THIS is a continuation from last week’s article: Researchers are also using implementation science to understand why prevention methods such as circumcision and prophylactic drug treatment have not been adopted as widely as they could have been.
For instance, trials in the mid-2000s proved that voluntary circumcision for men cut the risk of their acquiring HIV from a female sexual partner by 60 per cent.
The World Health Organisation recommended in 2007 that circumcision be used for prevention and, with UNAIDS and the Bill & Melinda Gates Foundation in Seattle, Washington, set a target to circumcise 80 per cent of eligible men in Africa by 2016 to prevent up to 3.4 million new HIV infections. PEPFAR and others provided funding, and 9 million circumcisions have been performed since 2007.
But even this massive campaign has up to now reached only 28 per cent of its target. One problem is that circumcision is a surgical procedure and so requires different expertise and resources from those in current HIV programmes.
And setting up stand-alone circumcision programmes diverts resources from existing surgery, which is already under-resourced. “There are a whole lot of logistical and operational issues that are resulting in countries not meeting their targets,” Cleghorn says.
A different set of real-world issues has complicated what is known as pre-exposure prophylaxis (PReP) — the concept of taking a dose of antiretroviral medication regularly or around the time of sexual intercourse to prevent infection.
In the PROUD study in the United Kingdom, which reported results in February, this has been shown to reduce the risk of infection by 86 per cent in men who have sex with men, and studies of PReP in Africa showed a decrease of 73 per cent in heterosexual couples.
But despite these results, PReP is not widely used. One reason is that some people at highest risk of becoming infected with HIV are also those most likely to be in denial about their risk, or unable to access services, and are therefore least likely to take a medicine to prevent infection.
And developing countries have enough difficulty distributing antiretrovirals to people already infected to make a serious effort to give them to anyone else. In June, for instance, MSF reported that one in three health facilities in South Africa reported a shortage of medications for HIV or tuberculosis late last year. That makes it hard to face the additional challenge of getting drugs to those who are HIV negative.
“They can’t wrap their heads around it,” Cleghorn says.
In addition, PReP has consistently failed to protect those arguably most in need of new prevention options — young unmarried women. In most of the poor countries hit hard by HIV, 80 per cent of new infections among adolescents are in girls.
Yet PReP has failed in this demographic in trials that used many different delivery approaches, such as vaginal gels containing antiretroviral medication or oral pills taken daily or before and after sex.
The main problem is that many women did not use the products they were given. In one study of 5,000 women in South Africa, Zimbabwe and Uganda, blood tests showed that only 25–30 per cent of participants actually used the medications, even though 88 per cent said that they had.
Those questioned in small groups said that they did not use the products because of social factors, such as fear that they would be ostracised or perceived as having HIV already if they were known to possess HIV drugs.
The problem is part of a broader social context that makes girls more vulnerable to HIV than boys of their age. Many date older men, who have a higher prevalence of HIV infection than adolescent boys; some engage in transactional sex to afford necessities; and some are abused.
Responding to findings such as these, in December 2014, PEPFAR announced the DREAMS initiative which, in conjunction with the Bill & Melinda Gates Foundation and the Nike Foundation, will spend $210 million over two years to provide a combination of preventive interventions targeting young girls, such as HIV testing, counseling and care for rape survivors, and programmes aimed to boost the resilience of girls and their families, such as cash payments for girls who stay in school.
But drawing a direct link between some of these interventions and lowering the risk of HIV infection in girls has been difficult.
Two studies that are specifically testing whether cash transfers for children who meet certain academic goals can cut the risk of new HIV infections in South Africa are expected to report their results at the upcoming meeting of the International AIDS Society in Vancouver, Canada, on 19–22 July.
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