Patching the Leaky Cascade: Report From the 2015 Adherence Conference

Thirty-three million people are infected with HIV worldwide, but less than 50% receive antiretroviral therapy. This was the stark reality addressed in June at the 10th International Conference on HIV Treatment and Prevention Adherence (Adherence 2015), which is jointly provided by the International Association of Providers of AIDS Care (IAPAC) and the Postgraduate Institute for Medicine (PIM). Every aspect of the ubiquitous treatment cascade was addressed in an effort to stop the "leaks" of people not engaging in treatment, falling out of care or not maintaining viral suppression. While access to prevention and treatment has significantly improved worldwide, certain issues such as stigma still impact prevention and treatment, and gender, age, race and sexual orientation continue to make certain populations vulnerable and in need of interventions tailored to their specific needs.

Delegates shared a variety of promising findings and strategies, many focused on "implementation science" that integrates research and practice. K. Rivet Amico, Ph.D.,'s proposed "prevention cascade," for example, provides a new approach to identify opportunities for prevention activities at four specific points of risk, including "viral presence" (interventions could include couple's testing, status discussions or 4th generation tests) and "viral entry" (interventions such as barriers and needle exchange). Other innovations, such as those related to technology, were highlighted. Mobile electronics and social media are proving effective not only at retaining people in care with medication reminders, but also at having a psychological impact by making patients feel "cared about." The value of peers was widely documented as a means by which to expand workforce capacity and improve retention and reduce viral load. For example, Quaraisha Abdool-Karim, Ph.D., presented an effective peer-based model implemented in Mozambique in which one person who is virally suppressed is linked with five others, each taking a turn to pick up medication for the group, with all supporting each other.

Of all the many obstacles to prevention and treatment worldwide, stigma remains the most challenging. Presenters underscored the need to address it not only at the individual level, but also at community and societal levels. Jason Sigurdson, a senior policy and strategy adviser of the Joint United Nations Programme on HIV/AIDS, reported disturbing findings from the Global Commission on HIV and the Law: Two-thirds of countries still have laws that present obstacles to vulnerable populations; 36 have entry or stay restrictions, and 61 criminalize transmission -- with several U.S. states among those jurisdictions having the most HIV criminal prosecutions in the world. In some countries, health care workers continue to stigmatize and gossip about people living with HIV/AIDS (PLWHA), resulting in less access to care. Some progress fighting stigma was noted, including the use of the UNAIDS "PLWHA Stigma Index" in more than 50 countries, and ever-increasing efforts to modernize HIV criminalization statutes. Anna Zakowicz, M.P.H., identified one aspect of fighting stigma as the need to recognize community values and preferences, emphasizing that if groups of people are not explicitly included, then they are implicitly excluded.

Substance use continues to impact prevention and treatment and is a primary risk behavior in Eastern Europe and among some men who have sex with men (MSM). Approaches need to be tailored to specific substances and communities as various recreational drugs have differential effects on risk and adherence. Heidi Crane, M.D., for example, reported that alcohol, methamphetamine and crack cocaine have double the impact on adherence as opioids or marijuana, and that some benefit for antiretroviral therapy adherence was documented even without total cessation of the recreational drug, implying the importance of harm-reduction efforts. This is especially significant for a drug such as methamphetamine, which dramatically heightens both HIV risk and antiretroviral therapy non-adherence, and which is characterized by high recidivism.

Depression and anxiety have also long been associated with both HIV risk and health outcomes. Findings from specific interventions for mood disorders were both hopeful and illuminating, such as Moka Yoo, R.N.,'s report on how depression mediates both HIV and gastrointestinal-related physical symptoms. Trauma-informed care is increasingly recognized as an essential aspect of HIV prevention and treatment. Women and transgender communities are especially impacted by trauma, as well as stigma and poverty. One innovative approach to trauma included gathering assessment data through the use of technology. It was found that patients reveal more sensitive information utilizing a computerized assessment than they would in face-to-face interviews.

Delegates to the conference also reported on issues concerning a variety of vulnerable populations. JoAnne Keatley, director of UCSF's Center of Excellence for Transgender Health, noted the ongoing health disparities in that community fueled by stigma, poverty, violence, provider bias and conflation of transgender concerns with those of MSM. She addressed the need for transgender-specific interventions and provider capacity. This is increasingly complicated as many AIDS service organizations (ASOs) serving that community (and other vulnerable populations) are struggling with displacement due to rising rents in their neighborhoods. Capitol Hill in Seattle, for example, an area with a large LGBT population and home to several ASOs, is experiencing increasing rents as the city's business climate improves and gentrification occurs.

The specific needs of women were addressed in a variety of sessions throughout the conference. Stigma, substance abuse, trauma, sexual assault and other factors affect prevention, engagement in care and retention for women across the globe. Research from Emory University identified multilevel factors affecting women in the U.S. Southern region, providing a useful framework for understanding specific prevention and treatment barriers and facilitators for three specific categories of women. The first is called "care engaged," those women whose entry, engagement and adherence to HIV care is affected adversely by enduring challenges such as with transportation and substance abuse, yet whose care at that level is facilitated by being well-connected to providers. The second category is "care consistent," those whose retention is affected more by positive experiences than by challenges, although barriers such as access to medications, unfamiliar providers, substance abuse and stigma make retention inconsistent. The third category is the "care detached," those for whom barriers outweighed facilitators, taking into account such factors as access to medications and housing, and stigma. This and similar models show the need to apply the correct intervention where it is most effective.

Adherence 2015 provided valuable information to help providers, case managers and community-based services develop targeted interventions that more effectively address the unique factors affecting various populations. Though much remains to be done, this work is having a tremendous impact sealing the "leaky cascade" and moving us closer toward UNAIDS' goal of 90-90-90 by 2020: 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving treatment will have viral suppression.