Truvada as PrEP: A new HIV prevention option on the table for Zimbabwe?

Zimbabwean advocate Paul Sixpence’s opinion piece, Truvada as PrEP: A new HIV prevention option on the table for Zimbabwe? was published in The Zimbabwe Chronicle. Given scientific evidence that PrEP works, he calls for PrEP rollout for young women, sex workers and serodiscordant couples in Zimbabwe. Paul’s work centers on the use of media as an advocacy tool to push for policy support around new HIV prevention science.

Recent policy pronouncements by the World Health Organisation (WHO) recommending national public health systems to incorporate Truvada as Pre-Exposure Prophylaxis (PrEP) into their prevention interventions present a new revolution in the fight against new HIV infections. The WHO guidelines came on the background of overwhelming science that proves that Truvada as PrEP works when taken correctly as presented at two major global HIV and AIDS conferences namely the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) and the International AIDS Society (IAS) 2015.

In light of scientific evidence that proves that PrEP works and considering the burden of HIV and AIDS to Zimbabwe’s socio-economic development, this instalment advocates for PrEP roll-out for young women, sex workers and sero-discordant couples in Zimbabwe.

What is PrEP?

Pre-exposure prophylaxis is the use of antiretroviral medications (ARVs) to reduce the risk of HIV infection in people who are HIV negative. Truvada is an ARV that has been approved in Zimbabwe for treatment purposes. In a nutshell, PrEP is the taking of preventive drugs to prevent primary infection prior to engaging in a potential risky sexual encounter that can possible expose one to HIV infection. In other words, it is akin to taking anti-malaria tablets prior to getting into a malaria zone.

Evidence that proves that PrEP works

This article is based on the TDF2 and Partners PrEP clinical trials. TDF2 was conducted in Botswana among young heterosexual couples and Partners PrEP was conducted among sero-discordant couples in Kenya and Uganda. Both clinical trials exhibited efficacy rates of over 80 percent.

PrEP efficacy and feasibility case studies presented in this piece have been deliberately chosen because they were conducted in Africa and in resource constrained settings relatively similar to those obtaining in Zimbabwe. There are other clinical trials that have been conducted in France, Britain, Brazil and the United States of America, among diverse sets of population and they all indicate that PrEP works.

Taking note of all these positive and inspiring findings in the field of HIV biomedical interventions, the president of the International AIDS Society and Chair of IAS 2015, Chris Beyrer had this to say:

“The science on PrEP is overwhelming and its conclusions are clear: PrEP works when taken. Access to PrEP is now a public health and human rights imperative. The studies presented here [at IAS 2015] provide the most detailed data to date on PrEP implementation successes and challenges, underscoring that the intervention is feasible and effective in the real world. We hope these studies launch the beginning of a new PrEP era.”

Current global trends in adopting PrEP

PrEP was licensed for treatment purposes in the United States of America in July 2012. Applications for regulatory approval have been filed in Australia, Brazil, Canada, South Africa and Thailand.

Is PrEP for Zimbabwe?

PrEP is not for everyone but for specific populations at high risk of infection. Among those who are in need of PrEP in Zimbabwe are key populations, namely, young women, sero-discordant couples and sex workers.

Presenting oral evidence to the Parliament of Zimbabwe Thematic Committee on HIV and AIDS in July 2015, National AIDS Council (Nac) Chief Operations Officer, told the Committee that his organisation was worried about the increasing rates of new infections among girls and young women between the ages of 15 and 24 years.

He noted that about 80,000 young girls and women were living with HIV as compared to 36,000 of their male counterparts. These statistics speak of an urgent need to offer young women with a wide range of HIV prevention options.

According to the Centre for Sexual Health and HIV/ AIDS Research (Ceshhar) out of 52,214 sex workers almost 11,000 (20 percent) are living with HIV. These figures speak of an urgent need to provide sex workers with new and effective solutions in preventing primary HIV infection in addition to messages on correct and consistent use of condoms and behaviour change.

The way forward

There is an urgent need for collaborative engagement between policy makers in relevant State institutions, HIV and AIDS researchers and civil society actors to analyse the science that proves that PrEP works with the local context in mind, work on regulatory approval, develop guidelines and roll-out PrEP to those at high risk of HIV infection and who need it.

From November 29 to December 4, 2015, Zimbabwe will host the International Conference on AIDS and STIs in Africa (ICASA).

In light of the encouraging PrEP efficacy and feasibility results, ICASA 2015, should serve as a marketplace of ideas and exchange of knowledge on how to mobilise resources for PrEP roll-out, enhancing the capacity of public health systems to integrate PrEP into their existing comprehensive HIV treatment and prevention packages and ways of raising awareness among people of the existence of this new HIV prevention option.

Paul Sixpence is an HIV prevention and treatment advocate and 2015 AVAC fellow. He can be contacted at: [email protected].

Clearinghouse Quarterly Research Digest

The Clearinghouse on Male Circumcision has announced a new feature to their site – Clearinghouse’s Quarterly Research Digest. The digest provides links to full text of articles that are open access. The Clearinghouse is a global resource center designed to expand access to information and resources on voluntary medical male circumcision for HIV prevention. It is a collaboration between FHI 360, WHO, UNAIDS and AVAC. Details on this digest are available in the Clearinghouse’s announcement at this link, and you may click here to sign up for periodic updates from the Clearinghouse.

Pre-exposure Prophylaxis in Kenya, Can it be Real?

Kenyan advocate Carolyn Njoroge published an opinion piece, Pre-exposure Prophylaxis in Kenya, Can it be Real?, calling for immediate action on PrEP as an HIV prevention option for individuals at high risk of HIV infection. An openly HIV positive activist and sex worker herself, Carolyn lauds the Kenyan government for including PrEP in its roadmap to an HIV-free Kenya by 2030 but challenges them, and other governments, to talk less and act more.

This is a timely piece given that just last week, on September 30, WHO issued an “Early Release Guideline” on when to start antiretroviral therapy and on pre-exposure prophylaxis (PrEP) for HIV. Carolyn is a 2015 AVAC Fellow advocating for the roll out of PrEP that would empower and protect sex workers, and other key populations. She is hosted by the Kenya Sex Worker Alliance (KESWA). Read more about her advocacy activities here.

Interview with an Advocate: Fearless leader of Uganda’s Voluntary Medical Male Circumcision (VMMC) Program speaks of momentum, motivation and maintaining success

Uganda has made tremendous progress in its VMMC (also known as Safe Male Circumcision or SMC in Uganda) scale-up over the past two years, with over 1.7 million men were circumcised in 2013 and 2014 alone. A cumulative total of 2.1 million circumcisions have been done in Uganda since 2008 according to WHO’s recent Progress Brief. As Coordinator of the National Safe Male Circumcision, Dr. Barbara Nanteza has led the Uganda program during this critical period of scale-up. Dr. Nanteza talked to the coordinators of the VMMC Truth-tellers Initiative about leadership, collaboration with the Ministry of Health and implementing partners, the unmet need for sustainable funding, best practices and loving her work.

Truth-tellers (TT): What is your role as the head of the National Safe Male Circumcision (SMC) program in Uganda?

Dr. Barbara Nanteza (BN): My roles are really many and broad. I’m responsible for management of the program – in other words providing coordination, leadership, and ensuring that the program has the infrastructure, logistics and supplies to keep it running smoothly. I’m also responsible for maintaining standards of the program on a range of issues including policy, capacity building, training, supervision and quality improvement. As head of the program, I also mobilize resources and lead its strategic planning.

TT: What was the program’s biggest challenge when you took over in 2012, and what’s the biggest challenge today?

BN: Much as Uganda spearheaded the clinical trials in 2005, the country didn’t take on safe male circumcision immediately. It wasn’t until 2010 that some SMC work started. The US President’s Emergency Plan for AIDS Relief (PEPFAR) had already started funding the program directly through the implementing partners (IPs), but the entire management system was down. It took a lot of courage and effort to streamline both management and maintaining the standards given that IPs had been given a lot of money by PEPFAR. It’s rather ironic that our biggest challenge today is funding.

Unfortunately, the funding challenges are coming at the back of three years of our biggest scale-up. Demand for SMC services is very high at the moment. Last year our target was one million circumcised, but we had funding for 750,000. We ended the year with 878,109 males circumcised. Our target for 2015 is still one million, but I have funding for only 330,000 procedures. That’s a huge funding gap, which without a doubt, will slow down the program.

TT: Some issues came up around tetanus and SMC in Uganda last year; can you tell me about them? [Editor’s note: In 2014, nine cases of tetanus were reported across multiple country national VMMC programs—six resulted in death. Consequently, WHO and partners assessed tetanus risk associated with VMMC and different circumcision methods. To minimize tetanus risk, WHO now advises a dual approach of clean care (emphasis on clean wound care and standard surgical protocols for sterility) and tetanus vaccine interventions. For more information go to WHO Informal Consultation on Tetanus and VMMC.]


BN: In 2014, we faced another unforeseen challenge – tetanus. There were reported cases of tetanus among five males [in Uganda] who had undergone circumcision [with either surgical or device methods]. The reality is that the SMC program helped Uganda realize that as a country we have high background tetanus. The SMC program should be strengthened to help save many Ugandans from this immunizable disease. Through the SMC program we can reach many Ugandans, both men and women. If funds are available, we can make the SMC program become proud of vaccinating Ugandans against tetanus, which has a mortality of more than 56 percent.

TT: The program has made tremendous progress since you took over—from about 80,000 circumcisions in 2011 to a cumulative total of 2.1 million by 2014—about 80 per cent of which were accomplished in 2013–14. What are your plans to maintain this pace of scale-up or even surpass it?


BN: I attribute the achievements to hard work and focus. A few individuals and institutions stand out – including those at PEPFAR, the Ministry of Health (MoH), the AIDS Control Program, the National SMC task force, the implementing partners and many others.

The plan to maintain this scale-up is very simple—we need stable funding. We have proven that we have the desire and ability to get the results. We can even surpass the targets if every stakeholder can play their role.

TT: How did your approach change from when you first took over the program?


BN: Management has been very instrumental to this. I made sure that all IPs operated under MoH guidance. This was very difficult in the beginning but with time most IPs have realized that they offer services to Ugandans and it’s MoH that is answerable to their health.

My approach is straight and candid. I never want anyone to use me as an excuse for his/her failure. I focus on the ultimate goal of averting HIV infections through the SMC program.

TT: If another program manager in another country wanted to achieve what you’re achieving in Uganda, what would you advise he/she to do?


BN: I have always wanted to share Uganda’s best practices but have never had an opportunity. Though I can talk till the cows come home, I’ll give a few pieces of advice:

  • Love your work: We should love our work even in the absence of money. Since childhood I have liked to make a difference in another person’s life so when I was given this job (initially I started as a volunteer) I was very happy. Today, my accomplishments speak volumes. I know my daughter will be happy to know that I did something for my country when the opportunity came.
  • Be in control: MoH leadership is key. Through my years at the MoH, it has been tough simply because it’s the IPs with the money. This puts MoH officers in a very tricky situation. But when you know your role, everything else doesn’t count. I have been able to tell IPs to follow MoH even though they have lots of money. Those who didn’t follow can tell you that I have had to communicate to them in a way many have not liked, but in the end, I’m sure the IPs are also enjoying our success.
  • Data: All mangers should ensure that they have and control data for their programs. That way they are able to analyze and make informed decisions to improve their programs.
  • Research: Nothing beats scientific evidence. I really like to do research or implementation science. This improves programs and helps formulate better policies.
  • Results dissemination: I always want to share what I do with others such that we can learn from each other. This can be through meetings, workshops, and conferences, though as MoH we always have limited resources to do all this.

TT: You’re a vocal advocate for the program yourself, what’s your message to your own government? And funders? And other advocates like you?


BN: First, I would like to thank the government for the support and guidance they offer to the program though I am requesting that they allocate more funds to the SMC program since it’s an important piece of combination prevention.

To the funders – if they want value for their money, I can assure them that Uganda is currently the country that can give the much-needed results in a very short time. My only caution though would be for them to respect the MoH, and let the MoH take leadership.

To my fellow advocates – they should keep the fire burning. Despite the challenges we face, no condition is permanent and all good things are worth fighting for. Every infection is worth our sweat!

Groundbreaking New WHO Guidelines on ART and PrEP

UPDATE: Slides and audio from the webinar mentioned below are now available. Click here.

WHO today issued an “Early Release Guideline” on when to start antiretroviral therapy and on pre-exposure prophylaxis (PrEP) for HIV. This document recommends 1) initiation of ART in adults living with HIV, regardless of CD4 cell count, and 2) offer of PrEP as a prevention option to all people at substantial risk of acquiring HIV. (The release is “early” relative to a comprehensive update of its consolidated ARV guidelines, slated to come out at the end of the year.)

If implemented, these sweeping recommendations have the potential to change the world by simplifying ART for people living with HIV and revolutionizing prevention for people at risk. So it is, first, a moment for some celebration. At AVAC, we can’t think of another time in the history of the epidemic when there has been a simultaneous game-changing shift on two fronts—prevention and treatment. Of course, the boundaries are blurred—effective ART in people living with HIV also reduces the chances that they will pass on the virus, so it is a prevention innovation, too. Now the real work begins: figuring out how to bring the blurred boundaries into sharp clarity in comprehensive national plans and global strategies.

As we celebrate, we also note the great work that lies ahead to ensure that these guidelines are turned into practice. There are funding and logistics hurdles, and there are also major information gaps. PrEP-awareness is growing, but there are still plenty of questions—see below for links to some key resources. And ART “on demand” is a wholly new concept in many parts of the world where people were told to wait until they were sick or approaching low CD4 cell counts to begin.

The work of answering these questions with smart implementation, rapid data collection and analysis, and expanded funding for civil society-led service delivery and advocacy is great work indeed. And we can’t wait to get started!

To get the conversation going, here are a few key points from an initial read of the document, as well as some additional background resources related to daily oral PrEP and the new guideline.

In addition, join advocates on a global webinar with representatives from WHO to hear more and ask questions on Monday, October 5:

Guidelines overall:

  • The document lays out four principles that should underpin implementation efforts. One that civil society will need to ensure is enacted is: “Implementation of the guideline needs to be accompanied by efforts to promote and protect the human rights of people in need of HIV services, including by ensuring informed consent, preventing stigma and discrimination in the provision of services and promoting gender equity.” (Click here for more on the barriers and facilitators to women’s access to ART.)

Immediate initiation of ART:

  • The guideline calculates that, if implemented, immediate initiation of ART would increase the number of people living with HIV eligible for treatment by up to 35 percent.
  • Throughout the discussion of on-demand ART—which is broken down by age groups, but not disaggregated by gender or other identity—there is recognition of knowledge gaps in how to deliver ART on demand. The guideline refers to qualitative research with people living with HIV and a literature review highlighting messages about how early ART can reduce mortality risk, compared to waiting until CD4 thresholds from former guidance.
  • The guideline contains a bit of a mixed message regarding CD4 cell count versus viral load. Noting that “it may be reasonable to reduce or stop CD4,” the document also says that CD4 has an important role to play in many contexts.

PrEP:

  • The recommendation of PrEP for all people at substantial risk expands prior WHO guidance focusing on men who have sex with men and serodiscordant couples. Importantly, it vastly expands the likelihood that oral PrEP will be offered to adolescents and young women. As it is the first intervention that women can use discretely—not at the time of sex—this is a potentially profound development, and one that can lay the groundwork for other tools in the pipeline, such as the vaginal dapivirine ring, which is in trials, with data expected in early 2016.
  • But what does substantial risk mean? Well, WHO will tell you—it means living in a context or community where the background incidence (number of new cases of HIV per year) is 3 percent. This doesn’t mean the overall incidence in your country has to be 3 percent—but that this is the estimated or documented rate in a context like serodiscordant couple-hood, being a man who has sex with men, a person in prison, a sex worker, an adolescent girl. The reason it’s phrased this way, WHO says, is to allow offer of PrEP “based on individual assessment, versus risk group.” WHO also notes that there are times when PrEP should be offered at a lower incidence, too.

Some more resources:

TB and HIV Join Together for Combined Community Engagement Forum

Stacey Hannah and Jessica Handibode are AVAC staff members.

We sang. We danced. We shared our experiences, and we learned from each other. Most importantly, we strategized as equals about how to promote the work of community engagement in clinical trials. And for the first time, engagement implementers from both TB and HIV research fields convened in one room, in one workshop, to address tactically the strengths and weaknesses of participatory practice.

The Combined Community Engagement Forum, the first forum of its kind, took place September 27-29 in Johannesburg as a joint effort between AVAC, IAVI and TB Alliance. This was not your average community engagers’ workshop. It was a venue to learn new tactics across fields, to openly voice challenges and for the group of over 80 to plan next steps for making engagement work more robust, including efforts like publication and monitoring and evaluation. Kagisho Baepanye of the Aurum Institute in South Africa said, “This year’s forum took stakeholder engagement to another level and pushed community educators to think deeper and step up to be counted.”

More and more, there is agreement that stakeholder engagement is critical to the clinical trials process. It doesn’t, however, get the recognition or support it needs, nor has it necessarily produced strong evidence of impact on research or communities. By collaborating across fields, across sites, across research networks and with advocacy organizations, the Combined Community Engagement Forum served as a step forward in building a stronger, more strategic and more clearly understood community of participatory and stakeholder engagement practice.

To learn more and to get linked into the virtual Stakeholder Engagement Community of Practice, please email [email protected].

Health Journalists Link Up with Scientists at Science Cafés

In Health Journalists link up with Scientists at Science Cafés, Ugandan freelance science journalist and trainer, Esther Nakkazi, reflects on her experience of executing “media science cafés” – a innovative project aimed at bringing science closer to journalists, and journalists closer to scientists and other key stakeholders involved in health and health research, advocacy and delivery, such as government officials, civil society, program implementers and others. Esther’s organization, Health Journalists Network in Uganda (HEJNU) is implementing this project in collaboration with AVAC. AVAC is partnering with partners in Zambia and Zimbabwe on similar projects. In her piece, Esther reflects on what this project is, their “wins and whines”, and provides insights of some of the benefactors of this project.

Once every month, health journalists in Uganda attend a Science Café. It is usually held on a Wednesday from 3-5 pm, a day and time largely selected by them.

The Health Journalists Network in Uganda (HEJNU), an independent, non-profit organization dedicated to increasing understanding of health care issues and improving health literacy among Africans organises the Science Cafés in partnership with AVAC, a global non-profit organisation that works to accelerate the ethical development and global delivery of HIV prevention options.

Generally, Science Cafés present a platform for unique public engagement on issues that may be rather isolated from the general public including journalists.

“This is a very impressive innovation and it is good to know that journalists are interested in what is going on in research,” said Francis Kiweewa, the head of research and scientific affairs, Makerere University Walter Reed Project (MUWRP).

Kiweewa was the scientist featured at the fifth Science Café that discussed HIV ‘Cure’ at the HEJNU home in Ntinda alongside journalist Hilary Bainemigisha, the editor at the leading daily newspaper The New Vision.

“The science cafe concept is spot on in the way it mobilises science writers, keeps us in touch with each other as we share updates for our improvement of skills in writing science,” said Bainemigisha.

We hold them in an informal setting and keep the numbers small ranging from 20 to 25 people, which allows for more in-depth interaction and absorption of the topics discussed, said freelance science journalist and the head of HEJNU, Esther Nakkazi.

“I was very free wearing sneakers. I liked the free environment, any body can shoot any question any time,” said Dr. Salim Wakabi a senior researcher at MUWRP who was featured at the fourth Science Café that discussed vaccines.

“Chances of impact are greater when people see their opinions and participation being valued during the sessions. We believe the speakers divulge more in-depth information and thorough explanations because of the small groups and in such a setting,” said Nakkazi.

On a typical day, at the monthly HEJNU Science Cafés, two young journalists employed at media houses elsewhere come over and clean the chairs, set up tents and make sure drinks and stationery are available. They are also responsible for mobilising the journalists.

That makes the Cafés extremely cheap since there is no money spent on the venue in a posh hotel or building. But that also means that the rain can stop a Café from happening but so far that has not happened, said Nakkazi.



Dr. Barbra Marjorie Nanteza and Marion Natukunda at a Café.

Wilfred Ssenyange, working with the national broadcaster, Uganda Broadcasting Service (UBC) makes sure genuine journalists are invited and they have to confirm attendance with him.

He said he knows that the numbers have to be kept small and so warns them not to come along with friends who have not been invited, a practice that is so common among Ugandan journalists.

Jael Namiganda, a journalist with Metro FM, ensures that the journalists register and that they are comfortable. But also follows up on the stories produced.

She says its good training for her and hopes to become a prominent science journalist. The two only graduated in 2014 and they are referred as ‘HEJNU interns’ which they protest.

“To measure the impact, we provide a detailed report to our sponsors from the sessions,” said Evelyn Lirri, a journalist and the deputy at HEJNU who writes out the reports. These entail the discussions and the stories that are published out of the Science Cafés.

“We love that the journalists can write stories from the Science Café but we do emphasise that we are more interested in them learning. So actually, when you observe, most of them are listening to the speakers instead of the rush mood when they have to produce a story,” said Lirri.

At the Science Café there are usually two speakers either a researcher or scientist, and someone from civil society. Discussions are fluid and interactive through how the speaker engages with the audience in a casual manner.

Angelo Kaggwa-Katumba, a program manager at the AVAC office based in New York helps with choosing the topics and invitations for speakers.

“It has been excellent,” said Kenneth Mwehonge from HEPS Uganda, civil society organisation. “Sharing information on on-going biomedical HIV prevention research with journalists is integral in having a successful role out of new prevention technologies.”

Nakkazi explained that so far, the Science Cafés are only about HIV prevention but they will soon expand to other areas and cover a bigger geographical area beyond Kampala so that other journalists benefit.

She said these offer journalists an opportunity where many would never otherwise interact with some of the guest speakers on such an informal yet personal level as well as generate story ideas, critique work and engage in thought provoking debate.

“The informal setting of the Science Cafés works well because it reduces the distance between the speakers and the journalists. This particular setting makes it easier to freely ask questions and have a discussion,” said Rosanne Anholt a research intern at Athena Institute and HEJNU for a Masters in International Public Health, VU University Amsterdam, the Netherlands.

When Dr. Barbara Marjorie Nanteza the National Safe Male Circumcision (SMC) Coordinator at the AIDS Control Program, Ministry of Health, Uganda was invited to speak to journalists at the 3rd Science Café on Safe Male Circumcision, she first expressed how she was not happy about the media reporting on the topic.

But after the Science Café and the media coverage that followed from it, she sent the HEJNU secretariat a message saying she had heard on radio what the journalists had aired and it was good.

“I would like to thank you for the chance you offered me to talk to the journalists about SMC programme in Uganda. I am really happy about the media awareness by the respective journalists… and if they ever want to hear from me again, just let me know in advance, said Dr. Nanteza.

“Over time, the quality of questions at the Science Café, the sharing of story ideas, peer criticism and final output in the different media houses is improving,” Bainemigisha who edits the Saturday New Vision paper observed. “Writers now have easier access to sources they have met at cafes which eases work.”

Although it is a good innovation it still needs some improvement. For instance, Anholt thought that for two Science Cafés she attended (on male circumcision and HIV vaccine research), the way the topics were discussed remained very (bio) medical without adding a social aspect.

“By social aspects I mean, what are the social issues around male circumcision? Are there any cultural practices or beliefs that interfere with circumcision campaigns? Are there any misconceptions that need addressing?,” said Anholt.

She said that adding the political, economic and cultural context, which could be achieved by the same speaker or having an additional speaker would be valuable and add to journalists’ in-depth understanding of HIV.

Nakkazi said the Science Cafés are also meant to promote a culture of scientists sharing their findings outside of the scientific community in a relaxed setting and prepare the media for research studies results.

At one of the Cafés they have featured Dr. Clemensia Nakabiito a lead researcher in the ASPIRE study who talked about the vaginal ring as an HIV prevention tool for women. Although journalists did not produce any stories they were prepared for the upcoming results, which could be announced by early 2016, said Nakkazi.

There is enthusiasm from the journalists to be part of the monthly Science Cafés as evidenced from the consistency of the turn up, which also means that they are gaining knowledge and want to continuously improve their understanding and skills of reporting about health care issues.

Most of them record the speakers, get their contacts, take pictures and they usually ask a lot of questions creating lively debates, which indicates a genuine interest. Dr. Wakabi commented that it is what is said ‘off cuff’ that sinks in best.

“We have regular journalists attending and we hope they will learn the science and create a solid Network even beyond this,” said Nakkazi after the Science Café was concluded and journalists rushed to get sound bites.

Reflections from the United States Conference on AIDS

Earlier this month, providers, frontline workers, activists and others met in Washington, DC for the annual United States Conference on AIDS, the largest gathering in the nation of organizations working on HIV/AIDS.

The theme—The Numbers Don’t Lie: It’s Time to End Disparities—was evident throughout the meeting, from a kick-off plenary on #blacklivesmatter to various actions by and for transgender communities. These sessions and actions highlighted the myriad issues many communities face, in addition to HIV/AIDS—and the recognition that without acknowledging intersectionality (a framework of understanding how a variety of oppressions can intersect), the HIV epidemic will never end.

Members of the AVAC team and its US PxROAR program were active at the conference discussing HIV prevention in this context. The conference was appreciated all around as a place to reflect and strategize. Read the ROARers’ blogs below as they take measure of the past year’s successes in trans visibility, PrEP acceleration, treatment trends and the stubborn challenges of criminalization of sex work, drug use and people living with HIV; racism; poverty; lack of health literacy and access disparities, still at the forefront of HIV in the US.

Integrating Advocacy for Prevention Now!

In an ideal world, a woman or girl would be able to walk into a “one-stop-shop” clinic and have all of her health needs met, with respect for her sexual, reproductive and human rights. In order to achieve this goal, funding streams, public policies, and advocacy strategies must also be integrated. (Prevention Now Report)

On September 2 in Washington, DC, CHANGE and AVAC launched the Prevention Now report, which lays out critical actions to better integrate and coordinate advocacy for improved prevention for women and girls. This report is the product of a meeting convened by CHANGE and AVAC in June 2015 in Nairobi that brought together a dynamic group of advocates from across sub-Saharan Africa and the US. Participants included women who lead advocacy efforts on sexual and reproductive health and rights (SRHR), HIV prevention and treatment, gender-based violence (GBV), sex worker health and rights, youth health and rights, maternal health, and abortion access organizations. Participants gathered to develop an advocacy agenda around integrating women’s health services. Perhaps one of the most exciting aspects of this meeting was that so many of us had not met each other before, yet work on similar issues: further evidence on the schism between advocates working in HIV, SRHR and GBV.

It’s a schism that makes no sense in the real world. Preventing unwanted pregnancy and HIV transmission are inextricably linked in the lived experiences of women and girls yet family or fertility planning, STI, HIV, and maternal health funding and service delivery and advocacy are often disconnected.

As the field wrestles with delivering HIV prevention options that women and girls want and can use, it’s critical to remember that women do not think of HIV or prevention as a singular specific issue. Women’s (and everyone’s, for that matter) lives are not compartmentalized in the way that services and product development often are.

There’s a lot of talk, globally, about prevention for women and girls. A myriad of global strategies directly refer to women—the PEPFAR DREAMS Initiaive; the UNAIDS Action Framework Addressing Women, Girls, and Gender Equality; the United Nations Strategy on Maternal and Child Health; Family Planning 2020; and the new Structural Development Goals. But this talk, for now, doesn’t translate into enough action.

There is also HIV prevention research focused on young women. Ongoing and planned studies are exploring microbicides, multi-purpose prevention technologies (MPTs), long-acting injectable ARVs for prevention and HIV vaccines. Many of these studies are focused on or include women. And there are a range of “demonstration projects” designed to learn more about daily oral PrEP in the real world, many of these enrolling women — offering the first strategy that a woman can use for HIV prevention that doesn’t require partner negotiation at the time of sex. Up next are results are expected from trials of the vaginal microbicide dapivirine ring in early 2016. Also beginning this year is the ECHO trial that will study the possible relationship between HIV and long-acting hormonal contraception.

All of this means there are ample opportunities — and needs — for advocates to influence the implementation of SRHR and HIV integration strategies and research initiatives and to advocate for a new paradigm in which donors, policymakers, researchers and providers understand and act on women’s SRHR needs and preferences.

Participants at the Nairobi meeting in June looked at barriers and opportunities and proposed creative strategies to address and take advantage of them. The meeting report launch in DC this September brought those recommendations to US-based policy makers, advocates and implementers in the room—and sparked a discussion about next steps in the US and global context.

Over 30 participants in DC from the HIV and SRHR worlds discussed and compared barriers to more integrated advocacy. Topics included the pressure to respond to donor-driven agendas, some of the discontent in the SRHR world on the increased amount of funding for HIV vs. the drying funding streams for SRHR, the fear of diluting “the message” when integrating agendas and just the sheer amount of work to be done. One participant—a long-time HIV activist herself—noted that it was time for HIV advocates to do the hard work of building the case for SRHR advocacy and funding and play a more prominent role in making the inroads into SRHR work. Echoing the discussion in Nairobi, the DC participants noted the importance of “power-building” young women to lead the charge in integrated advocacy efforts and underscored the need to include frontline clinicians in the dialogue on integration.

Integration is a development buzzword. It sounds like a pretty technical term to many and means different things to different people. Depending on who you ask, it can mean combining budgets, work plans, staff training, counseling and public education messages for diseases, health needs or populations that are, inexplicably, often treated in siloes. So, for example, there are active conversations about integrating TB and HIV services; integrating HIV and broader sexual and reproductive health (SRH) services; ensuring that sexual and reproductive rights are integrated into all services; looking to integrate assessment of gender-based violence into services; ensuring cervical cancer screening, prevention and treatment is included; integrating services for adults and children under one roof… and the list goes on…

The bottom line for advocates is clear: If we want integrated services, we need integrated advocacy. As HIV prevention advocates we must challenge ourselves and others to go beyond lip service when considering what it would take to deliver new HIV interventions to women and girls. When we talk about an integrated package of interventions we need to understand what that means, to be able to describe what the package looks like and potential delivery challenges. (See resources on ongoing Integration initiatives below.)

What’s the one simple thing you can do today towards integrated advocacy? Is there a word or phrase you can add to your HIV prevention message? Is there someone from a cervical cancer screening program you can invite to your next meeting? Read the report, it may inspire you.

Resources on Integration HIV/SRHR Initiatives

Notice of public meeting of the President’s Emergency Plan for AIDS Relief (PEPFAR) Scientific Advisory Board

The PEPFAR Scientific Advisory Board will meet October 14, 2015 from 8:30 am to 5:30 pm at 1800 G St. NW., Suite 10300, Washington DC. The meeting is open to the public and will be led by Ambassador Deborah Birx and Board Chair Dr. Carlos del Rio. Meeting topics include recommendations from Expert Working Groups focused on “Test and START” and pre-exposure prophylaxis (PrEP) initiatives for PEPFAR, and updates on PEPFAR 3.0 programmatic activities.