March 18, 2014
One of the most significant developments in HIV research in the past few years has been the discovery that antiretroviral therapy (ART) can dramatically reduce the risk of HIV transmission. Indeed, research continues to emerge that supports the use of ART as an HIV prevention tool for HIV-positive individuals and as a public health strategy to reduce new HIV infections within some populations. While promising, the use of ART for prevention has raised some concerns among people living with HIV, their communities and their caregivers. A lack of guiding principles has also resulted in some uncertainty as to how this information should be integrated into frontline prevention work.
To address these concerns, the European AIDS Treatment Group (EATG), in collaboration with the England-based HIV organization NAM, recently released a community consensus statement on the use of HIV treatment as prevention. This statement contains a series of guiding principles to help move treatment as prevention forward in a way that protects the rights, dignity, self-determination and overall health and well-being of people living with HIV and their partners. These principles were developed through a community-driven process, within a Greater Involvement of People Living with HIV and AIDS (GIPA) framework.
These are some highlights of the statement's principles:
Nobody should be coerced or pressured into getting tested for HIV or starting ART for prevention purposes. Getting tested for HIV and starting ART are important decisions that are not without challenges and risks. For example, treatment generally requires life-long adherence to daily pill-taking and can have short and long term side-effects. Therefore, the statement recommends that service providers develop safeguards to prevent coercion and ensure that the decision to start treatment is the free choice of the person living with HIV. According to the statement, "the provision of ART for prevention purposes should never violate individuals' rights to health, self-determination, consent or confidentiality." Pressure or coercion may come from various sources, such as sex partners, public health workers or other service providers.
Assessing an HIV-positive person's readiness to start ART is important and should begin early (when a person's CD4 counts are high). Treatment readiness is important to ensure that a client/patient makes an informed decision and is prepared to adhere to daily pill-taking once ART is started. Tools are needed to help assess an individual's readiness to start treatment and some have already been developed.
ART should be considered one part of a comprehensive approach to improving HIV prevention and the health of people living with HIV. Although it is an important component of the response to HIV, treatment as prevention will not by itself end the epidemic. This strategy should not draw attention away from other effective HIV prevention strategies, such as risk-reduction counselling, the use of sterile equipment for injecting drugs, condom use and social support programs. Furthermore, increasing the number of people on successful ART is dependent on improving other aspects of the response to HIV, such as access to testing, care and support. Approaches to improving the health of those living with HIV should be holistic and go beyond ART: They must "be part of a general programme whose aim is to improve the physical and emotional health and social position of people with HIV and their partners."
The community consensus statement provides important guidance on how HIV treatment as prevention should be integrated into frontline work. Hopefully the statement will encourage further discussions on this topic, as well as the development and implementation of new and enhanced services that aim to safeguard "the health and wellbeing of people living with HIV, whether they choose to take ART or not." Individuals and organizations can sign on and endorse this statement online.
Treatment and viral load: what do we know about their effect on HIV transmission? -- Prevention in Focus, Fall 2013.
Treatment as prevention: do the individual prevention benefits translate to the population level? -- Prevention in Focus, Fall 2013.
HIV viral load, HIV treatment and sexual HIV transmission -- CATIE fact sheet.
Starting and staying on treatment -- a collection of CATIE resources.
The Vancouver STOP Project -- Programming Connection.
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