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] 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.
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."