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Monday, 13 November 2017 20:50

The 18 million and the two thousand

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The opening session of the 13th International AIDS Impact Conference in Cape Town (13-15 November 2017) laid bare the challenges ahead for the global HIV community. On the one hand, the campaign to scale up HIV treatment has been successful and, according to UNAIDS South African country director Mbulawa Mugabe, 18 million people are accessing the drugs. We are well on our way to meeting the agreed 90-90-90 treatment targets.

On the other hand, new HIV infections are unacceptably high, particularly among adolescents in eastern and southern Africa. There are two thousand new HIV infections a week among South African girls and young women: two thousand reasons to do things better.

“What got us here will not get us there,” warned Prof Quarraisha Abdool Karim. Karim summarised the ground breaking CAPRISA research in KwaZulu-Natal that demonstrated the cycle of HIV transmission between young women and older men and women. The research, presented at the International AIDS Conference in 2016, showed that HIV-positive men who transmitted HIV to women under the age of 25 years received their HIV from women aged 25-40 years, who in turn had been infected some years before, when they themselves had sex with an older man.

To break this vicious circle, we need to intervene at all levels: young women need to have the tools to protect themselves from infection, including pre-exposure prophylaxis (PrEP). Older HIV-positive women need to be on treatment and virally suppressed, so that they do not transmit the virus. But the biggest challenge of all is to reach the “missing men” with both treatment and prevention services.

Although the prevention toolbox is continually expanding, we are still losing the battle in prevention due to a wide range of complex psychosocial and structural factors. An experience from the US, presented by Dr Jeffrey Parsons, gave a fascinating example of this. The drug Truvada has been licenced for PrEP in that country since 2012, but by 2016 only 80,000 out of the 4.7 million eligible Americans were accessing PrEP. Why? Parsons’ research showed that while a large percentage of young gay men said they were willing to use PrEP, in practice only a tiny minority accessed the drug to protect themselves from HIV.

Eliminating mother-to-child (MTCT) transmission of HIV is another example. PMTCT programmes have been renowned for their success in reducing vertical transmission from over 30% to under 1% in many countries. But UCT’s Prof Landon Myer warned about “the dark side” of maternal disengagement with PMTCT services. In Malawi for example, there is a much lower rate of retention and adherence by women in the PMTCT programme than by women who have accessed ART for their own health. Similar observations have been made in the US and in the UK. There so much we still need to understand about pregnancy and motherhood in the context of HIV, says Myer.   For many women, issues about HIV and treatment are not foremost in their mind when the demands of pregnancy and motherhood are taking precedence.

Treatment programmes will also need to innovate if they are to continue to expand. As Karim warned, so far, treatment programmes have accessed the easiest-to-reach. “The next 50% - will be harder,” she says.

Mugabe agreed that behavioural and psychosocial issues are central to the success of the treatment cascade. “We need a broader response to the HIV epidemic” he said. This includes an appreciation of structural factors, such as the role of social protection and social security. And a better understanding what it really means to be a person living with HIV. We need to promote issues of equity, dignity and justice.

Tomorrow’s blog: Read about EHPSA-funded research on HIV prevention for adolescents...

 

“What got us here will not get us there,” warned Prof. Quarraisha Abdool Karim. Karim summarised the ground breaking CAPRISA research in KwaZulu Natal that demonstrated the cycle of HIV transmission between young women and older men and women. The research, presented at the International AIDS Conference in 2016, showed that HIV-positive men who transmitted HIV to women under the age of 25 years received their HIV from women aged 25-40 years, who in turn had been infected some years before, when they themselves had sex with an older man.

To break this vicious circle, we need to intervene at all levels: young women need to have the tools to protect themselves from infection, including pre-exposure prophylaxis (PrEP). Older HIV-positive women need to be on treatment and virally suppressed, so that they do not transmit the virus. But the biggest challenge of all is to reach the “missing men” with both treatment and prevention services.

Although the prevention toolbox is continually expanding, we are still losing the battle in prevention due to a wide range of complex psychosocial and structural factors. An experience from the US, presented by Dr Jeffrey Parsons, gave a fascinating example of this. The drug Truvada has been licenced for PrEP in that country since 2012, but by 2016 only 80,000 out of the 4.7 million eligible Americans were accessing PrEP. Why? Parsons’ research showed that while a large percentage of young gay men were willing to use PrEP, in practice only a tiny minority accessed the drug to protect themselves from HIV.

Eliminating mother-to-child (MTCT) transmission of HIV is another example. PMTCT programmes have been renowned for their success in reducing vertical transmission from over 30% to under 1% in many countries. But UCT’s Prof Landon Myer warned about “the dark side” of maternal disengagement with PMTCT services. In Malawi for example, there is a much lower rate of retention and adherence by women in the PMTCT programme than by women who have accessed ART for their own health. Similar observations have been made in the US and in the UK. There so much we still need to understand about pregnancy and motherhood in the context of HIV, says Myer.   For many women, issues about HIV and treatment are not foremost in their mind when the demands of pregnancy and motherhood are taking precedence.

Treatment programmes will also need to innovate if they are to continue to expand. As Karim warned, so far treatment programmes have accessed the easiest-to-reach. “The next 50% - will be harder,” she says.

Mugabe agreed that behavioural and psychosocial issues are central to the success of the treatment cascade. “We need a broader response to the HIV epidemic” he said. This includes an appreciation of structural factors, such as the role of social protection and social security. And a better understanding what it really means to be a person living with HIV. We need to promote issues of equity, dignity and justice.

Tomorrow’s blog: Read about EHPSA-funded research on HIV prevention for adolescents.

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