In the last decade huge advances have been made in biomedical approaches to HIV prevention, particularly in terms of TAP and PrEP. TAP, or treatment as prevention, means giving ART (anti-retroviral treatment) to men who are HIV positive to reduce onward HIV transmission, while PrEP means giving medication to men who are HIV negative to reduce the chance that they become HIV positive (seroconverting). At the turn of the century these methods of HIV prevention did not even exist and now trials are being conducted to determine whether they can be used on large scales around the world. In London the Proud study is currently recruiting men who have had unprotected sex to take part in PrEP trials (For more information and to participate in the study click here ).
But what trials into biomedical HIV prevention show and what consequences do they have for HIV prevention work in the future? Well, by and large trial results are promising with most trials showing a reduction in HIV transmission. However, this varies depending on the study, with some trials showing exceptionally high reduced transmission rates, such as the HIV Prevention Trial Network (96% reduction), whereas others show much more modest rates of reduction (see this study and this overview, for example) and some have had to be stopped altogether as they were inconclusive. Studies have shown that varying efficacy is likely to be the result of various factors such as the type of sexual behaviour, varying rates of site effectiveness (e.g. after gel application) and adherence to medication. Consequently, while biomedical prevention is going to play a much bigger role in HIV prevention it would seem that alone it cannot prevent HIV transmission and would be best looked at as part of a wider approach incorporating current successful behavioural approaches. In particular, research suggests that behavioural approaches focused on one-to-one, participant centred, long term support must be carried out in conjunction with TAP or PrEP to bring about significant reductions in HIV transmission. Related to this, studies also show the importance of behavioural approaches focused on medication and adherence to medication. This might include factors such as barriers to taking medication, feelings about medication and specific factors that might influence medication adherence (which studies have shown have a large . One example could be the party drug scene popular amongst gay and bisexual men in the UK (and elsewhere), which could have a huge impact on whether treatment is taken as required for PrEP/TAP and attitudes towards treatment, as well as sexual behaviour. Failure to include such elements means even treatment approaches successful in other settings might be far less successful when applied to MSM in Western cities, for example.
So, do biomedical approaches to HIV prevention represent a breakthrough? Undoubtedly – huge changes have occurred since the start of the 21st century and knowledge in the area had increased exponentially. Will they change the way HIV prevention looks in the years to come? Absolutely – indeed HIV prevention approaches are already changing as a result. Do they present all the answers for HIV prevention? Definitely not – the consensus amongst researchers and providers is that a combined approach to HIV prevention is more effective than either a biomedical or behavioural approach alone. Thus, while biomedical approaches provide hope, they do not, single handedly, represent the key to reducing HIV transmission. This was reiterated this week when Roger Peabody of Aidsmap argued that ideas to the contrary must be challenged as they ‘rely on utopian assumptions, such as 100% of people getting tested and 100% of diagnosed people taking antiretroviral treatment’ (see here). In reality, a combined approach to HIV prevention which acknowledges the importance of human behaviour in HIV prevention as well as focusing on medication can ensure that the breakthroughs that have been made in recent years are translated through to reductions in HIV transmission.
What do you think? Maybe you disagree and feel that TAP and PrEP can shape future HIV prevention alone. We want to hear from you Leave any comments below. The views above are those of the author and do not necessarily represent those of the GMI Partnership.
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