Treatment marries prevention was one of the slogans of the latest International AIDS conference which took place in Mexico last summer. Does this mean that all our efforts to stop the epidemic should be focused on putting everybody on treatment as soon as possible – as latest WHO papers suggest? Or is there more to prevention? Above all, what does this new focus on treatment as prevention really mean for us who live with HIV?
Treatment has been openly used as prevention for a long time, for example in preventing mother to child transmission. This is one of the of the greatest success stories of the epidemic: HIV treatment used during pregnancy gives HIV positive women 99% chances of having an HIV negative baby. However, only about 30% of HIV positive pregnant women in the developing world have access to this treatment, and furthermore, once the pregnancy is over, only 10% will have access to treatments that would allow them to see their children grow up, but that’s another story… However, it does demonstrate how treatment based prevention strategies, which are known to work extremely well, are still not implemented. Prevention is a complex business. So, can treatment really be the main star?
Recently it has been highlighted that HIV treatment is effective in reducing sexual HIV transmission, especially among heterosexual couples where one partner is positive and the other is negative. A panel of Swiss experts last year published a statement saying that the risk of transmission for a couple – where the positive person had an undetectable viral load for at least six months, was under medical supervision, adherent to treatment and didn’t have any other STDs – was ‘negligible’.
Recognising that people living with HIV with an undetectable viral load are only to some extent infectious is a big step. This information had been known for a long time, but people were cautious about debating it more openly because of the fear that people living with HIV would act irresponsibly and have random unprotected sex. However, the feedback Positively Women (PW) had from a large number of women living with HIV when discussing this topic gave a very different picture.
Women welcomed the Swiss statement as reassuring, but still felt very wary and felt that insisting on using condoms and femidoms was still important. As a member of PozFem UK – the National Network of Women Living with HIV commented: ‘I think that after all this time of using condoms … it does give me a degree of tranquillity and ease in my sexuality – I can relax more because I feel protective and protected … If a condom broke I would probably feel a bit easier thinking about the Swiss guidelines.’ Moreover, many women who participated in the feedback sessions on Mexico 2008 run by PW recognised the Swiss statement as beneficial in challenging HIV-related stigma. Women felt a huge sense of relief that the statement could be used to challenge the view of people living with HIV as vectors of infection and potentially dangerous.
Another huge benefit related to the recognition of the decrease in infectiousness in people with an undetectable viral load is that at a policy level it implies the promotion of scaling up of testing and treatment as a form of prevention. This is extremely important especially in the developing world where, according to the latest figures from UNAIDS, only three million people are receiving ARVs of the nine million who need them immediately. However sometimes there can be too much of a good thing and this seems the case with how this policy recommendation has been taken to an extreme by the World Health Organisation (WHO) in a new radical strategy released just a few days before World AIDS Day. The WHO strategy plans to test everybody for HIV every year in hard-hit areas and put those who are positive immediately on treatment regardless whether they need it or not. The rationale behind this extreme plan is based on a mathematical model that calculates that by reducing people infectiousness to very low levels using treatment the proportion of people living with HIV in sub-Saharan Africa could decrease to 1% in less then 50 years. The authors of the paper on which the WHO strategy is based include Kevin de Cock the HIV/AIDS director at the WHO. The paper was published by the authoritative medical journal The Lancet.
Obviously HIV activists and other Human Rights organisations have been highly alarmed by these plans. Marginalised groups like Injecting drug users, sex workers, and migrants are particularly vulnerable to the enforcement of those extreme guidelines, especially around testing. Melissa Hope Ditmore co-ordinator of the Sex Worker Network reports: ‘We are all for expanded access to treatment but I’m really concerned about this. Sex workers in Macedonia and Mongolia have reported forced testing at police stations, which has been described as provider-initiated testing. This is the work of the Global Fund in Mongolia. I don’t know which agencies are behind the forced testing in Macedonia. Forced testing is a human rights violation. If the police are involved, it’s clearly not consensual. We all know that the police are not health care providers. So we as activists need to be vigilant about preventing and protesting forced testing, which has already begun on sex workers.’
The Global Network of People Living with HIV (GNP+) has also raised concerns around possible human rights violation that could be caused by the enforcement of the new WHO strategy. GNP+ press release ‘welcomes the WHO breakthrough in thinking on Treatment as Prevention’ but it also highlights the following concerns:
- HIV testing should never be mandatory
- Treatment commencement must remain the individual choice of the person living with HIV and must consider implications for toxicity and adherence first.
- Feasibility – up to now governments have been unable to live up to their commitment of providing treatment to PLWH who need it to stay alive. How are they going to be able to afford and deliver treatment to all who test positive regardless of CD4 count?
- Criminalisation (sic): current legislation in some cases criminalises the mere exposure to HIV, will increase in testing lead to more criminalisation of PLWH? Increased testing efforts must be balanced with the concerns of PLWH not to be criminalised.
The general consensus among social scientists, activists and Doctors at the Mexico conference last summer was that there is not single ‘technological solution’ to address prevention. What is envisaged is a multi-disciplinary approach to prevention similar to treatment: Combination Prevention. The cocktail of Highly Active HIV Prevention – as it was named by Professor Myron S. Cohen in Mexico – would have as ingredients: 1) Behavioral change – e.g. partner reductions, use of condoms and femidoms, 2) Bio medical Strategies – e.g. microbicides, vaccines. circumcision, 3)Treatment – including ARVS and STI treatment, 4) Social Justice and Human Rights – which of course means challenging stigma and discrimination, addressing socio-economic issues such as poverty, food security, gender-based violence, xenophobia, homophobia and last, but not least, sexism!
In all of this of course the role of governments is paramount. Leadership from the top is needed in scaling up treatment/prevention efforts as well as a push from the bottom and a strong emphasis on Community Involvement, especially our involvement as people living with HIV. It is vital that prevention strategies are designed on the base of strong socio-economic research, not simplistic mathematical models. Everybody in society has a role to play in HIV prevention. As HIV positive men and women we have the knowledge and the experience of what it really means to live with HIV, especially the consequences of stigma and discrimination, which is still what prevents so many of us either to be tested or to access care and support once diagnosed, or disclose our status and negotiating safer sex when entering a relationship. Because of our in depth insights in the psycho-social issues related to HIV it is necessary that we are consulted and fully participate in designing and implementing prevention strategies. It is essential to involve and protect all the groups who are potentially most vulnerable to HIV.
Unfortunately at present the UK prevention strategy doesn’t involve women adequately. Having a gendered approach means taking into account how women are more vulnerable to HIV because of their anatomy as well as gender inequity. This means we need to look at power dynamics between men and women: Do women have power within their relationship to disclose their status and negotiate safe and pleasurable sex? How is women’s power in intimate relationships affected by an HIV diagnosis? What process needs to take place for women to acquire more power within this context? And more importantly in the field of prevention: How can more women have access to power and control in their intimate relationships before becoming infected? I believe many HIV positive women (especially those who had access to good psycho-social support) have gone through the process of addressing those questions themselves in order to deal with their diagnosis and are therefore in a privileged position to lead other women so that they can protect themselves.
It is important to acknowledge also that a gendered approach that really wants to change power dynamics between the sexes successfully can’t just work with women but also needs to involve men. To challenge gender roles men need also to explore ideas of masculinity and how they limit and condition relationships and sex as well as predispose them to risky behaviour.