No Prevention, No End – AVAC launches new report and call to action

Today AVAC released No Prevention, No End, our 2018 annual report on the state of the field. Starting from the title—which humbly borrows the cadence of the call for an end to state-sanctioned violence against Black Americans, “No Justice, No Peace”—through to the closing words, “This is the worst possible moment for slowing down,” the Report is a call to action and guide for addressing the HIV prevention crisis that threatens progress in curtailing epidemics worldwide.

Click here to download the Report and individual sections and graphics; click here for a new episode of the Px Pulse podcast which covers the Report’s key themes and features lead author Emily Bass, AVAC’s Director of Strategy and Content.

UNAIDS named the prevention crisis in its July 2018 report, Miles to Go. It acknowledged that the scale-up of antiretroviral treatment, while essential, is insufficient as a prevention strategy. AVAC has been warning of an imbalance in approaches and investments across approaches, and calling for ambitious targets matched with political will, financing, timelines and more since the UNAIDS targets were first launched in 2014. (Check out AVAC Report 2014/5: Prevention on the Line for a summary of this critique of targets.)

In this year’s Report, we call out three core problems with primary prevention and the global HIV response, identifying the risks they bring and the path to a solution. Specifically, we focus on:

  • Investing in demand creation: The private-sector gloss on this term cannot obscure its essential role in making primary prevention work. Strategies that might save lives are condemned as unwanted or unfeasible when they’re delivered in programs that lack integrated demand-side thinking, which is a science and not a set of slogans.
  • Making informed choice central to HIV prevention: Programs that offer more than one option, along with a supportive environment for a provider and client to discuss risks, benefits and personal preferences aren’t a luxury but a necessity. The family planning field has metrics to measure choice; HIV should pick these up, with prevention programs leading the way.
  • Unstinting radical action: Progress in the global AIDS response is tenuous; so is the state of democratic institutions and the future of the planet. These interconnected issues require more bold action, including from countries that are aid beneficiaries, and from the citizens of those countries who unite to hold truth to power. In the HIV prevention context, this means accountability for primary prevention at every level, including research for next-generation options.

AVAC is launching this Report as many stakeholders in HIV prevention research gather in Madrid for the HIV Research for Prevention (R4P) conference. Visit our special R4P page to find us on-site and follow along from afar, to see how the themes of this year’s Report resonate in a global and wide-ranging discussion of HIV prevention research and implementation at a critical time.

New Issue! Px Wire: The prevention question cascade

In the new issue of Px Wire, AVAC gives our take on this year’s PEPFAR process for establishing the Country Operational Plans (COPs). These plans define what work will be done with PEPFAR money at the country level and how that work will be evaluated in each of the 63 countries that receive PEPFAR money.

The process has changed considerably since last year, allowing for deeper insights into what’s working and what’s not. In this issue, AVAC takes you through the good and bad of PEPFAR’s emphasis on index testing, analyzes crucial gaps in combination prevention, and lays out a series of questions to shape a powerful agenda for advocacy.

This issue’s centerspread takes a closer look at Zimbabwe’s data, and highlights amfAR’s detailed country factsheets that draw from PEPFAR’s giant data sets. Additional tools and information on influencing the COPs process are available from COMPASS partner Health GAP’s PEPFAR Watch.

Find the full issue Px Wire and the archive of past issues at www.avac.org/pxwire.

CROI 2018: Research for the Front Lines

Rob Newells is the newly appointed Executive Director of AIDS Project of the East Bay; he is minister and founder of the the HIV program at Imani Community Church in Oakland and is a PxROAR member since 2012.

The annual Conference on Retroviruses and Opportunistic Infections (CROI) brings together thousands of researchers from around the world to share the latest information on HIV, AIDS, and related infectious diseases. The 2018 meeting in Boston highlighted 114 oral abstracts and 991 posters in 23 different science categories, from Virology to Population and Cost Modeling.

The time lag from research to implementation in health can be long. One study from 2011 suggested an average 17-year delay (Morris, Wooding, and Grant, 2011). This graphic (adapted by AVAC from Dana Hovig at the Bill and Melinda Gates Foundation) shows a five year lag in the US for vaccines and drugs. As one of 26 Community Educator Scholarship Awardees at this year’s Conference on Retroviruses and Opportunistic Infections (CROI), it is my goal to help reduce that delay by focusing on research that has the potential to impact community members and frontline workers who I interact with on a daily basis in the short term.

I am sure that scientists and advocates will spend the next year talking to each other about the issues and information that came from oral abstract sessions reporting on long-acting cabotegravir (Abstract 83) and dapivirine ring studies (Abstract 143LB and Abstract 144LB). Advocates should also be engaging community members and frontline workers in conversations about these emerging tools for HIV prevention.

Almost six years after FDA approval, oral PrEP is a part of the HIV prevention landscape worldwide, but it looks different depending who you are and where you live. PrEP access still seems to be among the most relevant issues for HIV-negative black MSM in the United States, while viral suppression (which is key to improving health outcomes and eliminating the risk of onward transmission) remains a priority concern for PLHIV. Do PrEP and treatment as prevention really give us all of the tools we need to end the HIV epidemic? What follows are a few of my (US-centered, black MSM-focused) highlights from #CROI2018:

Oral Pre-Exposure Prophylaxis (PrEP)

Does PrEP drive STI rates? No! Abstract 1025 looked at condom use patterns in about 300 MSM and transgender participants in a PrEP pilot study. Reported condom use did drop, but overall rates of STI diagnosis didn’t not rise. The investigators conclude that “neither overall condom use nor change in condom use were associated with STI diagnosis.” Good predictors of STI diagnosis among PrEP users included being under 25 years old, being diagnosed with an STI in the 6 months prior to starting PrEP, and the number of sex partners. The researchers conclude that “particular attention and support is needed for younger PrEP users,” and, “although many PrEP prevention messages stress condom use, the number of partners appears to be a more important predictor of STI diagnosis among PrEP users.”

…and, in an exploration of the intersection of PrEP and STIs in the United States, Dr. Julia Schillinger said, “as researchers are looking at retention on PrEP, maybe one of the things they could also measure is, even if people aren’t retained on PrEP, are they retained in a system of testing and primary care?”

Should PrEP be prescribed for people who use meth? Yes! Starting with data from the iPrEX study and its open-label extension, it’s been clear that people at risk of HIV and unable to use condoms will use PrEP correctly and consistently. A study of these issues at CROI found more evidence of this. The study enrolled MSM who were using PrEP and reported condomless anal sex with multiple partners (CAS-MP). Some also reported stimulant use. The researchers wanted to know how stimulant use and condomless anal sex affected adherence to PrEP. They measured the presence of PrEP in blood samples from the study participants. (This can give a more accurate picture of whether people are taking PrEP than their own reports. Overall, 80 percent of participants in the study had protective levels of PrEP in their blood over the course of the 48 week study, regardless of stimulant use or frequency of condomles anal sex.) Conclusion: “Stimulant use should not be a deterrent to prescribe PrEP to high-risk individuals engaging in CAS-MP.”

Short-term PrEP as part of vacation package??? Yes! Advocates have stressed for years that oral PrEP is not forever. Rather, it should be used during a person’s “season of risk.” Sometimes those seasons aren’t very clear. Sometimes they are. Researchers investigating the feasibility of short-term, fixed interval, episodic PrEP (epi-PrEP) found in a study of 54 men who have sex with men (MSM) that most were adherent during short, high risk vacation periods. Study participants started oral PrEP 7 days prior to vacation and were instructed to adhere to daily dosing through seven days post-vacation. (They also received a single session of cognitive behavioral therapy at least two weeks before the vacation.) Nearly 94 percent of the men in the trial had protective levels of tenofovir-based PrEP in their blood at a study visit three days after their vacation was over. Epi-PrEP may be a good option for some men with episodic high risk for HIV infection, and as an added bonus, “initiating PrEP on vacation may provide a helpful way to initiate long term PrEP.”

Oral tenofovir-based PrEP is still one of the most important tools for HIV prevention available today, but it is not a magic pill. Dr. Roel Coutinho reminded CROI attendees that using PrEP to eliminate HIV would take about 80 to 120 years without including other HIV prevention strategies. This is why viral suppression for people living with HIV is still a priority.

Viral Suppression

Findings from CROI:

  • Higher HIV viral load was independently associated with the likelihood of transactional sex. Additionally, those testing positive for an STI were nearly twice as likely to report transactional sex as compared to those without STIs.
  • Decreasing alcohol use without abstinence from alcohol was associated with a lower viral load. In other words, people with HIV whose drinking interferes with adherence to medication may be better able to take their medications when they reduce their drinking-without completely stopping. This can inform counseling messages and harm reduction approaches.
  • A study of PLHIV living in the San Francisco Bay Area got nuanced about types of homelessness-which can range from living outdoors to crashing with friends or family. It looked at the relationship between different types of homelessness and virologic suppression. Although living outdoors was associated with the lowest proportion of viral suppression, other forms of unstable housing (including living in a shelter, ‘couch-surfing’, and being in an single-room occupancy) were also associated with lower levels of viral suppression compared to renting or owning. Interventions are needed to increase viral suppression among PLHIV across a spectrum of unstable housing arrangements.
  • More frequent social work visits and nurse phone calls were associated with retention in care for young adults with HIV, but improved retention did not to lead to improved viral suppression. In general, young adults have lower rates of antiretroviral use and medication adherence than older adults, so lower rates of viral suppression in this group should come as no surprise. CDC’s HIV Care Continuum by Age shows that young people living with HIV are less likely than older Americans to be diagnosed, to be in care, and to be virally suppressed. Socioeconomic challenges, depression, and lack of tailored interventions to improve adherence among young people are among the issues that must be addressed to improve viral suppression for young adults with HIV.

HIV Care Continuum, by Age, US 2014

So much information, so little time. This year’s CROI featured lots of research focused on women, hepatitis C, tuberculosis, anal cancer, and a host of other issues that will continue to be analyzed and reported over the next several months. My initial brain dump to frontline staff at APEB was intended to share information that they might find useful in their work with members of our community now. We’ll continue to develop workshops and presentations and events that attempt to keep folks armed with the latest information available and prepared for what’s coming next. Somewhere between “now” and “next,” we have a lot of work to do!

Target Tracking for Epidemic Control

Calculating progress toward the UNAIDS Fast Track Goals is complex but ambitious targets are the best kind. AVAC has long argued they propel action even if they aren’t met. But when it comes to achieving epidemic control, progress must be properly calculated, and can never be confused with success.

Appearing in Px Wire, this is a modified version of a graphic appearing in AVAC Report 2017.

New Px Wire — 2018: Countdowns and counting what matters

The first issue of AVAC’s quarterly newsletter for 2018 is here! It’s designed to help you mark your calendars and make your advocacy plans for critical events in the next 12 months. These include:

  • The upcoming country deadlines for creating roadmaps to implement the priorities laid out by the UNAIDS’ Global Prevention Coalition. This work is supposed to jump-start primary prevention and bring down the rate of new diagnoses by 75 percent by 2020. Will it? Only if you get involved!
  • In the coming weeks, PEPFAR and many stakeholders will gather to develop targets, service delivery approaches and comprehensive plans for testing, prevention, treatment and virologic suppression in PEPFAR countries. It’s a key process for civil society to track. Find out how!
  • In 2019, the ECHO trial is expected to release its results on whether three different contraceptive methods impact women’s risk of HIV—but preparation for these trial results is starting now! Get involved!
  • Seven major efficacy trials of biomedical prevention tools are currently underway—read on to find out where, what and how to learn more.

This issue of Px Wire also includes a detailed infographic showing the status of oral PrEP rollout in the countries where trial sites are located. And don’t miss the infographic explaining the demographics of Africa’s “youth bulge” and its implications for the global response.

Find the full issue of Px Wire and the archive of past issues at www.avac.org/pxwire.

NIH-Funded HIV Trial Networks: A family tree

This graphic provides a visual history of the DAIDS Networks and a look at what’s proposed for the next funding cycle. It appears in AVAC Report 2017: Mixed messages and how to untangle them.

The Delivery Challenge

This figure shows the timeline to achieve public health targets related to a new intervention, both globally and (in dashed lines) in the US. The message: it takes time and, based on history, today’s prevention tools are on track. It appears in AVAC Report 2017: Mixed messages and how to untangle them.

Total Global HIV Prevention R&D Investment by Prevention Option, 2015–2016

This graphic shows the percentage of total global investment in HIV prevention spent on different interventions in 2015 and 2016. For much more on HIV prevention research & development funding, visit www.hivresourcetracking.org.

US HIV Research: A family tree

This graphics shows a family tree representing HIV research in the United States. It appears in AVAC Report 2017: Mixed messages and how to untangle them.

Target Tracking, 2010–2020

Calculating progress toward the UNAIDS Fast Track Goals is complex but ambitious targets are the best kind. AVAC has long argued they propel action even if they aren’t met. But when it comes to achieving epidemic control, progress must be properly calculated, and can never be confused with success. This graphic appears in AVAC Report 2017: Mixed messages and how to untangle them.