “community viral load” would fall. Providing effective treatment to more individuals with HIV can reduce onward infections in a community because people on treatment are less likely to transmit the virus. The chances of HIV-negative people becoming infected would reduce progressively over time. An approach that focuses on improving access to care and antiretrovirals is sometimes called TLC+ (testing, linkage to care, plus treatment).
2. Provide antiretroviral medication for HIV-negative people who are at high risk of infection: Some HIV-negative people at the highest risk of being infected by HIV cannot modify their risk of being exposed. For example, sex workers may be unable to persuade their clients to use condoms and intravenous drug users may not have access to clean needles. For many of them, stopping the underlying risk behaviour – sex work or drug use in these examples – is not feasible. These HIV-negative people, at very high risk of infection, can be offered antiretroviral medicines to lower their chances of becoming infected in the future. They would have to take these medicines routinely and they would still be at some, albeit lower, risk of becoming infected if they could not avoid risky behavior. This approach is usually called pre-exposure prohphylaxis (PrEP). Recent trials have shown that PrEP can reduce the risk of infection significantly in gay men although puzzling findings suggest that they may not protect women.
3. Provide topical, antiretroviral-based microbicides to HIV-negative people: Antiretrovirals could be used topically – in a gel or lubricant formulation, for example – in the vagina or the rectum by HIV-negative people. The topical medicine could reduce the risk of HIV acquisition. This approach is often called microbicides or topical PrEP. A recent study in South Africa proved that the concept works and showed a degree of efficacy in protecting women from infection. Other studies have provided encouraging data on rectal and vaginal products.

Some behaviour change efforts have worked well – especially those run by affected communities for their own vulnerable people. Many behaviour change efforts barely worked at all but continue to be funded because there have been no alternatives. (Evaluation of individual efforts will always be complex – see, for example, the extended debate over the evaluation of the LoveLife programme in South Africa – but Northern Europe is an interesting example: countries such as Belgium, the Netherlands and the UK followed very different behavioural interventions but all have ended up with very similar epidemics.) Money from under-performing programmes can be re-directed to prevention efforts that have been proven to be effective in well-controlled prospective trials. Effective prevention, of course, reduces the need for treatment in the medium to long term.

My colleague, Jim Pickett, uses car safety as an analogy: nothing can take the place of safe, skilled driving but seat belts, air bags and better car design have reduced the number and severity of accidents dramatically, even as the number of cars and drivers has increased. These three approaches to using antiretrovirals might be the air bags, seat belts and safety frames of the HIV epidemic.

[Content that is linked from other sources is for informational purposes and should not construe a Mapping Pathways position.]