Treatment as prevention: what’s required to make this a relevant strategy in Aboriginal and Torres Strait Islander communitiesadmin
Treatment as prevention: what’s required to make this a relevant strategy in Aboriginal and Torres Strait Islander communities
HIV Australia | Vol. 11 No. 3 | October 2013
By James Ward
There have been some significant advances in knowledge recently in the HIV field. Of particular significance is the concept that HIV treatment can be used as prevention tool in reducing HIV transmission for individuals, at the community level and even globally.
This agenda is more commonly known as ‘treatment as prevention’ (TasP).
So how does this work? Where did this concept arise from and what would need to happen for this to become reality in Aboriginal and Torres Strait Islander communities?
TasP as an agenda: recognising what has been done so far and ensuring we keep this up!
Australian Aboriginal and Torres Strait Islander peoples experience the worst health status of any identifiable group in Australia, and the population remains particularly vulnerable to HIV.
New and emerging issues as well as social determinants of HIV raise the level of vulnerability.
Despite this vulnerability, the Australian response to HIV over the last thirty years – both Indigenous and non-Indigenous led – has resulted in relatively low and stable rates of HIV among Australia’s Aboriginal and Torres Strait Islander population.
Some of the mainstays in HIV prevention thus far have included early recognition by Aboriginal peoples of the potential effect that HIV could have on their communities; the supply of health hardware (needle and syringe programs and condoms); the development and implementation of culturally appropriate health promotion messages such as the internationally recognised ‘Condoman’ campaign; the inclusion of dedicated Aboriginal and Torres Strait Islander Sexual Health Workers in communities; and an inclusive policy and partnership approach.
Furthermore, the efforts of peak Aboriginal health organisations including the National Aboriginal Community Controlled Health Organisation (NACCHO) and its member services, and Indigenous programs in mainstream community organisations like the Australian Federation of AIDS Organisations (AFAO) and its member organisations, have all contributed to prevention success.
Efforts need to be maintained, however, to ensure an escalated epidemic does not occur, particularly among heterosexual people, and especially among women, and people who inject drugs.
TasP: where did this concept arise from?
Advocates, researchers and others have used evidence from several recent large clinical trials which have demonstrated that people with HIV who have suppressed or undetectable viral loads – particularly those on treatment – are much less likely to transmit HIV than untreated persons.
Specifically, this is based on the knowledge that antiretroviral therapy (ARV) reduces the HIV viral load in blood as well as in genital secretions (for both men and women).
A number of studies have shown that people who are on ARV treatment are less likely to transmit HIV to their partners.
One study (the ‘Partners in Prevention’ study from 2010) showed that heterosexual HIV-positive people on ARV treatment were 92% less likely to transmit the virus to their partners than people who were are not taking treatment.1
The most important evidence about the efficacy of treatment as prevention arrived in 2011 with results from the HPTN 052 trial.
This study demonstrated that for people in serodiscordant relationships (where one partner is HIV-positive and the other HIV-negative) there was a 96% reduction in HIV transmission risk where the HIV-positive partner was on ARV treatment.2
Further studies are continuing in this vein to determine the effects of TasP, particularly among gay men – but the evidence is clear and has been described as a ‘game changer’ in HIV prevention by Michel Sidibé, Director of UNAIDS.3
How does TasP work?
The treatment as a prevention agenda works not only at the individual level but also, importantly, at the community level.
The theory works like this: we know that an individual living with HIV who is on ARV and with suppressed and/or undetectable viral loads has minimal risk of transmitting HIV to another person, therefore if everyone with HIV were on effective ARV treatment there would be minimal risk of transmission in the whole community.
What does TasP mean for Aboriginal and Torres Strait Islander communities?
Currently there are about 400 Aboriginal and/or Torres Strait Islander people diagnosed with HIV in Australia.4
There may be many more undiagnosed cases in the community or maybe not – just as there are in other identified communities.
For instance, it is estimated that between 10 and 30% of gay men in Australia are living with HIV but are undiagnosed.5, 6 To decrease chances of HIV transmission at the individual level and at the community level among Aboriginal and Torres Strait Islander communities, the 400 or so people living with HIV would each need to be on effective ARV.
We do not currently know the number of HIV-positive people who are engaged with treatment, so some innovative and sensitive research would be required, as well as a targeted campaign about treatment and its benefits.
To work at the community level it would also mean that everyone in these communities who is living with HIV but is undiagnosed would need to be diagnosed and then commence treatment.
One way of doing this is to initiate a national targeted campaign tailored Islander community as well as a strategy of increased testing within primary and other health services that see Aboriginal and Torres Strait Islander patients.
This strategy would need to be balanced and include appropriate pre- and posttest conversations with patients, and effective follow-up and case management.
Assuming people living with HIV wish to be on treatment, and that they are actively engaged with their doctors and regular monitoring occurs to ensure the medications are suppressing viral loads, this should work in any context.
Data from the HIV Futures 6 study shows the myriad of complex issues currently faced by who are living with HIV.
Firstly, of 1,106 people who completed the survey, 80% were on HIV treatment,7 meaning another 20% would need to commence treatment for TasP to work in this population.
However, for people on treatment who responded to the survey, almost 40% had difficulty in taking them all the time.8
Common issues that affected adherence included side effects, remembering to take medication on time, transporting medications, taking medications in public and organising meals around medications, as well as the quantity of drugs to be taken.9
Issues of discrimination, employment, housing were all issues affecting people living with HIV.10
For Aboriginal and Torres Strait Islander people these issues are impacted further by experiences of racism and discrimination both within and outside the health care system.
Aside from the current gaps in our knowledge to make TasP an appropriate strategy in Aboriginal and Torres Strait Island communities (treatment rates and undiagnosed cases) we would need to look holistically at the treatment and management cascade to ensure TasP can be a success.
In doing so, the following are essential for the strategy to work:
- maintaining efforts in addressing the social determinants of health that impact Aboriginal and Torres Strait Islander people disproportionately (poverty, education, housing, employment and racism), because if these are not addressed then it makes it much more difficult for people to be engaged with health services
- a continuation of reducing some of the existing factors that increase vulnerability of HIV transmission within Aboriginal and Torres Strait Island people such as high rates of other STIs and unsafe injecting practices
- continue to promote traditional and proven prevention strategies such as safe sex, condom use and needle and syringe use
- increasing our understanding of the barriers and facilitators of HIV testing and treatment, including medication compliance for Aboriginal and Torres Strait Islander people living with HIV
- increasing the health workforces’ capacity to be able to test, diagnose and manage patients within health services free of racism and discrimination and make our health services pathways easy to navigate; from diagnosis to management
- the implementation of health promotion work in the community about the benefits of testing and treatment for HIV.
Finally, in engaging in the treatment as prevention strategy, it will take a coordinated approach – with the communities involved, with government, with academia and non-government organisations to make this happen.
This is where we have to start, and we should start, to continue the relatively good news story of HIV in Aboriginal health.
James Ward is an Indigenous health researcher with more than 15 years’ experience working within Aboriginal health and communities in Australia.
He is Head of Preventive Health and Deputy Director at Baker IDI, Central Australia, Alice Springs.
He is also lead researcher on several current key research studies relating to STIs and reproductive health among Aboriginal and Torres Strait Islander communities, including STRIVE and GOANNA.
James is a guest editor of this edition of HIV Australia.
1 Donnell, D., Baeten, J., Kiarie, J., Thomas, K., Stevens, Cohen, C., et al.; for the Partners in Prevention HSV/HIV Transmission Study Team.(2010). Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. The Lancet 375(9731), 2092–2098. doi:10.1016/S0140-6736(10)60705-2
2 Cohen, M., Chen, Y., McCauley, M., Gamble, T., Hosseinipour, M. Kumarasamy, N., et al.; for the HPTN 052 Study Team. (2011). Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N. Engl. J. Med. 365(6), 493–505. doi:10.1056/NEJMoa1105243
4 The Kirby Institute. (2013). Bloodborne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander people: Surveillance and Evaluation Report 2013. The Kirby Institute, University of NSW, Sydney.
5 Jansson, J., Wilson, D., Watson, J. (2010). Mapping HIV Outcomes: Geographical and clinical forecasts of numbers of people living with HIV in Australia. National Centre in HIV Epidemiology and Clinical Research (NCHECR), Sydney, National Association of People Living with HIV/AIDS (NAPWA), Sydney.
6 The Kirby Institute. (2011). National Bloodborne Virus and Sexually Transmissible Infections Surveillance and Monitoring Report, 2011. The Kirby Institute, University of NSW, Sydney, 38.
7 Grierson, J., Power, J., Pitts, M., Croy, S., Clement, T., Thorpe, R., et al. (2009). HIV Futures 6: Making Positive Lives Count, monograph series number 74. The Australian Research Centre in Sex, Health and Society, Latrobe University, Melbourne, 23.