If the world scales-up HIV treatment and prevention in the next two years, a critical tipping point - in which those on treatment outnumber those newly infected with the virus - could be reached, according to the global HIV prevention advocacy organization AVAC.
On the heels of AVAC's annual African Partners Forum, which was held in early December, IRIN/PlusNews breaks down the issues likely to top the HIV prevention agenda in the coming year.
1. End confusion over "combination prevention". It may have been the catch phrase of 2012, but “combination prevention” - the use of complementary behavioural, biomedical and other prevention strategies - remains poorly defined. AVAC is urging activists to help guide focused discussions about combination prevention and how donors, policy makers and implementers can best develop combination prevention packages tailored to individual countries’ needs.
2. Start - and keep - people on antiretroviral (ARV) therapy. While the latest UNAIDS report charts increasing access to ARVs over the past decade, only about half of those who need ARVs are receiving them. Meanwhile, more health officials are starting to shift their focus away from treatment numbers and towards treatment quality to ensure that people who begin treatment stay on it, and to make sure this treatment is working. According to AVAC, more innovative strategies are needed to improve uptake and retention in treatment programmes.
Such strategies will be especially important in “treatment as prevention” programmes. In most treatment protocols, only people living with HIV who have relatively low CD4 counts - indicating weaker immune strength - are put on ARVs. With treatment as prevention, even HIV-positive people with higher CD4 counts will take ARVs in order to decrease the likelihood of transmitting the virus to their partners. “Treatment as prevention” has also been used to describe the use of ARVs by people who are HIV-negative but at a high risk of contracting the virus.
Although there are treatment as prevention pilot projects underway among high-risk populations, policymakers remain unsure how treatment as prevention will work in contexts of generalized risk.
3. Prepare for the next wave of non-surgical medical male circumcision (MMC) devices. South African activists continue to protest the use of the controversial, unapproved Tara Klamp, a non-surgical device used to perform MMC. Even so, the first non-surgical MMC devices are expected to receive UN World Health Organization (WHO) prequalification in 2013, according to AVAC. Prequalification allows 14 prioritized African countries, including Swaziland, Ethiopia and South Africa, to use the devices,
which could offer MMC in areas where surgical options are not safely available.
But AVAC cautions this new technology might not suit all countries and that policy makers need to be prepared to decide whether they’ll stick with the surgical “snip” or move towards new devices that allow lower cadre health workers to perform circumcisions, AVAC says.
4. Define and launch a core package of pre-exposure prophylaxis (PrEP) demonstration projects. Although the WHO issued guidance on the use of PrEP in July 2012, AVAC says that many global health agencies and national HIV programmes are hesitant to adopt the strategy of giving HIV-negative people at high risk of contracting the virus ARVs to prevent infection without first conducting more pilot programmes.
According to AVAC, the PrEP agenda will hinge on defining just what kinds of pilot projects or studies policymakers need in order to be convinced.
5. Safeguard HIV-prevention research funding. Finally, AVAC says research funding for new prevention methods - like vaccines or ARV-based microbicides - needs to sustained. Luckily, the US President's Emergency Plan for AIDS Relief (PEPFAR) will likely continue to support research not only into vaccines but also into point-of-care HIV technology, according to its latest blueprint.
Meanwhile, South Africa has taken a keen interest in supporting its own national research into a microbicide using the ARV tenofovir.