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Synthesising the empirical evidence to map pathways for HIV prevention planning


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This Mapping Pathways poster was presented at the AIDS 2012 conference on Monday July 23, 2012.

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Synthesising the empirical evidence to map pathways for HIV prevention planning

  1. 1. Synthesising the empirical evidence to map pathways for HIV prevention planning BACKGROUND METHODS New trial data has begun to provide empirical The Mapping Pathways study has developed and synthesised the evidence base for ARV- support for innovation in the use of antiretroviral based prevention, and the implications for India, South Africa, and the United States. (ARV) drugs for HIV prevention. However, there has A structured literature review mapped and analysed published empirical data on ExpertLens methodology been little synthesis of the full breadth of individual, four ARV-based prevention strategies: testing, linkage to care plus (TLC+), pre- clinical, social, political, and economic impacts of exposure prophylaxis (PrEP), microbicides, and post-exposure prophylaxis (PEP). ARV-based prevention strategies, and the evidence ROUND 1 ROUND 2 ROUND 3 for them. Share views and Online, interactive Incorporate new A Delphi-based ExpertLens identified fault-lines in the evidence for existing knowledge discussions generate knowledge into your new knowledge reflections implementation of the strategies as perceived by HIV/AIDS experts. Respond to questions ExpertLens harnesses the about the patient- Engage with other Revisit the first set of centred, economic, experts from South questions. Apply new wisdom of groups and can bring PrEP Microbicides TLC+, Test PEP social, and clinical Africa, India, and the insights gained in the geographically dispersed and Treat implications and United States. Experts discussions to the What is the efficacy? How robust is it? impacts of HIV/AIDS compare answers with answers participants together. treatment as prevention others’ and share What are the effectiveness measures? What is missing? strategies perspectives What is the data for comparative cost-effectiveness? 1. Empirical What do we know about indirect outcomes? What more can we know? Reflect, compare, engage, deliberate. Repeat evidence base What information can inform epidemiological, or other modelling? What are the framework conditions needed for drug development? map by relevance to key research 200 Number of articles questions RESULTS 150 100 50 The literature review retrieved 5,811 articles from a keyword search and 0 302 abstracts were mapped for their methodology and relevance to efficacy, cost-effectiveness, indirect outcomes, and epidemiological ? ? s? ra s gy ? ? en s ra ct s? gy te l iti rk st es ra a iv e Empirical evidence gy es gy ra y st ire co ew s of ffic es of io es ct uss st ic on te nd o te st ac am se of en impacts (Figures 1 and 2). One-hundred articles were fully 2. te a log e s g em ss nd fr cus s s iv ffe sc cu lin d cu es i re ect -e i st D is es is el epi Dis analysed. There is a relatively sparse evidence base for the efficacy of D base for ARV-based su eff D om ss tc cu ea s m sse of ARV-based prevention. Modelling and cost-effectiveness studies ou Dis co cu prevention strategies is revealed optimism for effectiveness of TLC+ and PrEP strategies, od D m TLC+, Test & Treat, etc. although caveats about adherence, risk compensation, and drug Microbicides resistance exist. Overall we observe gaps in the evidence base in 30 Number of studies PrEP the following areas: examination of indirect outcomes of ARV- 25 PEP based prevention strategies; clinical trial data for microbicides 20 and ‘treatment as prevention’ strategies; and divergent, context- 15 dependent evidence about the epidemiological implications of 10 different strategies. 5 0 g dy dy y od dy at ase dy ca udy y y rt al ud nt tud ud Pa ent ellin po tri tu tu tu u st st st st re ts ls ls s al e tie ion Sc se c na na os ic e ifi tiv M nc lin “Let us not pitch one prevention option against another - people have unique situations C tio di c ip Type of study re ie C itu nt e cr ec iv rv fe es ng -s te at different points of their lives and are likely to make different choices. Some on D ss lit in Lo C ro ua er migration might happen but overall most people will have more options to choose from.” C Q th O (ExpertLens participant) TLC+, Test & Treat, etc. Microbicides PrEP PEP The views of thirty-two experts, including clinicians, health providers, policy-makers, advocates, and researchers were solicited on factors which would influence the ExpertLens effectiveness of different strategies, such as socio-economic or clinical delivery contexts. Levels of agreement were highly varied and distributed amongst the comparative assessment 3. of biomedical prevention strategies strategies and the different conditions for implementation (Figure 3). When asked about the comparative strengths of the strategies, experts generally thought TLC+ had the strongest scientific evidence, was ready for ExpertLens 1 implementation, and most deserving of funds. While agreement between 4. experts varied on these comparative strengths, consensus only emerged for comparative assessment Relative assessment 0.8 the TLC+ strategy in three areas: strength of the science, readiness for 0.6 implementation, and allocation of funds. There was disagreement on the of factors affecting 0.4 cost feasibility issue, with no consensus emerging for any strategy. implementation Relative ranking/rating 1 between strategies 0.2 0 Qualitative analysis of the ExpertLens discussions revealed e s of tion n sc of ty nc nd tio en ss as t ili gy h fe os ie fu ca ta em ne ib te gt faultlines on the viability of treatment as prevention strategies C lo ra n pl di st Stre Al m ea 0 and risk disinhibition in relation to TLC+ (Figure 4). The chart R ro Oc wh ave ua ha nce lin dic lin te ow e ic a ica stin -up te rug l H are ef e m exu or en ail y & ult ted nt m il c al ina ion ro or at av us div urs rd , h l h x w u ls t, ero lth h m rs ex l c ers ng of Sex oup s u o s C -im car ssa s e c ide s s In in mu co ditio s st ua ity dit s pu tur & ct s s s ble rap o f pta g sid ista k M In ros isk dhe ility nin D ve lthc y le s lt H & con ed nd taff l c ple se w le a r it Fa ial nt- live linic line lth m mic on ion fra eq n n n Po c ty ru n la e & dis ure ct c id ll c e nc le a it t e in ed es ris co nt na se ug ua om p e u an et ea it se C alth al rke Av bilit C mit me yste o n Pa l & and gu g k ru li st io n- he par fe k Se disc cup o h no l in vio ab a ur f at Sk Su ity ces acc nc ri en t e b re e R a b ua ou shows the relative distribution of the mean rating of each dis da io e dr id ea co o c it t co s nd r IV & elia m & rela ry al w fo e ce l r os a an ica l he x implementation issue as they varied between strategies. Where of s TLC+, Test & Treat, etc. pli g ho s r x m lo tio o co bio So tie d ro s a l St tim ily e nt & Microbicides the markers overlap, this indicates similar mean rankings between et ille ita Vic U C me tie al H pa nic c d a h Cli PrEP ail strategies, and where they are spread apart, the mean ranking was Av ig PEP Se H different. The analysis reveals that questions were raised about implementation issues, such as who would monitor patient compliance and drug resistance, while consensus emerged around the TLC+, Test & Treat, etc. importance of socioeconomic conditions being favourable to Microbicides implementation of the strategies; the importance of community and PrEP political buy-in; expanded testing alongside treatment; and the need for the PEP strategies to be implemented alongside other prevention strategies. “It is important to keep attention on treatment which requires political and financial resources.” (ExpertLens participant) CONCLUSIONS There is little published, systematic analysis of the full evidence base for ARV-based prevention to utilize for policy development. Existing data is inconsistent with regard to efficacy and effectiveness, varies by country, and expert perspectives are divergent and dynamic. Critical gaps exist in the evidence base and the need for policy- relevant and robust evidence remains.Mapping Pathways has six partner organisations: AIDS Foundation of Chicago, AIDS United, Bairds CMC, Desmond Tutu HIV Foundation, Naz India and RAND. Mapping Pathways is funded by an initial grant fromMerck & Co., as well as an additional NIH ‘Be the Generation Bridge’ grant for dissemination and community engagement activities.Blog: www.mappingpathways.blogspot.comFacebook: @MappingPathways DESMOND TUTU HIV FOUNDATION BAIRD’S CMC