Leading experts on building an AIDS-free generation

By Jennifer Brookland

August 1, 2013

Photos by: Creative Associates International

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Charito Kruvant, President and CEO of Creative Associates International, called on participants at “Building an AIDS-Free Generation: Science, Care & More” to “ask the hardest questions you can possibly ask” about what works in HIV programming.

On the five-year anniversary of the President’s Emergency Plan for AIDS Relief reauthorization, some of the foremost experts in HIV-focused programming say the science is there, but building an AIDS-free generation will require more than biomedical interventions.

“We need to integrate science and social services so we can talk to one another and resolve complex problems,” said Charito Kruvant, President and CEO of Creative Associates International, which organized the July 30 event in Washington, D.C.

“Ask the hardest questions you can possibly ask,” Kruvant encouraged the 90-plus attendees. “We need to sort out what works and what doesn’t.”

Experts spoke directly to that question during the conference, entitled “Building an AIDS-Free Generation: Science, Care & More.”

David Wilson, the Global HIV/AIDS program Director for the World Bank, said three types of interventions have proven effective from among more than 40 randomized control trials.

“When we’re looking at proven approaches, we really look at male circumcision, treatment based prevention and maybe, just maybe, some financial incentives,” he says.

Recent World Bank work on financial incentives like cash transfers reduced the transmission of sexually transmitted infections and HIV. In Malawi, for example, girls who were offered up to $15 per month to stay in school had 60 percent lower HIV prevalence, whether they stayed in school or not.

“Young African females don’t have access to good jobs and opportunities and they rely on men and therefore don’t have the power to negotiate safer sex,” said Dr. Nomonde Xundu, Health Attaché for the South African mission to the United States and co-author of her country’s 2007-2011 National HIV and AIDS and STI Strategic Plan. “Incentives will give them more power to make better decisions.”

Almost one-third of black African females aged 20 to 34 in South Africa are HIV positive, according to a 2012 national household survey.

“If financial incentives prove to be effective at both empowering women and reducing the rate of transmission, there is no reason policy cannot be crafted around it,” said Dr. Xundu.

That proof, for some, is the sticking point.

Wilson emphasized that in order for any prevention to be effective, it has to be based on evidence.

U.S. Agency for International Development’s Kendra Phillips seemed to agree.

“When you don’t have data, you can’t advocate for the issues or make the case for the resources,” said Phillips, Chief of the Implementation Support Division in the Bureau for Global Health, Office of HIV/AIDS.

Better data can lead to more effective prevention and treatment models. Sex workers, men who have sex with men and intravenous drug users are commonly recognized as vulnerable groups whose practices need to be better documented and who need more targeted programming and resources from national governments.

Other populations cry out for focused attention as well. Youths make up 40 percent of new infections worldwide, pointed out Gillian Dolce, Project Coordinator for the Global Youth Coalition on HIV/AIDS, a project of the Public Health Institute.

Women in low-resource settings might put a special premium on new technologies, medicines or devices that effectively prevent against at least two things, such as pregnancy and HIV, according to Joe Romano, Senior Consultant to the Coalition Advancing Multipurpose Innovations.

Treatment just a piece of prevention

Even presenters who emphasized advances in biomedical prevention and treatment methods seemed to concur that no matter how targeted or how well funded, these programs are unlikely to succeed in isolation.

Kenya, for example, is the largest global recipient of PEPFAR and capable of mounting complex health programs. Yet after five years, according to Wilson, retention in care of those on antiretroviral treatment there is below 60 percent.

Despite what Wilson deemed the “herculean effort” of PEPFAR, much more needs to be done to ensure that treatment results in viral suppression, a prerequisite to halting HIV transmission.

Dr. Charles van der Horst, Professor of Medicine and Infectious Diseases at the University of North Carolina-Chapel Hill, who helped establish Malawi’s prevention of mother-to-child transmission program, said medical interventions need to be supported with programs promoting human rights and health equity, and local capacity-building.

Other presenters were even more adamant that prevention and care must not focus solely on biomedical approaches.
“Behavioral and social strategies are necessary but not sufficient for HIV prevention and treatment,” said Tom Coates, Professor at the Geffen School of Medicine at the University of California-Los Angeles. “The same is true of biomedical strategies.”

Instead, Coates suggests, highly effective prevention is at the intersection of behavioral change, treatment, biomedical strategies, and social justice and human rights—all bolstered by community involvement and leadership.

Beyond medicine, an unclear path

The medical interventions are, by now, well known: get infected people on treatment immediately, reduce their viral load, conduct male circumcision, et cetera.

“But the behavioral agenda is much more murky,” said Coates.

For starters, whose behavior is the most important? The historic focus on treating or caring for the individual fails to account for all the other factors that influence adherence and retention.

“We need effective patient-centered services, community support systems, effective counseling, and strategies for monitoring output and using it to maintain quantity and quality,” Coates said. “These are the behaviors we need to focus on.”

In Zambia, for instance, Population Council senior associate Paul Hewett and partners are helping take the proven technology of male circumcision to a national scale.

He found that the behavioral dimensions of scaling up voluntary circumcision extend far beyond the individuals who showed up to have the procedure.

Problems with the system and service quality were just as influential, from how long the men had to wait to glitches in which days the procedure was offered.

The men’s social networks were also important for interpreting the message about circumcision and weighing secondary benefits like sexual appeal and performance.

“What they’re telling their friends and family really makes a difference in terms of driving demand,” said Hewett.

Information and awareness is always hard to study and quantify, yet it could be what makes a difference in a population at risk of continued HIV prevalence.

“Community education and mobilization are fundamental,” said Creative’s Senior Associate for Health Mary Lyn Field-Nguer. “We know that a community where stigma is rampant, HIV transmission knowledge is lacking, and families continue to blame women for ‘bringing the virus home’ is not a community that is safe from new HIV infections.”

She said putting energy and resources into community education has obvious and important value—even if its effectiveness can’t always be evaluated with something like a clinical trial.

Dr. Xundu told how the South African government realized it had to work with traditional communities to explain the difference between medical and ceremonial male circumcision. It had to provide reassurance that customary practices would still be respected.

Offering the procedure alone would not have resulted in successful prevention in these groups.

Her example shows the importance of more connected interventions that can adjust for the behaviors of individuals, communities, and institutions all.

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