Combination prevention is all about connecting distinct interventions into a single package of services. In late May, the World Health Organization (WHO) prequalified PrePex, a nonsurgical device for voluntary medical male circumcision (VMMC). In mid-June, researchers from the US Centers for Disease Control and Prevention, the Bangkok Metropolitan Administration and the Thailand Ministry of Public Health announced a positive result from the long-running Bangkok Tenofovir Study of daily oral tenofovir as PrEP for HIV prevention in people who inject drugs. And in early July, the WHO issued new guidelines on antiretrovirals (ARVs) for treatment and prevention recommending antiretroviral treatment (ART) for all HIV-positive people with CD4 cell counts of 500 or below.
What links a plastic ring, a pill for prevention and a document that adds 19.2 million people to those needing ART worldwide? They all currently face issues of implementation. For each strategy, three major questions are: What is the next step? Who will take it? How and when will the views of people living in impacted areas and communities be sought and used to guide relevant decisions?
Each of these developments puts a spotlight on the gap between what a normative agency does and what happens on the ground. WHO prequalification is just the first step in delivering devices to countries implementing VMMC. It will be up to countries to act on the new ARV guidelines. And the Thai PrEP trial data are just the latest confirmation that daily oral tenofovir-based PrEP works when taken consistently. These data that come at a time when there is still little clarity about the suite of demonstration and pilot projects that are needed to build on the WHO guidance on PrEP that was issued almost exactly a year ago. In the intervening 12 months, activity on new demonstration projects has been slow, and there still isn't a shared agenda that could help countries' decision-making processes.
The history of the AIDS response holds examples of new guidelines that don't necessarily translate into action and impact. It's relatively new territory for prevention research advocates, who have long focused on the swift and ethical implementation of trials. Today we have to continue that research-oriented work -- see this issue's infographic for the latest information on investments in HIV prevention research globally -- while also acting as implementation advocates to ensure that the complicated challenge of rolling out combination prevention and treatment stays on track. With no new HIV prevention efficacy trial results expected until late 2014, now is the time to turn our attention to the specific next steps dictated by the past quarter's developments.
PrePex Circumcision Ring: Defining Price, Managing Expectations
We don't yet know the exact price of the PrePex device -- the first nonsurgical device to receive WHO prequalification for voluntary medical male circumcision. Prequalification signals that the device has met international regulatory standards and clears the way for donors and governments to purchase the device for public health programs. On a recent AVAC webinar discussing device development, Tzameret Fuerst, Co-Founder and President of PrePex manufacturer Circ MedTech said that the company was in "daily conversations" with PEPFAR and other donors and implementing partners about the price of the device, which has been previously quoted at approximately US$20. Plans for bulk procurement could bring that number down but initial costing studies have shown that at this price PrePex would be comparable to surgical VMMC. For advocates, it's critical to track pricing developments, urging that cost be set so that non-surgical VMMC is affordable and sustainable. At the same time, it's key to manage expectations of what this, or any device, can and cannot do to simplify the procedure, save funds and increase uptake.
Bangkok Tenofovir Study: Looking Back and Moving Forward
What happens when a trial that was launched and conducted amidst controversy and community concern ends with a positive result? When the Bangkok Tenofovir Study announced its finding of a 49 percent overall prevention benefit, the conclusion of the trial brought up fresh discussion on its beginning and how it was run over its eight-year history. In the weeks after the announcement, the Thai Drug Users Network (TDN), Thai AIDS Treatment Action Group (TTAG) and the Treatment Action Group issued a statement that said, in part, "While TTAG is glad for any evidence of reduced HIV transmission among people who inject drugs, this trial failed to promote basic ethical practices and patently ignored community concerns. In our opinion, the trial serves as a 'worst practice' example of community engagement, failing to ensure participant access to a comprehensive prevention package in a placebo trial, and ignoring other issues we tried to raise to researchers at the outset."
The concerns raised about the trial were one impetus for the development of the Good participatory practice guidelines for biomedical HIV prevention trials that were first published in 2007 and updated in 2011. These guidelines -- informed by community input -- map out key activities and best practices for stakeholder engagement and have been put to use in several large-scale trials to date. The guidelines also lay out best practices for stakeholder engagement during the results dissemination and post-trial access stages. As this issue went to press, the Thai NGO Coalition on AIDS (TNCA) and various civil society partners convened a community dialogue to discuss the results with key Thai government officials -- an activity that is part of a broader initiative to develop a national community advisory board in Thailand.
New WHO Treatment Guidelines: Putting Individual Choice at the Heart of Combination Prevention
The new WHO guidelines on the use of ARVs have triggered a global debate about the feasibility of, and scientific rationale for, expanding ART eligibility criteria to CD4 cell counts of 500 and below. Continued advocacy and engagement in this conversation is needed to ensure that treatment fulfills its promise as a prevention option.
Combination prevention is the best way to begin to end the epidemic; implementing a range of options is also the best way to meet the needs of individuals living with or at risk of HIV. Sustained advocacy from research to rollout is essential to ensure that the element of choice -- and of changing needs across the life cycle -- is preserved.