I want to make this clear. I am completely in support of early testing and universal access to ARVs. However I am pretty doubtful that the ‘Test and Treat’ approach can work in the real world as an effective prevention strategy.
Untangling what works in prevention is not an easy task, and this is probably why the HIV epidemic hasn’t been halted yet. One of the most interesting approaches to prevention is the concept of ‘Combination Prevention’. This has been around for the past few years and was prominent at the last International AIDS Conference Vienna 2010.
As we know, HIV is a complex virus that can not be stopped by one single drug once it is in our bodies. This is why a combination of 3 or more drugs, is used to attack it from different angles. Likely, the use of several strategies to prevent the virus to even enter the body is seen as ‘Highly Active Prevention’ or ‘Combination Prevention’.
As in HIV treatment there are many classes of drugs, so there are different components of Combination Prevention.
Behavioural : start using condoms and femidoms, delaying starting having sex, choosing partners who have your same HIV status (sero-sorting), having not penetrative sex, using clean injecting equipment etc. .
Bio-medical Interventions: access to ARVs for PLHIV, ARVs used as a Pre Exposure Protection ( PreP) or Post Exposure Profilaxis (PEP), Microbicides (when we will have them!), Male Circumcision etc
Structural : availability of harm reduction for drug users, gender violence, gender inequity, poverty, homophobia, racism, HIV stigma etc
Those ‘ingredients’ need ‘boosters’, like some HIV drugs, to make things happen:
Political will: the support of political leaders, governments, multilateral agencies.
Economic investment: Money is needed to carry out research, as well as for delivery of all prevention aspects. Obviously AIDS funding is an increasing struggle in the present economic climate.
Community Engagement: People who are infected or at risk of becoming infected need to be involved at all the stages of prevention planning and implementation .
One of the prevention success stories presented at Vienna 2010 was the evidence from the World Bank that cash transfers to young women in Malawi and Tanzania were associated with lowering HIV infections among those adolescents. This clearly shows the links of between a Structural element (poverty/ access to cash) and Individual behaviour (not using sex in exchange of money/school fees or other benefits) and how they can result in preventing HIV infection.
One of the of the major challenges of Combination Prevention is the need of more evidence and of clear evaluation processes . It is very difficult to understand what is working in the short or long-term and how the different elements interact and influence each other. Social scientists are looking now at developing a Combination Evaluation!
7000 people are infected with HIV everyday. Complacency in not an option in prevention. UNAIDS has called for a Prevention Revolution. Here is the video launching the campaign: