HIV prevention is for life

'Universal access to HIV prevention, treatment and care' has over recent years become a mantra within the AIDS community. It was in Barcelona that the integral connection between treatment and prevention became more widely understood and supported, as people woke up to the fact that it is impossible to have one without the other. In Bangkok, 'microbicides-treatment-vaccines' joint advocacy was unveiled with the catchy title 'MTV'.

But how does the expectation of these new tools fit into the broader panorama of prevention efforts? Has the prospect of new technology distracted us from the urgent need to expand and build HIV prevention as a whole in all its complexity?

This August, UNAIDS published Intensifying HIV Preventiona policy position paper designed to 'energize and mobilize an intensification' of prevention in light of strong progress in the effort to make treatment more affordable and accessible. While it acknowledges that there is still a long way to go on treatment access, the paper draws attention to a widening prevention gap, which, in the view of UNAIDS, poses a 'major threat to the whole AIDS response' [2]. Among the most serious problems identified are cultural resistance to HIV prevention efforts and a lack of commodities and coordination mechanisms.

The Global Campaign for Microbicides was actively involved with many other constituencies and community organisations to try to shape the UNAIDS strategy.

Together with the International HIV/AIDS Alliance, the International Planned Parenthood Federation (IPPF) and the International Harm Reduction Association (IHRA), we co-hosted an international consultation to seek civil society input on the strategy and we participated in an expert group meeting to comment on a draft. Thanks to the concerted efforts over the past year of a wide range of actors, we believe the paper is now an excellent mobilising tool for a renewed focus on prevention with a strong gender and human rights focus.

Before turning to the specific points which the paper raises on new prevention technologies, let's address the central issue of the need to talk about the basics of prevention again.

Why intensify prevention?
Many people could argue with some force that with some 5 million people newly infected in 2004 alone, prevention has failed. At a personal level, each new sero-conversion represents a collective failure to uphold the universal right to health. However, by this same token, every time a clean needle is used or a condom is agreed upon, HIV prevention efforts succeed. It is impossible to know how many times infection has thus been averted.

What epidemiologists and HIV professionals consider a prevention success is when localised epidemics within specific populations are prevented from becoming a generalised HIV epidemic [3]. There are some well–known examples of countries which have achieved this, including Uganda, Thailand, Brazil and many Western European countries. Nonetheless, at a global level, there are more HIV infections each year, and half of these new infections are in young people.

Whether prevention is failing or not, we know that globally, less than one person in five at risk of HIV had access to basic HIV prevention services and only one in ten people living with HIV has even been tested [4]. Specifically, only 10% of men who have sex with men and 5% of injecting drug users have access to prevention tools [5].

Faced with equally desperate treatment and prevention scenarios, priority has been given to date to addressing a shocking level of complacency around the fate of people living with HIV. The treatment access campaign has had to fight tremendously hard to get where we are today. While WHO's 3 by 5 target will by their own admission not be reached, this initiative has ultimately resulted in a huge increase in funding for treatment programmes and has brought the goal of universal treatment access closer than ever before. This battle will have to continue to be fought until everyone who needs treatment has access to it.

With the expanded delivery of ART into resourcepoor settings, what will be the impact on prevention efforts? Dr Salim Abdool Karim, Professor of Clinical Epidemiology at Columbia University and Interim Vice- Chancellor at the University of KwaZulu-Natal, South Africa, points to some key challenges. Biologically, ARV therapy will reduce viral loads, making new infections less likely to happen. Psychologically, the availability of treatment may affect sexual behaviour, either through the false belief that HIV is curable, or by making testing something that seems more worthwhile. At a public health level, treatment expansion and delivery could make a huge difference to health systems and the integration of reproductive health, TB and AIDS care services [6].

We are only at the very beginning of this pandemic. Even by conservative estimates, the numbers of people expected to be in need of treatment in years to come defy the imagination [7]. With fewer AIDS deaths due to treatment, there could be ever–greater numbers of people living with HIV. Dr. Karim, speaking at the IAS Rio Conference in July, warned that prevention needs to expand at the same rate as treatment efforts so that decreases in AIDS deaths are matched by decrease in infections: ”For global control of the HIV epidemic, AIDS treatment must be accompanied by successful prevention.“

The need to take a long-term view
In a special lecture at the Rio Conference, Executive Director of UNAIDS, Dr Peter Piot, expressed his frustration and disappointment that the G8 had not called for universal access to prevention as well as treatment: ”As we take emergency actions…we must also establish systems critical to achieving long-term solutions such as vaccines and microbicides“. Without a long-term horizon, he argued, real success will never be made.

In 'Intensifying HIV Prevention', UNAIDS makes the strongest case yet for increased investment in new prevention options and for measures which address the long-term future of the pandemic. The paper outlines specific 'essential actions' required not only at the policy and programmatic levels, and validates the importance of continued advocacy and activism in this area.

”New technologies, such as HIV preventive vaccines and microbicides, offer hope for sustained control of the HIV epidemic, particularly in the world's most vulnerable and marginalised populations, of which women constitute such large proportions“ [8].

UNAIDS knows that meeting this challenge will require the participation of policy makers in both developed and developing worlds. In the corridors of power, they need to 'generate sufficient support for research and development in ways that promote efficiency and coordination and are based on ethical principles, as well as contributions of intellectual and financial capital by the private sector'. Meanwhile, in developing countries, they need with external support, to 'build capacity for clinical trials, social research, licensing and access' [9].

However, research and development is not sufficient alone. Access will be as much an issue for microbicides and vaccines as it is for treatment, condoms and clean needles.

In the struggles to make these existing resources accessible, we have learned that costs and financing is only half the battle. Without regulatory mechanisms, manufacturing capacity, procurement and delivery systems and networks, new options (whether in terms of treatment or prevention) will simply not reach those most in need. And what about health provider and consumer education to ensure high adoption? As we have seen with the female condom, the importance of this final aspect cannot be overestimated:

'For the distribution of safe and effective microbicides, as one example, we must design and engage in thoughtful preparedness studies, explore ways to use existing delivery or fulfillment systems for consumer products, and plan product attribute studies to determine women's preferences for a variety of products' [10].

In summary, UNAIDS makes the following key recommendations on new prevention options:

• Ensure that sufficient investments are made in the research and development of, and advocacy for, new prevention technologies as an essential policy action.
• Prepare for access and use of vaccines and microbicides as one of twelve essential programmatic actions.
• Build on the vaccine and microbicide campaigns success to create a vocal constituency and leadership on HIV prevention.

The need for a 'Global Campaign for Prevention'!
In recent years the vaccines and microbicides advocacy communities have demonstrated considerable success in putting new prevention options onto the agenda. At the UNAIDS civil society consultation in Brighton, however, the absence of a unified HIV prevention campaign was noted as one of the main problems facing the field. Instead of one movement, there are many actors, each calling for attention to a specific area.

In recognition of this, the UNAIDS paper calls for a campaign on the need for HIV prevention that is comparable to the huge mobilisation by the treatment access campaigns across the globe. It urges that 'a vocal constituency for HIV prevention needs to be developed, building on current HIV vaccines and microbicides activism' [11].

UNAIDS recognises that civil society advocacy 'provides one of the most important ways of overcoming unwillingness to act promptly on AIDS, whether it be at the individual level or societal'. Perhaps we need to realise that only a campaign by civil society that matches the dynamism and passion of the treatment access campaign can compel the G8 and the international community as a whole to respond. UNAIDS calls for this new movement to engage with networks of young people and of women in particular and for steps to be taken at the national level to resource this advocacy.

What does this mean for treatment activism? UNAIDS wants to promote the idea that a window of opportunity now exists for treatment activists and prevention mainstayers to come together, pointing out that in many cases, the organizations and individuals may be the same, and already providing articulate advocacy leadership platforms [12]. Recognising the strengths already present in the treatment access movement, their knowledge and their expertise are seen as setting a vital precedent –in the words of the report, 'the experiences of the treatment activism and advocacy need to be learned from' [13].

Why do we have to choose between prevention and treatment?
For too long, people were allowed to argue against universal access to treatment on the basis that it was too difficult. The proverb 'prevention is better than cure' and the slogan 'prevention must be the mainstay of the response' salved the consciences of decision-makers. Thanks to sustained and passionate campaigning, the case for universal treatment is no longer dismissed as a pipe-dream.

However, we have to ask ourselves, do we want a world in which HIV is allowed to take the upper hand? Do we tell ourselves that prevention is 'too difficult' and allow millions of people to enter a lottery for treatment access? We already know that women and young people, as well as stigmatised and vulnerable populations, will be least likely to hit the jackpot.

'Sustained progress in the response against AIDS will only be attained by intensifying HIV prevention and treatment simultaneously' [14].

The costs will not be insubstantial. UNAIDS recognises that its recommendations and in particular, those relating to the long-term, have 'major implications for national governments and donors'. The estimated amount required to implement a comprehensive HIV prevention package is $4.2 billion each year. However, it has been estimated that this same package could prevent 63% of the 45 million new infections expected 2010. The costs will only increase for every year that action is delayed [15].

What is now emerging is a growing call to not only defend existing prevention tools such as needle exchange and condoms from complacency or even attack, but also to scale-up the access to these tools to address the prevention gap, and importantly, to at the same time expand the range of prevention options available to people. UNAIDS reminds us that to be successful, HIV prevention must utilize 'all approaches known to be effective, not implementing exclusively one or a few select actions in isolation' [16]. This is not only a repudiation of abstinence-only programming. It also refers to the need for a variety of new prevention tools including microbicides, PREP, vaccines and continued research to expand and improve what we already have. As UNAIDS states, there are no easy solutions or ”quick fixes“. Only by broadening, lengthening, deepening, strengthening and integrating the response, will our HIV prevention efforts succeed.

UNAIDS' policy position paper Intensifying HIV Prevention is available online at:

http://www.unaids.org/html/pub/governance/pcb04/pcb _17_05_03_en_pdf.pdf

The Global Campaign for Microbicides is an international coalition of civil society organisations working to accelerate access to microbicides. Membership is open to all who endorse our goals.

For more information, please contact:
Rebekah Webb
European Coordinator
Global Campaign for Microbicides
Rue du Trône 98
Brussels 1000
Tel: +32 (0) 2507 1221
rwebb@global-campaign.org
www.global-campaign.org

Rebekah Webb, European Coordinator, Global Campaign for Microbicides

References

1 Intensifying HIV Prevention, UNAIDS Policy Position Paper, UNAIDS, 2005, page 13.

2 Ibid, page 9.

3 For definitions of epidemic states, see page 14 of the UNAIDS report.

4 'Access to HIV Prevention: Closing the Gap', Global HIV Prevention Working Group, 2003

5 Dr Peter Piot, closing speech in Rio, July 2005.

6 To view Dr. Karim's presentation in Rio see

www.ias-2005.org/planner/ProgrammeAtAGlance.aspx?SessionID=49

7 Barnett and Whiteside 'AIDS in the Twenty-First Century: Disease and Globalisation', Basingstoke, Palgrave, 2002.

8 'Intensifying HIV Prevention', UNAIDS Policy Position Paper, UNAIDS, 2005, page 21.

9 Ibid, page 21.

10 Ibid, page 25.

11 Ibid, page 30.

12 Ibid, page 30.

13 Ibid, page 30.

14 Ibid, page 10.

15 Ibid, page 8.

16 Ibid, page 15.

EATN - European AIDS Treatment News, Volume 14, II – Autumn 2005

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