community perspectives on when to initiate ART and the use of arvs for prevention a multi-country survey to inform WHO consolidated ARV guidelines

1. PRESENTED AT IAS 2013 – KUALA LUMPUR, MALAYSIA
Background
The HPTN052 trial showed a major impact on HIV transmission and a reduction in
opportunistic infections of immediate antiretroviral therapy (ART) initiation in heterosexual
sero-discordant couples. However, there remains limited information on community
perceptions regarding when to start ART and use of antiretroviral drugs (ARVs) for
prevention.To inform the 2013 WHO Consolidated Guidelines on the Use of Antiretroviral
Drugs forTreating and Preventing HIV Infection,WHO commissioned the International HIV/
AIDS Alliance (IHAA) and the Global Network of People Living with HIV (GNP+) to hold
a multi-country consultation among people living with HIV and other key populations to
understand their perspectives.
Anja K. Teltschik1
, Adam Garner2
, Mala Ram3
, Christopher Mallouris4
, Cadi Irvine5
, Philippa Easterbrook5
, Marco Vitoria5
, Meg Doherty5
, Andrew Ball5
1
International HIV/AIDS Alliance (IHAA), Hove, United Kingdom; 2
The Global Network of People Living with HIV (GNP+), Amsterdam, Netherlands; 3
International HIV/AIDS Alliance (IHAA), Hove, United Kingdom;
4
Social Justice 4 All, Amsterdam, Netherlands; 5
World Health Organization (WHO), Geneva, Switzerland
COMMUNITY PERSPECTIVES ON WHEN TO INITIATE ART
AND THE USE OF ARVS FOR PREVENTION A
MULTI-COUNTRY SURVEY TO INFORM WHO
CONSOLIDATED ARV GUIDELINES
Photo 1. ARVs in Ukraine
© 2006 Natalia Kravchuk for IHAA
Results
There were 1088 e-survey respondents from low (21%), middle (59%), and high (20%)
income countries. Of the 791 who reported gender, 38% were female, 61% were male, and
1% were transgender. Median age range was 35-44 years old (n=280).
Of the 864 who reported their HIV status, 50% self-reported as being a person living with
HIV (n=431). Of the 489 who identified with a key population, 45% were men who have
sex with men (n=220), 6% were people who use injecting drugs (n=28), 6% were sex
workers (n=30), 16% were pregnant women (n=80), and 9% were refugees or migrants
(n=42).
Of 696 respondents:
• 51% support offering ART to those whose CD4 count is between 350-500
cells/mm3
.
• Nearly half (48%) support offering ART to those with co-infections (TB, HBV,
HCV) regardless of CD4 count.
Photo 2. NAIROBI KENYA Mildred Machoria, a community mobiliser
at Ray Clinic, receives her current supply ofART and septrin.
© Nell Freeman for IHAA
Methods
From November-December 2012, a
consultation was conducted across 122
countries using an online e-survey (Arabic,
Chinese,English,French,RussianandSpanish).
Key questions included: When should people
living with HIV be offered ART?Which groups
should be prioritised regardless of CD4 count?
What are the challenges of earlier ART use?
E-surveyresponseswereanalysedoverall,and
by gender, age, population group, HIV status,
country income status and HIV epidemic type.
Key survey limitations were non-random
sampling, and that respondents were limited
to those with Internet access. Sample sizes for
each question varied since all questions were
optional, affecting statistical analysis.
In response to the question ‘Which groups of people living with HIV should have the
option to start ART regardless of CD4 count level?’, among the 676 respondents the most
frequently selected groups were (see Figure 1):
• Pregnant women (89.8% overall; 71.9% of people living with HIV),
• Sero-discordant couples (71.9% overall; 57.8% of people living with HIV),
• Sex workers (55.8% overall; 46.4% of people living with HIV),
• MSM (52.5% overall; 43.9% of people living with HIV)
There were no statistically significant differences by HIV status or country income level.
Figure 1. In your view which groups of people living with HIV (PLHIV)
should have the option to startART (regardless of their CD4 cell count)?
The most common concerns expressed regarding the use of ARVs for prevention were, in
order of importance rating: that ARVs do not substitute for behavioural interventions; that
the primary indication for ARVs must be for individual benefit; and that a human rights
approach should be used (see Figure 2).
Conclusion
The consultation showed that there is broad community support for earlier initiation of
ART (with the provisor that the newer regimens are simpler to take and safer), particularly
among pregnant women and sero-discordant couples.Targeted ARV use for treatment and
prevention is acceptable to community respondents, though with an understanding that
structural issues will be adequately addressed. The consultation made clear that the use
of ARVs for treatment and prevention should be paired with behavioural and community
interventions such as counselling, peer support, treatment literacy and adherence, among
others, to ensure that interventions are comprehensive and meet the clinical, psychosocial
and other needs of people living with HIV, their sexual partners and family members.
Acknowledgements
We thank all participants of the consultation for their collaboration in data collection.
Figure 2.How important will it be in your country to ensure the actions
below in regards to treatment as prevention?
Population groups to be offered ART
Importance in country for Treatment
as Prevention
83,9%
73,9%
68,5%
63,2%
62,7%
53,6%
44,6%
Proportion of Respondents
0% 100%
Importance Rating
Ensure that TasP approaches are always paired with and
not used as a substitute for behavioural and community
interventions
PLHIV in HIV-serodiscordant relationships
Sex workers
Men who have sex with men
People who inject drugs
Women living with HIV of reproductive age
Any PLHIV
Transgender people
Ensure the TasP approaches do not replace the need to
research vaccines and cures
TasP programmes acknowledge that the primary benefit
of treatment is for the individual and that the seconday
benefit is for prevention
Public education about TasP (including in schools) is
needed
TasP program uses a human rights approach