This document discusses the use of antiretroviral (ARV) drugs for HIV prevention, known as treatment as prevention (TasP). It notes that while TasP has benefits, its effects depend on how ARVs are implemented and taken up in different contexts. Concerns include risk compensation, lack of informed consent between partners, and prioritizing population health over individual clinical need. The document also questions assumptions in models showing TasP can eliminate HIV, as barriers to testing, relationship challenges, and sustainability over long term are not fully considered. Overall, it argues more research is needed on social factors that encourage voluntary and informed access to HIV prevention, testing and treatment.

1. ARV Treatment as Prevention
Kane Race
University of Sydney

2. Axiomatic
• ARV drugs have multiple applications that are worked
out through experimentation (official & unofficial)
• Effects of ARVs depend on practice and extend beyond
individual body
• Difficult to predict how drugs will be taken up in
different contexts
• As well as benefits, how they are taken up will produce
new and different problems

3. Preventive effects of ARVs …
• Already exploited in some sexual contexts
– Entry of VL into risk calculations from 1996
• Where treatment uptake has been high,
expected decrease in HIV incidence offset by ‘risk
compensation’ (e.g. Australia)
– No difference in risk among people taking ARVs
– BUT significantly higher risk practice across the board
among those who believed ARVs reduce risk of HIV
transmission

4. Prevention tools and techniques
• Increasing ‘prevention options’ does not always add more
layers of protection; tend to be used as substitutes for one
another
• Educational needs increase with introduction of new options
• Use of ARV/VL to inform sexual practice may be practical at
an individual partner level where decision is informed and
shared (but more knowledge on contextual factors, eg. Stis, needed)
• What about in other contexts? E.g. no disclosure
• What infrastructure is needed to make it work well?

5. Official uses of ARV as prevention
• PMTC (perinatal)
• PEP
• PREP (in trial) (incl. topical application)
• ATP (Anema 2008; Granich 2009)

6. Private prevention tools
• Advantage: don’t require knowledge, consent,
negotiation, cooperation with partners
– (e.g. female controlled, allows safer condomless sex)
• Disadvantage: don’t require knowledge,
consent, negotiation, cooperation with partners
– (lessens impetus for structural change around gender,
sexual practice, open discussion of sex, etc.)
• Toxicity and burden of toxicity (borne by certain
groups)

7. Granich paper, Lancet 2009
• Modelled effect of ‘universal voluntary testing
with immediate ARV’ on HIV incidence in
generalized epidemic
• Finds substantial decrease in HIV incidence
(‘elimination’) when TiRx is adopted
• But is this positive prevention??

8. • May have advantage of expediting treatment
access, increasing testing & improving follow‐
up with treatment
• BUT
• Prioritizes population health over clinical need
– No data on effects or sustainability over long term
• Requires substantial infrastructure &
resources
• Prone to abuse

9. What is left out of model?
• Possibility of reconstituted infectivity through
– STIs
– Treatment failure
– Poor adherence
• Possibility of risk compensation
• To work as intended, this technology requires new forms of
sustained behavioural change (i.e. does not eliminate the problem
of behavioural change, but in fact multiplies it)
• Model assumes universal uptake of testing
– (but what is ‘universal voluntary testing’??)

10. TiRx for prevention purposes
• Has the potential to be used coercively against ‘key
populations’
• Who will be targeted and prioritized and how? Will
public health calculations trump clinical need?
• Will viral load testing be part of this package? CD4?
• What is the effect on PLWHA of framing treatment as
prevention? (adherence, autonomy, confidentiality, etc.)

11. Barriers to testing
& risks of testing positive
• Safe disclosure not guaranteed in many contexts
• Particular risks for women
– Relationship breakdown
– Violence
– Being neglected or disowned by families/communities
– Stigma and discrimination: employment etc.
• Zambia 1999 study: 37% willing to test, 3.7% came
forward, only half returned for test results
• Some positive events. More research needed on effect
of testing positive in different contexts

12. Model conditions
• What needs to be modeled & emulated are the elements
of policy and social contexts where testing and treatment
uptake is voluntary and high
• Such conditions are completely overlooked in the Granich
study
• Voluntariness cannot be assumed, it is a social
achievement
• More research and programmatic action is needed on the
environmental elements and social conditions that
enhance voluntary access to testing, treatment and care

13. Affective climates of HIV prevention
• Affective climates of HIV prevention (fear, trust,
evasion, openness, secrecy, support, suspicion, concern, hope,
enabling or disabling environments)
• Affect the capacities of PLWHA
• (including untested/future positives).
• Shaped by policy and legal environment, social norms,
contextual factors, collective discourse
• effect the willingness to test and access care over the long
term, as well as willingness and inclination to care for the self
and others
• This in turn impacts the preventive spin‐offs of treatment

14. P. Sendziuk, Learning to Trust
• ‘Identify & contain’ strategies versus ‘Community
education, protection, empowerment’
• Identify & Contain strategies are not positive
prevention
• Do the principles of positive prevention (esp.
human right elements) need to extend to
untested/ future positives?