July 26, 2018
Emily Bass is the Director: Strategy & Content at AVAC.
“Making yourself vulnerable means looking in the mirror,” said David Malebranche in his plenary speech today (July 26) at the International AIDS Conference in Amsterdam. His talk was pure power and poetry, and I (yes, it’s Emily Bass here again) would probably be well-advised to get out of the way and just transcribe it, but instead I’ll urge everyone to view it in its entirety (what do you think comes up with a Google image search for idiot?!) and, in the meantime, look in the funhouse mirror of the conference a bit more.
What do I see when I look at myself? A white, American, feminist, writer, mother and rights-based social justice activist with a passion for queer and women’s issues who has focused her work on HIV in biomedical issues for much of her career. Rights is in that list, but it’s more context than primary subject—until this week, when, as lead rapporteur for Track D, which focuses on human rights, I’ve looked at the conference, combination prevention, and myself differently. (Check out daily summaries here.)
Here’s what I see at the conference: The biomedical prevention field that is one of my professional homes has both an obligation and an opportunity to merge science and rights. So do I. The field, with historic and ongoing acknowledgment of the human rights issues that affect whether a program works or a product gets used, has laid a fair foundation. But in many parts of the world, foundations stay bare for years. Especially if money is lacking. We need to build, together, a deeper, more systematic, detailed and intentionally-designed approach to a hybrid rights-and-science agenda. The anti-HIV criminalization movement says it perfectly: human rights plus science equals HIV justice.
The signpost at this intersection of rights and science? Combination prevention. It’s a destination we haven’t arrived at yet. Not me, not the biomedical prevention field, not the broader AIDS response.
From both the human rights and biomedical perspective, the AIDS response is largely missing the boat on combination prevention, with sloppy definitions, inadequate funding and poor adaptation of evidence. Fortunately, Wednesday’s plenary speaker Nduku Kilonzo, director of Kenya’s National AIDS Control Council, said as much in her tremendous presentation, highlighting a “prevention crisis” and calling for reinvigorating primary HIV prevention and delivering differentiated prevention programs. Peter Piot, another Thursday plenary speaker, said much the same thing, pointing out diminishing prevention funding and that the quality of funding matters as much as the quantity—and dollars dedicated to censorious programs that prevent discussion of comprehensive sexual and reproductive health are not high quality.
Yesterday also brought the release of data from several trials that were, when launched, billed as “combination prevention” trials. The Botswana Combination Prevention Project (BCPP) and the SEARCH study both claimed that moniker—and then defined the approach quite differently, as did PopART (HPTN 071), a study in Zambia and South Africa that has not yet released data. In Hall 12, the largest room in the conference center, BCPP reported a 30 percent incidence reduction in communities where individuals with HIV were initiated on ART compared to those who were treated according to national guidelines. While BCPP included that buzz-phrase “combination prevention” in its name, the other element in the combo package was HIV testing, which is not, in itself a prevention tool, unless all people who receive a test result, positive or negative, also get linked to evidence-based prevention or treatment.
SEARCH went much further, defining its package to include same-day ART, treatment for diabetes and hypertension, and testing for malaria and TB. This trial, which ran in Uganda and Kenya, did not find evidence of greater incidence reduction in those who received the package, though it did see significant reduction in viral load, TB diagnoses, hypertension, knowledge of status and linkage to treatment in the intervention arms compared to the control. Why no incidence reduction? One answer, offered by SEARCH principal investigator Diane Havlir, is that SEARCH had an “active control” arm insofar as all communities had access to ART under government programs, and the control arm also had health fairs at the beginning and end of the three-year trial.
There is much to say about what the studies did and didn’t find—and why. In this particular note, I want to call attention to the results but also to a broader issue, which is that neither defined combination prevention in ways that reflected the evidence available at the time that they were launched. For example, in the context of study countries, they could have but did not include data on the number of infections averted when voluntary medical male circumcision is taken to saturation coverage (80 percent) among target male populations. Data on oral PrEP arrived later in the trial periods; data from the DREAMS Initiative programs on the impact of layered structural interventions for adolescent girls and young women must be integrated in any meaningful examination of combination prevention.
Combination prevention also, per this conference, must address rights infringements. In a powerful, information-packed session (WEPDD01), researchers from Kenya, Canada and Russia described how food insecurity, gentrification and housing insecurity respectively were independently associated with having a detectable viral load (Kenya). The same was noted for lack of access to health services (Canada) and risk of sharing injection equipment or using a syringe after someone else (Russia). Given the emphasis on U=U (undetectable equals untransmittable) as a prevention tool (the co-chairs choice session also saw data showing U=U is true for men who have sex with men!), integration of methadone maintenance treatment, policies and practices supportive of housing and food security and decriminalization of sex work and drug use are all evidence-based components of true combination.
Do these things need to be evaluated in trials? Not necessarily. In pointed remarks from the floor of a session on PEPFAR engagement on different thorny issues, Ambassador-at-Large and PEPFAR head Debbi Birx compared the investment in combination trials with investment in national-level programs taking key interventions to scale. “My opinion on this, not the US government’s, is if I look at what Namibia did, they got the same results as PopART, SEARCH and BCPP—these three studies cost more than all the PHIAs (Population-level HIV Impact Analyses) put together. We have to relook at how we invest and what we invest in.”
To date, the PHIAs have captured a remarkable level of incidence reduction accomplished mainly through scale-up of testing, treatment and achievement of virologic suppression in people living with HIV. That’s significant but not adequate to dropping incidence to the levels that would be classified as epidemic control. What gets us all the way? Scale up at a level not yet attempted, or even funded, of the elements of true combination prevention. And, as David Malebranche told his fellow Black same-gender loving comrades, “Let’s love on ourselves.” He wasn’t talking to me, nor should he have been. But he offered an invitation, as I heard it, to pose these questions: When you look in the mirror do you love what you see? Do you love it if you admit what you don’t know, if you cease to be the expert? Does the definition of combination prevention look different? I know I will be checking myself on these questions more frequently in the months and years to come.